Care Bill [HL]

Earl Howe Excerpts

Wednesday 3rd July 2013 Lords Chamber

[Baroness Eaton]

I endorse what the noble Baroness, Lady Howarth, has just said because I am firmly of the belief that it will take time to find all the appropriate people for the move which the CQC has clearly said it would make, from generic to specialist inspectors. I am sure that this will make a huge difference to the outcomes of inspections. I, too, think that we should give this organisation time. From what I have seen, it has the drive and the initiative to make sure that things improve enormously.

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, this has been a very useful debate and in addressing this group of amendments, it might be helpful if I began by setting out why we believe this clause is necessary.

At the moment, there is no straightforward way for members of the public to get a clear view of performance in hospitals and care homes, nor is there a measure to help drive up performance, so we believe that a new system is needed to give patients and the public a fair, balanced and easy to understand assessment of the quality of care provided. Clear ratings on performance will help to incentivise providers to improve their services, as they will be able to see how well they are doing. One of the central principles behind this clause is that it will enable the CQC to develop the new performance assessment system—informed by the views of stakeholders, of course, but nevertheless independent of government. In its report into ratings, the Nuffield Trust said:

“While there is a legitimate role for … government … to influence priorities, the process should largely be sector-led including the public and users”.

I am rather pleased that we did not debate this group of amendments on the previous Committee day because the CQC has, in the mean time, published a consultation on changes to the way in which it regulates, inspects and monitors care. I draw that to the attention in particular of the noble Lord, Lord Campbell-Savours, whose points I will address in a moment. This consultation, A New Start, sets out the commission’s initial thinking on the timetable for implementing ratings. The consultation document also sets out some detailed thoughts on how the CQC will rate NHS acute hospitals. I take the point made by the noble Lord, Lord Sutherland: this rating process will have to have some fundamental differences from that followed by Ofsted. However, the ratings will be based primarily on inspection judgments. They will be informed by a series of indicators, using data already available and the findings of other bodies such as those from accreditation schemes, clinical peer review and the judgments of other regulators. The CQC will be consulting on this model more fully later this year.

Noble Lords have raised concerns about the ability of a rating system to reflect the complexity of NHS acute hospitals. I assure the Committee that both the CQC and the Government are fully alive to this risk. The CQC is committed to producing ratings at a level which recognises the complexity of NHS services and is useful to people who use them, as well as those who commission NHS care. It is therefore proposing to provide ratings for certain individual services, such as emergency and maternity services, as well as for each hospital.

A rating will also be provided against each of the CQC’s key questions. They are: is the service safe? Is it effective? Is it caring? Is it responsive to people’s needs, and is it well led? This will mean that where the evidence is available, a trust would have five ratings at three different levels—for the individual service level, for the hospital site and for the whole trust. I am sure that noble Lords will agree that this is an ambitious aim, and one that seeks to reflect the complexity of the organisations that provide care.

The Government will draw up regulations that will enable the CQC to develop the programme of performance assessment in the manner outlined in A New Start. The consultation is the first small, but important, step in the process of developing a robust system of performance assessment of providers of health and adult social care. The first ratings of acute hospitals will appear at the end of this year: I will come on to the timetable in a moment. This will be another significant step in developing a ratings system, but it will not be the end of the journey. The Government are clear that the development of ratings will be a process of continuous evolution.

Amendments, 74, 75, 76ZA, 76ZZA and 76ZAA set out areas that the CQC must or could consider as part of its performance assessment of providers. These amendments would mean that the CQC would be required to include or consider the specific issues raised as part of its methodology. The Government share the view of noble Lords on the importance of the issues they have raised through these amendments. I am sure we can all agree that they are useful ideas. However, I hope that they will equally accept the importance of the central principle that we believe should be adhered to: that the CQC should be given freedom to develop its own methodology for the new performance assessments. The clause is deliberately designed to be flexible in that sense. I therefore hope that noble Lords will be content to withdraw their amendments, in the knowledge that the CQC is ready and willing to listen to all good ideas as it puts its final plans together.

The noble Lord, Lord Hunt, has also tabled Amendment 76ZB, which would require the CQC to undertake a pilot of its new performance assessment system and require the evaluation report to be approved by Parliament. The Government agree that the CQC’s new performance assessment methodology should be subject to evaluation. This is why, in our response to the Francis inquiry, Patients First and Foremost, the Government made the commitment that:

“The Department of Health will commission an independent evaluation of the operation of the new ratings system, and this will inform future adaptations”.

The amendment would give Parliament a power of veto over the methodology which the CQC develops for performance assessment. This is not desirable as it would constrain the freedom of the CQC to act on the findings of its consultation with stakeholders. I therefore hope that noble Lords will be content not to move that amendment.

Amendment 74A would require the CQC to undertake performance assessments of commissioners of healthcare services, specifically clinical commissioning groups and NHS England. The wording of Clause 80 could enable the CQC to undertake reviews of local authority commissioning of adult social care services. The absence of a similar requirement for healthcare commissioning therefore requires an explanation. The requirement for the CQC to review healthcare commissioning was removed by the Health and Social Care Act 2012 on 1 April 2013 when primary care trusts were abolished. This is because the function of supporting the development of the commissioning system for healthcare in England has become the responsibility of NHS England. NHS England’s role is to determine how the performance of healthcare commissioners, including clinical commissioning groups, is assessed and managed. There is therefore no need for the CQC to carry out a virtually identical role. I trust that the noble Baroness will be content to withdraw her amendment, but I would like to address the particular points raised.

[Lord Hunt of Kings Heath]

I do not quite see the logic of that, because in a sense NHS England has a vested interest in ensuring that all is well with the CCGs. It is not an independent body in the way that the CQC would be.

The other question is about NHS England itself. It is a massive commissioner of specialist services. If a local authority is to be assessed, I still do not see why NHS England ought not to be subject to some kind of independent assessment. It could have a huge impact on where specialist services are going to be provided in future. We know that Ministers are no longer prepared to answer questions about lots of things that NHS England does, so there seems now to be a gap in the architecture.

[Earl Howe]

Ministers most certainly are willing and able to answer questions about what NHS England is doing, and will continue to do so. Parliament, of course, will be entitled to keep NHS England’s performance in the spotlight; that architecture was built into the 2012 Act very deliberately. I do not accept the noble Lord’s point about clinical commissioning groups, because it is for NHS England to assure itself that the commissioning system for healthcare in England is working properly. There will be a high degree of transparency in that regard. The performance management role of NHS England will be right there, and I think that the proof of that will emerge over the coming months.

Perhaps I could cover the individual points raised by noble Lords. The first point was raised by the noble Lord, Lord Hunt, and echoed by the noble Lord, Lord Campbell-Savours, about how we expect the CQC culture to change in a relatively short time. I say to both noble Lords that I firmly believe that the CQC is already very much a changed organisation. It has a new leadership team in which I have full confidence. It has a new board—which, incidentally, the noble Lord, Lord Hunt, may be interested to know will include Kay Sheldon—and I think it has a new attitude to openness and transparency, as its handling of the Grant Thornton report demonstrates.

On 16 July, the CQC’s chief inspector of hospitals, Professor Sir Mike Richards, will start in post, so that is very soon. By September the CQC will be publishing a list of hospitals that it has the greatest concerns about, and it will be using its new surveillance system to develop this list. The CQC is committed to learning from the past and pressing ahead rapidly to improve for the future. I agree with the noble Baroness, Lady Howarth, that the CQC needs stability.

[Lord Campbell-Savours]

On the question of the surveillance system that the Minister just referred to, what about the proposal that keeps coming up all the time of two unannounced visits per year for every care home within the United Kingdom? Why can that at least not be set down by the Government as a requirement, irrespective of all the other recommendations and decisions that the CQC comes to over its new so-called surveillance system?

[Earl Howe]

My Lords, it really is for the CQC to determine the frequency of its own inspections.

[Lord Campbell-Savours]

It will not work.

[Earl Howe]

It is not for Ministers to do that. I say that with great respect to the noble Lord. In saying that, however, I also highlight the ability of the CQC to flex its inspection frequency in accordance with information received. The noble Lord will know that organisations such as local Healthwatch, and indeed local authorities themselves, are able to alert the necessary authorities through Healthwatch England, which, as noble Lords know, is an integral part of the CQC, to any problems that may be flagged up. The CQC will be consulting in future on its proposals for care home inspections, and I do not doubt that a difference of view will emerge about the frequency of those inspections. I am the first to say how important it is that the inspections take place, and I totally take the point that those assessments should not be allowed to drift in any way. However, for better or worse we have an independent body known as the CQC, which should be allowed to act accordingly. The noble Lord, Lord Campbell-Savours, took us back to the 2008 Act. I would say to him that, in agreeing with the noble Baroness, Lady Howarth, Robert Francis was clear in his report that the system should not be significantly reorganised.

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[Lord Sutherland of Houndwood]

Perhaps I may ask for clarification on one further point relating to complaints. Amendment 76ZZA does not propose that the CQC should handle complaints, which was the gist of the Minister’s response. Rather, it proposes that there should be a clear and transparent method of handling complaints within each trust and relevant area. The role of the CQC is to open up that window, very much in line with the Francis report, so that we can know that complaints will be handled at the appropriate level and in the appropriate way.

[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.

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[Lord Beecham]

My noble friend is right to draw attention, as many of your Lordships already have, to the need to integrate the provision and to avoid the sort of cost-shunting that can arise if organisations are kept separate. That is the point of the pooled budget: you look not just at the straightforward provision of care by one or other partner, or both partners, but at what will perhaps reduce the need for care in other ways. As I say, other local services such as leisure and adequate housing, in conjunction with the public health agenda, may very well reduce the demand for particularly expensive forms of care, as I am sure we all agree.

Of course, local government’s track record is not uniform, but it is right to say that local government has proved over the years to be the most efficient part of the public sector. There has been a huge improvement programme in local government, recognised by the shortly to be lamented Audit Commission, and others, over the years. The LGA in particular has sought, through a whole series of policies, including the very extensive and successful use of peer review, to engender new approaches and more cost-effective ways of dealing with a range of problems, including those in the social care arena.

I was about to conclude by drawing attention to another figure, which has just emerged today. It is a rather startling figure: £9.8 billion of uncollected VAT—10% of the total take—according to today’s Guardian. That dwarfs the amount that the Government are putting into the new arrangements. Just as local government needs, together with its partners, to engender the utmost efficiency in the mechanisms that it develops to provide services and make them cost-effective, as my noble friend suggests, so on the revenue-raising side central government has a massive obligation to ensure that it collects the taxes—instead of cutting the resources going into HMRC, which is responsible for collecting VAT, by a further 5% in the spending review.

We do not consider the cost of £3.8 billion and the welcome money that the Government are going to provide to be the last word in these matters. There will have to be a continuing process of establishing programmes that are effective and cost-effective. Looking at the totality, there is scope within the system to prioritise this area, providing that the Government take the right decisions—across the piece, not merely on the narrow front of health and social care but considering the implications for other services and functions of government—and collect the money that they are due anyway and which would relieve the huge pressure on these services and others.

I have a good deal of sympathy with the concerns expressed by the noble Lord, Lord Best, but I share the view of the noble Lord, Lord Sutherland, that it would not be right to hold things up. We must get on, but in doing so we must be realistic about the challenges that will be posed to those responsible for delivering these services. I look forward to hearing the Minister’s response to the various questions that have been raised in the debate.

[Earl Howe]

My Lords, I do agree with the spirit of this amendment. It is critical that care and support generally, and these reforms in particular, are fully funded. Without adequate funding, they will not deliver the benefits we all want to see. However, let me reassure noble Lords that we already have full procedures in place to ensure that there is proper funding for social care.

The first and very basic point is that the Government set spending plans for all areas of public expenditure at once during a spending review. This ensures that decisions can be taken about the future funding requirements of government as a whole, rather than assessing each part piecemeal. The noble Lord, Lord Sutherland, spoke about the review of priorities being a task of government. I agree, and that is exactly what spending rounds are designed to do.

Secondly, we have the new burdens doctrine in place, which requires that,

“all new burdens on local authorities must be properly assessed and fully funded”.

That ensures that all new funding pressures, including those that result from this Bill, are fully funded. I can tell the noble Lord, Lord Best, that our commitments are in line with the new burdens doctrine, the costs have been identified in the impact assessment, and the funding in the spending round will support local authorities to deliver on current and future commitments through to 2015-16. To answer the noble Lord, Lord Campbell-Savours, yes, the work has been done.

It is only right that the Government take spending decisions for all areas of public expenditure at once. This ensures that future spending plans are drawn up which are coherent and consistent across all public services. This is exactly the purpose of a spending round, the latest of which concluded last week, as noble Lords know, and set spending plans for 2015-16. Fundamentally, this settlement delivers the funding required to ensure that service levels in the care and support system can be protected and are able to deliver on all the commitments in this Bill.

However, with additional pressure on the system, we must ensure that the Government, the NHS, local government and care and support services are all working together to offer the best possible services for patients while also addressing the growing demand on the system that the noble Lord, Lord Best, rightly referred to. That is why we have announced in this year’s settlement a £3.8 billion pooled health and care budget to ensure that everyone gets a properly joined-up service, so that they get the care and support they need from whoever is best placed to deliver it, whether that is the NHS or the local authority.

In 2014-15, the NHS will transfer £1.1 billion to support social care with a health benefit. The pooled fund will include £2 billion more through the NHS in 2015-16. But this money will be given only on the basis that services are commissioned jointly and seamlessly between the local NHS and local councils. I hope that that helps to answer the question posed by the noble Lord, Lord Beecham.

[Lord Campbell-Savours]

Before the noble Earl moves on, perhaps he can answer this question. Is he saying that the statistics that were used in the report by the Committee on Public Service and Demographic Change were known to the department and were all taken into account, and that the calculations the department made were based on those statistics, which were well sourced, when the budget for these areas was decided upon by the Government?

[Earl Howe]

The statistics that the Government relied upon were official statistics and, I think, were exactly the same as the statistics used by the report to which the noble Lord referred. Of course, that report takes us forward 10 and 20 years. I am not pretending that the spending round has done that—it never does and I think it is safe to say that it never will. But we did look forward in a rigorous way to the pressures on the system in 2015-16 and based our assessment on the statistics that are officially issued.

As all plans will be jointly agreed by the NHS and local authorities in the pooling arrangements that I referred to, that in itself will provide a strong guarantee that the money is spent in a way that delivers on the priorities of health as well as of care and support. Not only will this fund help to deliver joined-up services, it provides the necessary funding for all the commitments and duties set out in this Bill, and the growth in demand from an ageing population and growing number of disabled people—I say in particular to the noble Lord, Lord Rix, and the noble Baroness, Lady Campbell. In particular, funding worth £335 million has been set aside for the introduction of the cap on care costs and the extension of deferred payment agreements.

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[Lord Beecham]

My question was not about the purpose of the pooling, which I think we all share. My question was rather more detailed. If part of the funding is to be based on outcomes, how and when is that to be judged? If the outcomes are not achieved, how will the money be reclaimed? All this is something of a mystery as matters stand.

[Earl Howe]

The details of the payment-by-results system will be worked through. We are working with our partners in the sector including the LGA and NHS England to ensure that the system is designed with a view to incentivising integration. Further details of those arrangements are in course and we will announce them as soon as we can.

The kind of things that we will be looking for are, for example, the results that we have seen in places such as Cheshire West and Chester. The pilots, the whole place community budgets, showed that savings from integration could be substantial if implemented effectively. A business case needs to be presented. In that context, the pilot suggested that, once proposals are fully implemented, the net savings that could be achieved over five years are considerable.

Cheshire West and Chester has made savings of £26 million, with £3.8 million for Greater Manchester, £190 million for the Triborough authorities and £90 million for Essex. These savings are being identified. It gives us confidence to say that there is real potential to save money across the country, as shown by the pilots and other reviews, such as the Audit Commission review. Oxfordshire recently announced that it was nearly doubling the amount of money in its pooled budget for older people. That is a significant move.

I agreed with much of what the noble Baroness, Lady Wall, said. Savings are eminently possible without detracting from quality, by slowing and preventing the development of care needs or the onset of health conditions, or the loss of independence. We hope and believe that preventive care can increase the quality of life for individuals. A proactive stance by local authorities will deliver that. At the same time, preventive care will provide longer-term financial savings to the public purse. For the first time, Clause 2 creates a clear legal duty on local authorities to ensure the provision of preventive services.

I come to the point raised by the noble Lord, Lord Campbell-Savours, about the Dilnot package. I do not view the Dilnot package in the same way that he does. I do not see funding reform as being about protecting people’s inheritances. It is about providing hard-working people with peace of mind about how much they will pay for their care. Deferred payments will ensure that people will not have to sell their homes in their lifetime to pay for care. That will prevent distressing sales of houses and provide everyone with breathing space to make decisions and choices about what happens to their home. In the long term, the scheme is broadly cost-neutral to government, because the deferred payments will be repaid. Everyone will benefit from these reforms, but they will particularly help people with modest wealth who are most at risk in the current system of losing their entire home and savings.

Delivering on these transformational changes to health and care is the only way to secure the long-term sustainability of services, both for the NHS and local authorities. I would be firmly against delaying this —I think we would be heavily criticised if we did. The noble Lord, Lord Bichard, referred to the burgeoning weight of regulation during the past 60 years and one cannot argue with the statistics that he produced. This Bill serves to consolidate more than 60 years of legislation; it will repeal provisions from more than a dozen Acts of Parliament. Reducing the complexity of the statute and rationalising burdens on local authorities are our key aims in this context. I hope that, for the reasons that I have outlined, the noble Lord, Lord Best, will feel sufficiently reassured to be able to withdraw his amendment.

[Lord Best]

My Lords, I am deeply grateful to all noble Lords who have spoken: to the noble Lord, Lord Bichard, for pointing out that we cannot keep loading responsibilities on local authorities and others without willing the means to pay for those things; to the noble Baroness, Lady Howarth, who said that we cannot go on like this; and to the noble Lord, Lord Rix, who explained the position from the Mencap perspective—it could have been that of many other charities which are facing very tough times because local authorities cannot keep up the level of support that they used to have. The noble Lord, Lord Campbell-Savours, produced more impressive statistics, not least in relation to the people with long-term conditions and dementia who are living in the community and need to fund their care needs. The noble Baroness, Lady Campbell, brought us the users’ voice, pointing out that funding cuts have already meant people losing some of the control and choice which had been increasingly expected with use of direct payments and so on.

The noble Lord, Lord Sutherland, pointed out that the culprit is not local government or central government but demography, and that we need to make some choices as a result of those demographic pressures. However, in his view, one of those priorities is clear: it is that we should go ahead with this Bill. The noble Lord, Lord Beecham, also felt that it would be unwise for us to delay things, even though he accepted that cuts mean that social services in Newcastle have returned to the position that they faced in 1973 in terms of the resources available. He pointed that it is local government that has shown itself best able to be more efficient in these difficult times. We need to remember that. The noble Baroness, Lady Wall, pointed out that local authorities should try to make savings wherever they can, and the noble Lord, Lord Beecham, was right that statistics show that local government is doing just that.

I think that it is fair to say that the noble Lord, Lord Bentham, felt that it was necessary to find additional resources, but he thought that those could be found from the underspend in the NHS or the uncollected VAT or some other source. However, he did not want the amendment to delay the good things that the measures bring with them. The noble Earl, Lord Howe, agreed that we need fully to fund the measures—did I say Bentham?

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[Baroness Greengross]

My Lords, I support Amendment 78ZA. Six years of serving on the Equality and Human Rights Commission taught me that if we embedded dignity and respect into the training of staff we would avoid many of the tragedies we have read about. This applies, right across the board, to staff in health, social care and housing. It is essential that we take dignity and respect as very serious elements of the training of all staff who come into contact with frail and vulnerable people.

[Earl Howe]

My Lords, the well-being principle in Clause 1 was devised on the basis of the Law Commission’s report on adult social care which this part implements. The report recommended that the new statute should set out a single, overarching principle that adult care and support must promote or contribute to the well-being of the individual. Not least in the light of our debate at Second Reading, I can therefore understand the noble Lords’ intention in tabling Amendments 78 and 79. It is to ensure that any functions that the Secretary of State exercises under this part take into consideration how such provisions will impact upon people’s well-being. I can give the Committee what I hope will be a welcome reassurance on that issue and, in the process, a rather better and fuller answer than I gave at Second Reading.

It is already the case that the Secretary of State must have regard to the general duty of local authorities to promote an individual’s well-being when making guidance or issuing regulations. This is because, when making regulations or issuing guidance, the Secretary of State must consider how local authorities can fulfil their statutory obligations. He cannot ignore those obligations and I believe this addresses the central concern of the noble Lord, Lord Hunt, and others who have spoken to the amendment. The question is whether the Bill should go further. The Government do not believe that it is appropriate to apply the well-being principle directly to the Secretary of State. The well-being principle is intended to apply at a very real, individual level. It has been designed to frame the relationship that exists between the local authority and the individual adult, in effect setting out how it is expected the local authority will behave when making a decision, or doing anything else, in relation to a person needing care and support or to a carer. The Secretary of State does not act at this individual level, and I am still reluctant to make any amendment which might be seen to detract from this important legal reform.

Having said that, I have listened with care to the strength of feeling in this debate, not least to the point made by the noble Baroness, Lady Pitkeathley, about the Secretary of State’s duty to have regard to the NHS constitution and whether there was something comparable that we could devise in this context. That is an interesting comparison and, while I am not yet convinced that it is fully comparable, I am happy to take the points that have been made away with me and give this matter further thought before the next stage of the Bill.

Amendment 78A seeks to bring in to the well-being principle the idea of spiritual well-being and I listened with care to my noble friend Lady Barker who spoke to this amendment. The Government believe that the clause, as it is already drafted, takes such a factor into consideration. Clause 1(2) sets out that well-being means an individual’s well-being in relation to emotional well-being. The Government believe that emotional well-being incorporates the concept of spiritual well-being.

I turn to Amendment 78B, which proposes that local authorities must take into consideration an individual’s beliefs, values and past practices. While we share my noble friend’s intention in this regard, we believe that the clause as it stands already incorporates the idea that people’s beliefs and values should be taken into account when a local authority has regard to an individual’s views, wishes and feelings.

The second part of the amendment would be to ensure that “past practices” were also taken in account. I reassure my noble friend that we will be setting out in guidance the importance of taking into consideration, when planning a person’s care, their views and feelings as well as considering any practices in the past that have been important to that individual.

The noble Lord, Lord Bichard, highlights the importance of dignity in care in his Amendment 78ZA, and he spoke about that concept very powerfully. I am pleased to say that the Government agree that this is important, which is why we amended the Bill to make an explicit reference to dignity into the well-being principle, following pre-legislative scrutiny. With respect to the noble Lord, I cannot agree with him that the word has somehow been lost; it is right there on the page.

I turn to Amendments 78E, 87K and 88J, tabled by my noble friend Lord Black of Brentwood. These amendments focus on the very important topic of pets. The Government have considered this issue carefully since the amendment was tabled, and we believe that the Care Bill already allows for the consideration of pets. First, Clause 1, the well-being clause, provides that local authorities, when exercising any function under Part 1 of the Bill, have a duty to promote the well-being of an individual. Well-being is composed of many aspects, including emotional well-being. A pet might be so important to an individual that their emotional well-being would depend in some way on their pet. If that is the case, a local authority will have to take it into consideration.

Furthermore, Clause 1(3)(b) sets out that in exercising any function under Part 1 of the Care Bill a local authority must have regard to an individual’s “views, wishes, and feelings”. This could include how an individual feels about a pet, and their wishes for the pet. Clause 9, which covers the assessment of needs for care and support, also allows scope for pets to be taken into consideration in the assessment process. As Clause 9(4)(a) sets out, a needs assessment must take into consideration a person’s well-being. This could certainly include an individual’s pet, from which they derive a lot of emotional well-being.

I turn to Amendments 78D and 88L. The Government believe that it is more important than ever that care and support services operate in tandem with health services. The Government have committed to breaking down barriers between health, care and support, as well as encouraging co-operation, integration and joined-up working between local partners. The Government believe that the Care Bill already allows for such co-operation to occur, and I shall explain how. First, Clause 1(2)(a) makes it clear that the well-being principle incorporates physical and mental health. Local authorities must therefore already consider a person’s health when exercising any functions under Part 1. Secondly, Clause 3 details how local authorities must exercise their functions under Part 1 with a view to ensuring the integration of care and support with health provision, where they consider that this would promote the well-being of an individual.

Regulations on assessments for care and support are also relevant. As Clause 12(1)(f) sets out, regulations may set out when a local authority must consult someone with expertise before undertaking an assessment. Regulations may also set out conditions around co-operation with the NHS, by specifying the circumstances in which the local authority must refer the adult concerned for an assessment of eligibility for NHS continuing healthcare.

The noble Lord, Lord Hunt, expressed the view that the eligibility regulations do not sufficiently promote integration. I note the point that he made and look forward to debating this in perhaps fuller measure when we come to discuss eligibility. However, I ought to point out that the draft regulations published last week are subject to consultation, and I am sure that the discussion will explore the points that he made.

My noble friend Lady Tyler said that the regulations do not mention dignity specifically. I think that they have to be read in context. The well-being principle, including the reference to dignity, applies to the assessment of the adult’s needs and to the local authority’s determination of whether those needs are eligible.

To return to my noble friend Lord Black’s amendment on companion animals, we are clear that there should not be any limitations on the uses of direct payments, which was an issue that he raised, as long as they are used to meet needs for which they are paid and not in a way that is unlawful. The key is that direct payments are used to improve people’s outcomes.

I understand the intentions of noble Lords in tabling these amendments but I hope that they feel reassured that they are not necessary, although I will take back the specific issue that I referred to earlier. In the light of that, I hope that the noble Lord, Lord Hunt of Kings Heath, will feel able to withdraw the amendment.

[Baroness Masham of Ilton]

Before the Minister sits down, I would just like to ask him: does he not really want to get things right? When there were problems at Mid Staffordshire, people were desperately thirsty, drinking out of flower vases, and were lying in their own refuse in their beds. Surely dignity must be written in all over the Bill.

[Earl Howe]

I agree that dignity is a very important concept, which is why we expressly amended the Bill to include that word right at the beginning. Clause 1, which defines the well-being principle, is the foundation for everything that follows. While one could pepper the Bill with references to the word “dignity”, I am not sure that that would add very much in practice.

[Lord Hunt of Kings Heath]

My Lords, I am grateful to the Minister for that response. I hope that he will reflect a little on the amendment from the noble Lord, Lord Bichard, and the noble Baroness, Lady Tyler. I understand what he is saying about the words in the Bill; I think that noble Lords just wanted to find a way of giving that greater focus. That will be well worth giving further consideration to. With regard to the amendment from the noble Baroness, Lady Barker, I am grateful for the reassurance that the Minister has given.

On Amendments 78 and 79, the Minister has essentially said that he still sticks to the general principle that the well-being clause applies to local authorities and individuals. The point here, though, and the reason why I am glad he is taking it away, is a point raised by a number of noble Lords: this legislation, which is a wholesale recasting in the light of the Law Commission’s work, is likely to endure for many years to come. That is why it is so important that the link between the Secretary of State’s duties, and those of local authorities, and the Secretary of State’s powers regarding guidance and regulations are brought together. I hope that the Minister will find a way of getting this into the Bill.

The noble Baroness, Lady Campbell, was very eloquent when she talked about what happens if health and social care do not provide an integrated service. She gave an example of a very distressing case of someone who could be out of hospital and back into work. This was down to a failure of two public bodies to sort things out. I know that the Minister says that in fact the legislation is okay; the problem is that these public bodies will continue to fail people who fall between two stools. These bodies do not seem to have an understanding that it is imperative for them to look after the interests of those individuals. I hope that the noble Baroness might return to this at a later stage.

The noble Lord, Lord Black, made some wholly persuasive arguments. My noble friend Lady Wheeler reminded me that Canine Partnerships is another organisation that is very much involved in pet companions for people with stroke, epilepsy and other illnesses. I myself have come across organisations in Birmingham in connection with the health service that do a fantastic job. All I would say is that if the noble Lord put this to a vote, the Opposition would be right behind him, so let us see. I beg leave to withdraw the amendment.