Care Bill [Lords]

Debate between Liz Kendall and Alison McGovern

Monday 10th March 2014 Commons Chamber

[Liz Kendall]

If the right hon. Gentleman reads our new clause 18, he will see what our approach is. Local councils commissioning social care and having to fulfil their obligations under the Bill will need to look at employment terms and conditions. We have tabled the new clause because unfortunately the Government are removing the Care Quality Commission’s role in assessing how well councils are commissioning services, which I think is a mistake.

[Alison McGovern (Wirral South) (Lab)]

Given the point my hon. Friend has just made, does she agree that it is all the more important that councils up and down the country follow the lead that Labour Wirral has shown in sticking to the principles of Unison’s ethical care charter, which tries to rid us of 15-minute appointments and limit zero-hours contracts?

[Liz Kendall]

I know about the approach that has been taken in Wirral and think that it is an excellent example. If we kept the CQC’s role in assessing how well councils are commissioning services, that is just the sort of thing that it would be able to spread. It is a real problem that that role is being removed. We will come later to our amendments that seek to return it to the CQC.

I will now turn to a group of new clauses on how better to identify and support carers. They stand in the name of Opposition Front Benchers, but really they are the work of my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley), who has made sterling efforts in this regard. We have tabled them to give carers the focus and attention they deserve. They pick up on some of the points that the right hon. Member for Sutton and Cheam (Paul Burstow) made. New clause 19 would ensure that all health bodies have effective procedures in place to identify people who are or are about to become carers and ensure that they get the help and advice they need. New clause 20 would require local authorities to take all reasonable steps to ensure that schools in their area identify young carers and put support in place. New clause 21 would require universities and colleges to do the same.

As the right hon. Member for Sutton and Cheam said, family carers—unpaid family members looking after the people they love—are the absolute backbone of our care system. They need and deserve more support. They are looking after their relatives because they want to, but they really need help. One in five family carers provide more than 50 hours of care every single week, and their own health suffers as a result. One in three have to give up work or reduce their hours, which means their income suffers and the cost to the taxpayer goes up.

The Bill puts in place welcome new rights for carers, building on the approach taken by the previous Labour Government, but they will be meaningless if carers are not identified in the first place. Many carers do not actually come into contact with local authorities. Macmillan Cancer Support has made a powerful case, showing that 95% of the over 900,000 carers of people with cancer in England have not received a carer’s assessment—only one in three of them have even heard of it. That is because they are mostly in touch with the health system. Unfortunately, hospitals and GPs still do far too little to identify carers of people who have cancer and other conditions, such as stroke and heart disease. I understand that GPs identify only around 7% of carers, and other health professionals, particularly in hospitals, identify only one in 10. We need clear duties on those bodies and proper processes in place, because too often at the moment there is just a tick-box approach. I recently had to move GP practice, and the form I filled out contained two pages on how much alcohol I drank, which was welcome, and a little box that asked, “Are you a carer?” I knew what that meant—but did it mean a paid care worker, or a health care worker? That is not good enough and needs to be thought through.

I also stress the need to do far more to identify young carers, who we know can see their lives and life chances suffer because of what they do to help look after sick or disabled parents. Many schools might not understand if kids are not doing their homework or not turning up on time because of their responsibilities. If young carers are lucky enough to get to university or college, they may find their studies hard because they are travelling to and from home to try to help support their loved ones. We believe there should be clear duties on those bodies to identify young carers.

New clauses 22, 23 and 24 are about getting people the right financial advice—an issue we discussed a lot in Committee. The Bill introduces a new and complicated system of social care funding with the so-called cap on care costs and new deferred payment schemes. It is complicated and I have lost track of the number of times people have said to me, “Well, it’s okay because at least my care costs will be capped at £72,000 now”, and I have to go through the process of explaining to them that that is not actually the case. People are unaware of the new system, and if they are looking at financial products to help them cope with later costs, they need decent financial advice.

Currently, financial advisers must have studied a range of different financial and regulatory subjects, and they must sign up to a statement of professional standing and a code of ethics and conduct. Has the Minister talked to the Financial Conduct Authority about whether the training of financial advisers should change as a result of the Bill? Is he confident that all financial advisers can give people advice about the products they might want to take out to protect themselves against future costs, on the basis of the Bill?

I am concerned that unless people get high quality, proper financial advice, we could be in for another mis-selling scandal because the issue is complicated. People will have to figure out how much their average local authority rate will be for their area in five, six or seven years’ time, and how different that will be from what private providers charge. Will people’s care needs enable them to start counting towards the cap on care costs if they are not defined as “substantial”, as under current eligibility criteria? I would struggle to figure out all those finances, and we must ensure that financial advisers are properly trained.

New clause 22 states:

“The Financial Services Consumer Panel at the Financial Conduct Authority”

should publish an annual report on the

“availability, quality…and effectiveness of financial advice”

available to care users and their families. New clause 23 states that the FCA should consider raising the level of qualifications that financial advisers must have. We must ensure that people get high quality financial advice so that they are not mis-sold any products.

We also want much greater efforts to raise public awareness of the new capped cost model introduced by the Bill. Under the Bill, local authorities have a duty to raise awareness, but new clause 24 would make that much stronger and require them

“to prepare, publish, consult on and implement”

a proper plan for raising awareness among their local residents. That is important so that people know about the new system and what it means for them.

I support new clause 11, which would ensure that all users of publicly funded or arranged care have direct protection under the Human Rights Act 1998. Under the law as it stands, the fundamental protection and access to individual redress offered by the Act are not applied equally in all care settings. In the other place, Lord Low tabled the former clause 48, which sought to close that loophole. There was a long discussion on it in Committee—the clause was passed in the House of Lords but the Government voted to remove it in Committee. The Minister’s argument was that it went too far, because it would mean that the Human Rights Act applied to entirely privately funded and arranged care. He also claimed that the clause was not needed because the CQC could deal with the problems.

NHS Care of Older People

Debate between Liz Kendall and Alison McGovern

Thursday 27th October 2011 Westminster Hall

[Liz Kendall (Leicester West) (Lab)]

It is a pleasure to serve under your chairmanship, Mrs Brooke. I thank the Backbench Business Committee for allowing us to have the debate. In particular, I thank the hon. Member for Stourbridge (Margot James) for securing it. I also want to thank all other hon. Members who have spoken and given passionate, heartfelt and thoughtful contributions.

Hon. Members from all parts of the Chamber have spoken with one voice. It is completely unacceptable for any older person to receive the appalling standard of care that we have read about in the CQC report and in the ombudsman’s report. We have seen that appalling standard of care in our own constituencies. My hon. Friend the Member for Bolton West (Julie Hilling) has seen it in her own family. Although we may not have seen as poor a standard of care as she did, I am sure that many of us have been concerned about the care given to our own families. I would like to consider some potential causes of those poor standards of care, and talk about possible measures to tackle them and to ensure that every service matches the best standards.

It is important to look closely and carefully at this question and to avoid thinking that one issue, one group of staff or one set of problems is to blame. While there are some straightforward, practical steps that could be taken immediately, there will not be one simple quick fix that will solve the whole issue. There are deeper and more complex issues that are far harder to address. I will talk about five areas: staff levels and resources; staff training, which many hon. Members have spoken about; culture and leadership; the regulation of the NHS; and deeper issues that are very difficult to address.

Several hon. Members, particularly at the beginning of the debate, raised the issue of staffing levels and resources. If we talk to individual members of staff or organisations such as the Royal College of Nursing, they say that the issue is of concern. Staff to patient ratios were referred to by the hon. Member for Stourbridge and the hon. Member for St Ives (Andrew George). Peter Carter, who runs the RCN, gave me a stark example. The figures are rough and not perfect, but he said that paediatric and children’s wards have one nurse for every four patients, while in the wards that specialise in care for older people the ratio is around one nurse for every 10 patients. Elderly, dependent patients have different needs from sick young children, but in many ways they are just as challenging, so we need to look at that, particularly because, with an ageing population and some of the problems in social care, more sick elderly patients are ending up in hospitals, many with not only dementia but two or three other health problems. That co-morbidity issue will be important as we see hospitals with big financial challenges, which we will over the next couple of years.

On staff training, we often hear commentators or senior people in the NHS, frequently medics, who question whether moving nursing towards being a degree profession has been an entirely good thing. It is vital to get the right balance between academic and practical elements in nurse training. Degree courses have been around for many years—40, I think. As many hon. Members have said, we see differences between and even within hospitals that are using nurses with the same qualifications, often from the same universities, and some have their problems and some do not. We need to look at the balance, but we should not think that that is the entire cause of the problem. A lot is down to the culture created in wards, which I will say more about in a moment.

Concerns have been expressed by many hon. Members today, the media and NHS staff about health care assistants. Health care assistants in wards provide more and more of the care, some of which is intimate, such as feeding older people or helping those with continence problems, but it is a positive development. As other hon. Members have said, our staff have the right values, and that is partly about the training they get. I think the hon. Member for Stourbridge said that health care assistants do not get any training and are not regulated, but they do, or should, get training from their employer, the trusts. Such training can be patchy, and we need to look at that.

In 2003, I called for the regulation of health care assistants—as many people did, way before me—in a project I did called “The Future Healthcare Worker.” If nurses are to take on some of the more clinical roles, and health care assistants more care, we need to look at that issue. I had hoped for more progress on that under the previous Government. It would be interesting to hear from the Minister the current Government’s views on regulation. There are all sorts of issues around time and cost—for employers and individual staff—but it is something we need to look at.

Culture and leadership are woolly words, but in practice we know when we see good culture and good leadership. My hon. Friend the Member for Wirral South (Alison McGovern) made this point. What is it on the ward that matters above all? Yes, it is about how long it takes to be treated, whether operations are a success or whether medicine is taken on time, but it is also, crucially, about the experience of the patient, whether they and their families feel that they have been given enough information and the time to think about it. When the information is given can be important. We have all been in situations where the doctor has said something quite shocking and we were not prepared for it. What matters is the simple things such as whether the patients are covered up when they go to the toilet and cleaned effectively afterwards.

There are places where the patient’s experience is at the top of the agenda, not only of the individual ward but of the hospital as a whole. Simple and straightforward surveys, developed by organisations such as the Picker Institute, can help individual organisations and services to get that across.

Another thing about culture is a bit more tricky and concerns how we build a team and being open to questioning. In a team, staff should value each other’s different experiences. That might not be the case with some of the old-fashioned hierarchies in a hospital—doctor, nurse, care assistant—where they do not dare question one another. Teams need to value each other’s skills and experiences but also be open to questioning.

[Alison McGovern]

One of the best examples of quality of care that I have seen recently was in one of my local hospitals, when I was shown around a ward in part by the cleaner, because she was deemed to be so important to the good functioning of that ward.

[Liz Kendall]

That is absolutely right. It is not that everyone has the same skills and experience, but that all those different skills and experience are important. In a proper culture of learning, mistakes can be admitted, because we all want to learn from them to ensure that they do not happen again. We need to see not only the different health professionals as part of the team, but users and families too. Peter Carter of the RCN raised the issue of families being involved, and it was sad that all over the papers he was reported as saying, “Come in and care—it is up to you to care for members of your own family.” What we need, though, is for families to be part of the process, particularly if their relatives are elderly patients suffering from dementia. Family members know them best. We might not be able to hear what they are saying but their family will know how they react, and whether they like or dislike something.

Such a culture and such leadership need to be in evidence not only on the ward, but on the board—a point made by the hon. Member for Stourbridge. As the boss, the board should want to know what is happening on the ward and its members should be getting the surveys and patient feedback. As with Members of Parliament, hopefully, what they will most want to know is what individual constituents think of them. Accountability is vital, from the top down. Also, in particular for old people who might not have family members nearby, the idea of volunteers who can be advocates and part of the process is important.

On regulation and the Care Quality Commission, I am concerned about the issue. More could be done immediately. The CQC has an important role to play, but I want to be clear that responsibility for the quality of services lies with the providers and not with the regulator. However, people want to have confidence that, if the CQC says that somewhere is okay, it is okay and, if it is not okay, that the CQC will go back and ensure that it is sorted out. I am concerned that, almost six months after the initial inspections, the CQC has not been back to a third of the hospitals it said in its report were failing to respect and involve older people, and it has not been back to two thirds of the hospitals that were failing to meet nutritional needs. I have written to the CQC, which has not written back, but it said on the phone that it had received written reassurances. That is not good enough. It should be going back to those hospitals. I am keen to hear from the Minister whether he could take action to ensure that we know which hospitals have not had a follow-up and what the timetable for action is.

There are clear national guidelines for people who work for public bodies such as the council or the NHS. There are guidelines on raising the alert and referring a person immediately—within one day—if it is thought that they are vulnerable or at risk of neglect or abuse. I have asked the CQC whether it referred people, or whether it required the hospitals to do that. If someone has seen children at risk of neglect or abuse, action would need to be taken or they could face the legal consequences. I am concerned about that matter.

I have spoken longer than I intended. I want to finish by addressing what I call “deeper issues”: our model of health care, the nature of medicine and the way we as a society treat older people. When our NHS was established, our population had very different health problems. People needed episodes of care for acute conditions that could be treated and increasingly cured. Our health services were based on the model of individual district general hospitals. However, we have health problems now that are related to people living longer with long-term and chronic conditions. Improving health is no longer solely about needing episodes of acute care that seek to cure people. It is about increasingly helping people to manage their long-term health problem, and, when they are very old or suffering from dementia, helping them to live to the end of their days as comfortably as possible.

Our model of health care has not kept pace with changing needs. One third of hospital admissions are for people over 65, but, because on average they stay in hospital twice as long, two thirds of hospital beds have an older person in them. Hospitals are not the place to care for older people, but hospitals are where we care for them. We must change that situation, which means shifting services out of hospitals and into the community. We need to focus more on prevention and joining up with social care.

There is a big challenge for medicine. We have talked a lot about nurses, but not about doctors’ mentality. They are trained to cure. There is a big challenge for doctors as well as nurses as our health needs change. In too many places, doctors are still at the top of the hierarchy. They are the ones who help to determine the shape of care. It is important to look at their changing role, too.

I want to talk about how we as a society treat older people. I hope we will have a proper debate about that one day. I want to say two things. First—I think other hon. Members have mentioned this—we are not used to seeing people get so old. It is quite a recent thing to see people living for such a long time, often in pain, and it is very painful for families, particularly if they see people whom they love suffering with dementia. Society shuts older people away too often. We say, “You’re just getting old” or we prefer that they are not seen and not heard. In other countries, it is not like that. Older people feel more part of the community and they are perhaps more visible than in this country. I can give a simple example. Care homes in Spain do not have opening hours—they are simply open—and people see them as part of the community.

The issue is about how our services cope with an ageing population and how we treat older people. If someone is very old and slowly dying, including from something such as dementia, which is awful to see, we need to find a new way to deal with that.