Care Bill [HL]

Lord Campbell-Savours Excerpts

Wednesday 3rd July 2013 Lords Chamber

[Lord Campbell-Savours]

My Lords, the need for the specialist staff referred to by the noble Lord clearly lies behind the tabling of Amendment 76ZB. It is precisely why we need to pilot the proposed system.

My noble friend on the Front Bench referred to the system being created as a new system. We were told that we were going to get a new system in 2009. I sat on the third Bench behind my noble friend—the noble Earl was on the Front Bench on this side—and pointed consistently to the deficiencies in the system while it operated under CSCI and the inevitability of further problems arising under the new structure that was being created. Indeed that is precisely what has happened.

It seems to me that it can only get worse. The report of the Select Committee on Public Service and Demographic Change sets out the scale of the problem that confronts us in future. It prays in aid the Office for National Statistics updating its projections up to 2021 based on a recent release of data from the 2011 census on the ageing population. It says that, by 2021:

“There will be 24% more people aged 65 and over”,

and,

“39% more people aged 85 and over”.

It goes on to say that by 2030 there will be,

“will be 51% more people aged 65 and over”,

and that the population over 85 will have doubled. This means, to put it bluntly, that a lot more people will go into a lot more nursing homes throughout the country. Therefore, we have an absolute responsibility to make sure that the structure that we establish on this occasion is fit for purpose.

At the moment, I understand that there are 2,400 nursing homes catering for approximately 220,000 residents. That is going to increase, and I am still not convinced that the structure that this new so-called CQC is to set in place will be fit for purpose for taking on that task. Nor has the structure been defined in the legislation, as my noble friend has referred to. When I say fit for purpose I am reminded of the comments made by the noble Earl when we met on the last occasion to discuss this Bill, when he talked of a new broom at the CQC. As I understand it, it is not a new broom but an old broom with a new handle, because the person who is now running the operation is in fact the same person, I am told—and the information is available on the internet for anyone to read—who was responsible for the structure, which we are now debating, which has failed miserably over the past four years and is the subject of the complaint.

Mr David Behan, who runs the new operation, prior to his current appointment at the Care Quality Commission, was director-general of Social Care, Local Government and Care Partnerships at the Department of Health. As the director-general—and I read these words very carefully, because I do not want in any way to misrepresent the position—he had lead responsibility for the social care aspects of the Health and Social Care Act 2008, which created the CQC, the very organisation that we are having to review today because of its total failure and the scandals that have been drawn to our attention in the national media over recent years. I understand that he should have been aware of the Act’s requirements for the CQC to perform its functions for the general purpose of encouraging the improvement of health in social care services. This failure is implied in the Department of Health capability review, which in effect admits that the Department of Health was not sufficiently challenging and strategic in the way it supported the CQC.

David Behan is not new to social care regulation. Before taking up his appointment at the Department of Health, he was chief inspector of social services at the Commission for Social Care Inspection—CSCI—the organisation that we criticised in 2009 when the Act was going through on the basis of its failure in this particular area. I remember Ministers going to the Dispatch Box—Labour Ministers, yes—reading briefs produced by civil servants, in which they repeatedly assured us, as they did in personal correspondence to us, that the new structure that was going to be set up would work. It has not worked. It has been a complete and utter disaster area, which is why we are now faced with problems in this particular area that are reflected almost daily in the national press.

There is a very reputable organisation called the Relatives & Residents Association. Before anyone seeks to discredit its operations, it is worth pointing out that it is quoted in the most recent report by the House of Commons Health Select Committee. Its comments are prayed in aid in the committee’s criticism of the CQC. On 18 May 2009, in a letter to me following my criticism in the House, it affirmed its view. Four years ago, it said:

“we are concerned that … inspectors judge homes as delivering an adequate standard of care even when they are failing to meet national minimum standards for care homes”.

We were assured that that was going to be stopped. It has not been stopped under the structure that was established. The letter continued:

“the overall number of inspections of care homes has reduced. Homes that are failing to meet minimum standards are now inspected less often than used to be the case”.

We know that over the past 10 years, there has been a steady decline in the inspection of care homes nationally. We were told when the Act was passed in 2009 that it was going to be a risk-based system with a minimum of one inspection every three years. We know what a disaster that has been. We need an absolute minimum of unannounced inspections of care homes of at least twice per year, irrespective of the grading and irrespective of the ratings that have been applied to a particular home, because we all know that the management of a home can change over months, weeks or even overnight, and the home may drop in ratings dramatically as standards of care fall, depending on the financial considerations of the management of those homes.

The 2009 letter to me, four years before we stand here now, continued:

“requirements made by inspectors for action to improve care homes are often not met, there is little evidence of systematic follow-up by inspectors and requirements left unmet from one inspection to the next are common”.

That has happened over and over again over the past four years, and I am convinced that it will carry on happening until we set clear targets and a requirement of two unannounced inspections annually with a proper rating system, which is precisely why I support the amendment tabled by the noble Baroness, Lady Greengross, on the need for a pilot system for inspections.

I would now like to place on record the latest views expressed by the Relatives & Residents Association about what it believes the new structure should be. I do so because I understand that under the provisions of the Bill, the CQC will itself, following consultation with Ministers and others where necessary, be taking decisions on those very important areas. What does the Relatives & Residents Association say? I think that what it says should be implemented. It calls for the,

“reinstatement of regular twice-yearly inspections of all care homes to ensure compliance with regulations and standards. This case and others show that CQC needs to listen, record and act quickly on complaints which show older people are not receiving”,

the quality of care they should receive.

I add at that point that we are talking about complaints. I could never understand why we established the CQC without a proper complaints remit. According to the Relatives & Residents Association, people ring up to complain about the fact that the CQC is not dealing with complaints. The CQC says, “We do not deal with them, you have to go to the local authority”. The structure is wrong. The CQC should be the body that deals with those matters and should be given that responsibility. The association calls for investment and more and better training of all care home staff, with vastly improved training in leadership skills of care home managers and operators and up-to-date inspection reports which are easy to understand, with any action required by the provider clearly highlighted. It also wants to see:

“Care homes focusing on individual care rather than putting pressure on staff to complete daily tasks such as dressing and feeding.

Statutory registration of all care workers”—

a matter that we were dealing with on the last occasion we met as a Committee—

“by a professional body which can set standards for competence and hold individual care workers to account for their own practice.

The reinstatement of specific standards for care homes for older people”.

That might seem a particularly substantial agenda. However, if the Select Committee’s views on the ageing population are true and there is going to be a vast expansion of the care business in the future, more and more homes will have to open to deal with that increased population. We should be setting in place in this Bill a structure that is capable of dealing with that expansion in care. If we do not, we will be back here again in five years’ time arguing about a deficiency in the system. If I am still alive, I will be on my feet again complaining about the fact that the Bill we introduced in 2013 miserably failed. That is the route that the Government have set out to go down. Unless they make the resources available to address this, the CQC will inevitably fail again.

[Baroness Howarth of Breckland]

My Lords, I had not intended to speak in this debate and will do so briefly. We need to allow the CQC time to settle down under its new management. We should also remind ourselves of the rest of the history, because it is important to put it in context.

I was the deputy chair of the National Care Standards Commission, the first organisation that brought together the inspectorates for homes under the previous Government. It was also the previous Government who, after two years, made the decision concerning the organisation—which had been quite successful. It had established a baseline of inspection. It had integrated the inspectorates, which several other organisations which had tried to integrate the different teams had failed to do. Like other noble Lords, I would also cite CAFCASS in that regard. The commission did all of that. We should remind ourselves that it was only a year later that the previous Government announced through a newspaper, not directly to the staff, that the organisation would be merged with CSCI.

The merger took place and I think that it was extremely successful. David Behan was involved in ensuring that it went well. CSCI then took on the starring system which was put into place and was having some success. By that time, we had closed 400 poor establishments. The work was continuing in terms of co-operation when it was again decided that there should be a restructuring, this time to bring the inspectorate into health.

I think that we have two lessons to learn. The first is not to restructure yet again on a political basis. If there is good leadership and the lessons have been learnt, let the organisation settle down. The second lesson is clear. If you are going to inspect anything, you need to have the expertise within the teams to carry out the inspections. Again under the previous Government, it was a sort of theory that if you had somebody other than a nurse looking at nursing, a social worker looking at a social work establishment or a teacher looking at teaching—indeed, you usually did have teachers looking at teaching; that always seemed to be an exclusion—then you could get a better answer than if you had a professional do it.

I think that the present leadership at the CQC has learnt that lesson and understands that you need the professional expertise to know what you are looking for, although that should certainly be cross-checked by independents. I hope deeply that we will be able to keep that steadiness, because I understand absolutely what happens to organisations when they are in constant flux and change.

Perhaps I may make one other point while I am on my feet. I support anything that we can do about integration. We have singularly failed to reach some complex conclusions about how health and social care can truly be put together for the benefit of those who are the recipients of that care. We should ensure that we put into the Bill whatever we can about integration. I would support all of that.

--- Later in debate ---

[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.

--- Later in debate ---

[Lord Campbell-Savours]

My Lords, I shall refer to the report of the Public Service and Demographic Change Committee. Members of the House who have not read the report should do so because it is a fascinating document. It is probably one of the best documents to come out of the House of Lords for many years. On the question of Dilnot, to which I am opposed but I shall explain that later on in the Bill, paragraph 193 states:

“The major gainers will be the relatively better-off, who will be protected from depleting their housing assets”.

In other words, potentially we will be spending in the longer term money that could have been raised in taxation. We are losing that revenue at a time when the same report refers to the deteriorating ability of the state to help people who are in need of medical services. It refers to the fact that the number of people aged over 75 is expected grow from 5.4 million in 2015 to 8.8 million in 2035. It refers to the fact that the demand for hospital and community service spending by those aged 75 and over is, in general, more than three times the demand from those aged between 30 and 40. We have higher demands from the elderly, more people falling into the groups that are liable to want the services historically provided by local authorities and the state, and yet, at the same time, with these Dilnot proposals, over a period of time we will be handing back money to the taxpayer to which, in my view, the taxpayer has no right.

The report says that the number of people in England with three or more long-term conditions is predicted to grow from 1.9 million in 2008 to 2.9 million by 2018. It is forecast that the number of people in England and Wales aged 65 and over with dementia—we all know the care requirements of people with dementia—or moderate or severe cognitive impairment will increase by over 80% between 2010 and 2032 to 1.96 million. The report goes on to say that it is estimated that by 2022 the number of people in England aged 65 and over with some disability will increase by 40% to 3.3 million.

As I understand the amendment of the noble Lord, Lord Best, he is simply saying, “Hang on a minute, before we start spending money, we should take stock of what is available in the longer term. Can the state afford to pay all the bills that are to come? Has that work been done?”. I hope that the noble Earl will seek to give the Committee those assurances because if the work has not been done and the predictions of some have not been taken into account, it may well be that the amendment of the noble Lord, Lord Best, is relevant. Let us defer much of this expenditure until we have sorted out the budgeting.

[Baroness Campbell of Surbiton]

My Lords, I had thought that I would not respond to the amendment of the noble Lord, Lord Best. However, I feel I must because there seems to be a missing voice in this debate—the voice of the thousands of people who use social care, over 70,000 of whom receive some form of direct payment. Ten years ago, when direct payments were successfully introduced and allowed disabled people to live independently in this country, we were proud to be employers. We were able to employ RPAs at a good rate, with holiday pay, and we were able to advertise. We were equal to those who employed individuals in their own companies. Ten years on, many cannot even give holiday pay and cannot advertise. They fall back on costly social care services or enter hospital as a result of not being able to employ assistants.

We, too, want to know the costings before new services come into effect. Disabled people may have to accept these services and find that they lose choice and control over their lives. So please do not forget the voice of those who say, “We, too, wish to know that the money is settled. We, too, need a voice to remind people that, in order for us to employ or control our services, we must feel that we can do this with equality and dignity and do it absolutely properly”. Otherwise independent living will become just a memory.

--- Later in 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.