Sexually Transmitted Infections: England

Lord Cashman Excerpts

Thursday 5th September 2019 Lords Chamber

[Lord Cashman (Non-Afl)]

My Lords, I remind your Lordships that I intervene as a non-aligned Member of this House and declare my interest as a patron of the Terrence Higgins Trust. I thank the Minister for her response to the Question. What progress has been made towards PrEP being routinely commissioned for all who need it before the end of the trial in 2020? Does she agree that PrEP needs to be made available as part of routine sexual health services from April 2020 and that no gay or bisexual man should be discouraged from being placed on the PrEP impact trial?

[Baroness Blackwood of North Oxford]

The noble Lord will agree that this Government have shown significant commitment to the roll-out of PrEP since the start of the PrEP impact trial in October 2017. Over half of the 26,000 places have been filled, which is welcome progress. The trial is scheduled to continue until autumn 2020 and work is now starting to consider future commissioning for PrEP after the trial has ended.

Sexual Health Services

Lord Cashman Excerpts

Thursday 29th November 2018 Lords Chamber

Asked by

[Lord Cashman]

To ask Her Majesty’s Government what assessment they have made of the impact on public health outcomes of people being turned away from sexual health services, as reported by the British Association for Sexual Health and HIV.

[Lord Cashman (Lab)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper. I refer your Lordships to my registered interests; in particular, I am patron of the Terrence Higgins Trust.

[The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord O’Shaughnessy) (Con)]

My Lords, local authorities in England commission comprehensive open-access sexual health services based on the needs of their communities. Services have responded to meet increased demand, with attendances at sexual health services increasing by 13% between 2013 and 2017, from 2.9 million to 3.3 million.

[Lord Cashman]

I thank the Minister for that response. Much has indeed been achieved but there are worrying trends. As we know, sexual health services are funded by local authorities, which have endured reduced funding year on year and, to maintain other essential services, councils have disproportionately cut funding to sexual health services. Clinics have closed, staffing levels have reduced and capacity has reduced further because walk-in sessions have been replaced by appointment-only sessions that cap demand. The overall effect has been to reduce access to screening and treatment, with subsequent increases in sexually transmitted infections and considerable public health impacts, notably infertility, teenage pregnancy and HIV transmission. I therefore ask the Minister, in the context of these worrying developments, how the Government will ensure that councils maintain an adequate level of comprehensive sexual health service provision.

[Lord O’Shaughnessy]

I am grateful to the noble Lord for raising this important issue. First, it is worth saying that the public health grant to local authorities is ring-fenced, and that is meant to provide for sexual health services among others. He mentions STI rates and says attendances have increased. I know that service configurations are happening and there are changes in different parts of the country. It is important that attendances have increased. I think there is a mixed picture on ST infections; some are increasing but there is good news. The noble Lord mentioned teen pregnancy—not that that is a sexually transmitted disease, of course—the rates of which are down. HIV diagnoses are down and we see a positive picture in the new data today, so there is cause for optimism. As we look to the future in the spending review, we will be making the case for improved services at sexual health clinics through the public health spend.

Mental Capacity (Amendment) Bill [HL]

Lord Cashman Excerpts

Committee: 2nd sitting (Hansard): House of Lords
Monday 15th October 2018 Lords Chamber

[Baroness Finlay of Llandaff]

I would like to intervene for a moment as I think this has been a valuable debate, even though short. I shall pick up on the point made by the noble Baroness, Lady Barker, on conditions, which are incredibly important. She cited one example, and I return to the musician to whom I referred earlier. Most professional musicians will feel that their instrument is an integral part of their own personality. If they lose speech, they will communicate through their instrument, especially their mood—their feelings, responses and so on—so it is a terrible deprivation of liberty to separate a musician from their instrument.

If the musician plays a trumpet or another loud instrument and they are in a care home, it will be important to find somewhere they can go to play their instrument without disturbing everybody else. It sounds humorous but it is incredibly important to people. I was struck when I visited a care home some time ago and saw a man playing a piano. I thought he was a volunteer brought in to play—beautifully—to people. When he finished playing, I started to engage in conversation with him and it became clear that, while his recall for the symphony he had been playing from memory was superb, he could recall or discuss remarkably little else from which I could gain a modicum of sense. As a result, we had a bizarre conversation, other than about the symphony.

Conditions are absolutely essential. My hope would be that, in the code of practice, we require conditions to be put into the care plan that must be enacted on a daily basis. This should not be just a set of recommendations that could be ignored. My concern is that we link care planning to the delivery of care; that is extremely important.

I was grateful also for the support—albeit somewhat tentative—from the noble Baroness, Lady Tyler. I draw a distinction between the care manager and the care home manager. The care manager should be the person overseeing the direction of care planning; they could be the district nurse for somebody at home, or whoever runs the supported living environment on a day-to-day basis and looks at alterations in the care plan.

In a large care home, the care home manager often manages the building and the staff. They make sure that regulations are maintained and that the lifts work, dealing with all the things that happen on a day-to-day basis, but can have remarkably little contact with individuals. I do not want to sound disrespectful to care home managers when I say that I would envisage their co-ordinating role as much more like that of an administrative secretary, rather than as somebody who gets information directly from the person or the family. However, I would want them to make sure that the family had been consulted, that all the people who cared about the person had been spoken to and that that information was properly documented, with a package being put together for the local authority to inspect. I believe that the local authority will know which care homes on their patch are working well and which need an eye to be kept on them. I think I have half given my response to the Minister’s response.

[Lord Cashman (Lab)]

My Lords, before the Minister gets to his feet, I want to thank the noble Baroness, Lady Finlay, for that clarification. Precisely those concerns about the role of the care manager and the care home were put to us when we met 30 or so representatives from the different services. They also dealt with the potential conflict of interest. As was said earlier by the noble Baroness, Lady Murphy, there are always conflicts of interest in professional fields. Here, we are dealing with a conflict of interest around someone’s deprivation of their liberty, and we need to get it absolutely right. With that clarification, I say that the amendments make us think again about precisely how we can deal with the backlog and how we can be effective but give the individual the rights and protections they deserve.

Finally, I also thank the Minister for his early intervention and assurances around the inclusion of 16 and 17 year-olds and on the phrase “unsound mind”, which I raised during our first day in Committee. I hope that I have not detained him from his notes.

[Lord O'Shaughnessy]

I am grateful to Members of the Committee for their sympathy and for giving me breathing space. I was flustered by flipping forward and almost missing out this group of amendments.

As the noble Baroness, Lady Finlay, said, the issue of concern is the distinction between the person who is responsible for somebody’s care and the person who manages a care home—they are of course different. What we are trying to get right here—I understand that this is what the amendments are exploring—are the relevant responsibilities of those people, bearing in mind that we want to integrate liberty protection safeguards into the process of care planning.

The noble Baroness, Lady Barker, knows huge amounts about this topic and I very much respect her opinion. She pointed out that DoLS assessments are different from assessments under the Care Act. There are some overlaps. As she will know, there are similar questions or parts in both assessments concerning consent, for example, but she is right that they are different types of assessments. I want to explore whether her or indeed the Committee’s concern is that those assessments should not be carried out by care home managers or whether—a more positive view—they should be carried out by certain types of professional. Those are subtly different points. Perhaps I may give her the opportunity to respond in a moment, as I am really keen to explore this matter.

Clearly, we are trying to make sure that those who have the professional expertise to carry out certain types of assessments do so. Equally, we are trying to make sure that a co-ordinating body has responsibility for ensuring that these assessments are carried out in a proportionate way and are included with care assessments in an overall care plan, with people being answerable to the relevant regulatory bodies. If the noble Baroness would not mind, I would be grateful if she, along with other noble Lords, gave her perspective on that. I want to make sure that we determine the appropriate role of the care home manager.

Health: Contraceptive Services

Lord Cashman Excerpts

Thursday 11th October 2018 Lords Chamber

[Lord O’Shaughnessy]

Local authority budgets will of course be a matter for the spending review that will take place at some point during the next year.

[Lord Cashman (Lab)]

My Lords, I have raised this with the Minister on previous occasions as patron of the Terrence Higgins Trust. I share the concerns of my noble friend Lady Thornton that the vulnerable groups who need access to sexual health services are at the moment being denied that very access. Does he agree that a lack of access for these vulnerable groups will impact negatively on the health of the nation?

[Lord O’Shaughnessy]

I agree that there can be a negative impact. Indeed, one of the things that Public Health England has done recently is publish a consensus statement about sexual and reproductive health policy and actions, and it is updating its action plan. Nevertheless, it is important to point out that there were more attendances in clinics in 2017 than in 2013, which shows that it is possible to get appointments to be seen.

Mental Capacity (Amendment) Bill [HL]

Lord Cashman Excerpts

Committee: 1st sitting (Hansard): House of Lords
Wednesday 5th September 2018 Lords Chamber

[Lord Cashman (Lab)]

My Lords, I start with an apology, as I have not spoken on the Bill before. I thank, in particular, POhWER, the organisation of which I am a patron, for alerting me to the Bill and to its concerns, as well as the concerns shared by a wide range of groups, including Liberty, Age UK, Mencap and so on.

As other speakers have outlined, it is essential that we get this absolutely right, because we are talking about potential deprivation of liberty. According to those organisations, people with dementia or a learning disability are at risk under the proposed changes. Therefore, I speak in support of Amendment 1, proposed by the noble Baroness, Lady Finlay, and Amendment 20 in the name of my noble friend Lady Thornton. I believe that this amendment would ensure that the views of the donees and deputies already appointed by cared-for persons to make decisions in their best interests were given appropriate weight with regard to where the cared-for person resides for care and treatment.

I will say no more than that because there are experts on this issue in the Chamber. I sit willing to support but more willing to listen and learn.

[Baroness Barker (LD)]

My Lords, I apologise for being slightly late. I was taken by surprise at the swiftness with which we concluded our previous business.

I thank the noble Baroness, Lady Finlay of Llandaff, for many of the points that she made in her speech. It took a lot of work to get the concept of an advance statement on wishes into this legislation, and I, like her, regret that it has not been more widely adopted or accepted, particularly by the medical profession. She will know that when the Select Committee reviewed the legislation, one of the biggest disappointments was the extent to which the Mental Capacity Act had not been understood by the medical profession. She will perhaps remember that when representatives of different parts of the medical profession come to talk to us, they began by saying that in an A&E department it is extremely difficult to work out somebody’s advance decision. We knew that when we passed the initial legislation, but that legislation was not meant solely to take its lead from that; it was meant to apply to a whole range of matters just within medicine. It is a shame that the medical profession still relies on a very conservative interpretation of the existing legislation and takes a read-out from emergency situations when it really should not, as there is plenty of time to discuss with the person what is happening and to understand their previously stated wishes and feelings.

I am glad that the noble Baroness has raised this issue. She is right that at the heart of the Bill is a fundamental change from the Mental Capacity Act. There will no longer be a whole series of decision-specific assessments of people who lack capacity, and that is not something that I object to. Over the last few years while this legislation has been in place, we have quite often found people being subjected to unnecessary assessments. It is quite clear that when somebody has a medical assessment for advanced dementia, say, they will not have the capacity to make the same decision, even though they go to live in a different place. I accept that it is possible to make a decision of a lack of capacity and to carry that forward throughout a person’s care. What I am not clear about, though—given that people will be subject to fewer assessments, and therefore be less likely to have changes in their conditions brought to light—is the extent to which that will interplay with somebody’s statement of advance wishes. I would rather like it if the Minister, in his response, could talk about how that will work.

I agree with the noble Baroness, Lady Finlay. The safeguards on liberty and safeguarding have been thoroughly confused by many people. That is fundamental. Whether we turn this around from safeguards against deprivation of liberty or safeguarding the liberty of somebody, I do not think that anything I have seen in the Bill has yet addressed that fundamental misunderstanding. In fact, in some cases, it probably compounds it. I want to put that on record as we discuss the many issues the noble Baroness, Lady Finlay, has introduced so well.

--- Later in debate ---

[Baroness Murphy]

My Lords, I support this amendment. As the noble Baroness, Lady Thornton, has already said, the Royal College of Psychiatrists feels strongly that this would clarify decision-making. There may be issues arising from the fact that when the Bill was being put together we had not yet had the Birmingham judgment, which is why we are not quite there yet. However, having the four regimes that we currently have to choose from for this age group makes it very difficult to make appropriate choices. This would clarify it. It was strongly supported by the Law Commission in its first recommendations, and I support it.

[Lord Cashman]

My Lords, I too support Amendment 2 in the name of my noble friend Lady Thornton, and the consequential amendments. I am grateful to her for bringing her personal experience to this and reminding us of the young individuals involved. This amendment and the subsequent amendments are to be welcomed. By including 16 and 17 year-olds, it offers better safeguards to those who are not served well at the moment. The amendment would see 16 and 17 year-olds protected by the LPS. It would simplify the system, would bring clarity and ensure that their rights under Article 5 of the European Convention on Human Rights were therefore protected. For those reasons and many more, I support this amendment and the subsequent amendments.

[Baroness Tyler of Enfield]

My Lords, I rise briefly to support this group of amendments. I strongly support bringing 16 and 17 year-olds within the scope of the Mental Capacity Act, and support the proposed amendments to the authorisation and safeguards scheme. I will raise a couple of points, and I would be grateful if the Minister were able to provide some answers or reassurance.

First, clarity will be needed on the role of those who currently have parental responsibility, and how that will fit in with the proposals that are being put forward. Secondly, we need to make sure that there is a fully co-ordinated and joined-up approach across a number of different pieces of legislation. I have already talked about the join-up between the Mental Capacity Act and the Mental Health Act, but I am conscious that, when we are looking at 16 and 17 year-olds, we need to look also at other legal mechanisms that authorise a deprivation of liberty, such as Section 25 of the Children Act 1989, and at how the model dovetails with legal frameworks for the provision of care and support, such as education, health and care plans under the Children and Families Act 2014. So I would ask for some reassurance that someone is looking at the join-up with other relevant bits of children’s legislation.

--- Later in debate ---

[Baroness Tyler of Enfield]

My Lords, the essence of this amendment is about language and use of language—in particular, the term “unsound mind”. I think we would all agree that language is important; it sends very important signals. Many noble Lords raised this point with passion at the Second Reading debate. I was pleased that the Minister’s helpful letter of 24 July referred to the debate about “unsound mind” and made clear that the Minister was sensitive to the points made and would welcome views. I guess this amendment is my way of putting forward my views.

The fact remains that, despite growing awareness and acceptance of mental illness, stigma and discrimination remain a regular experience of people with mental illnesses and their families and can put people off seeking help. We were given to understand that the use of the term “unsound mind” within the Bill was to ensure that it was in line with the ECHR—but this was written in the 1950s. Many people, both inside this Chamber and outside, have expressed serious concerns about the inclusion of this language in the Bill in 2018. Frankly, it perpetuates very unhelpful negative stereotypes. I would contend that the phrase “unsound mind” is out of place in today’s society; it is out of place in legislation being looked at in 2018; it is stigmatising and has no clear clinical meaning; indeed, I would say it is offensive to many.

Therefore, my amendment proposes that, in paragraph 2(2)(c) of Schedule 1 to the Bill, the term “is of unsound mind” is replaced by “has any disorder or disability of the mind”. This terminology is already a well-established term in the Mental Capacity Act and has proven to be compliant with the ECHR without, in my view, having anything like the same stigmatising connotations of “unsound mind”. A disorder or disability of the mind, I am informed by the Royal College of Psychiatrists, has a clear clinical meaning. It is well understood by clinicians and should be no more stigmatising than saying someone has a physical disability.

I am aware that the BMA, which supports not using the term “of unsound mind”, has put forward a proposition that this term should be reconsidered and experts and patient groups consulted to find an alternative to it. The BMA may be right, but I felt that, for my starter for 10, I wanted to put forward terminology that I thought was right. I am sure that others will be able to improve on it.

To conclude, above all this Bill must put the people most affected centre stage—that means some of the most vulnerable people in society, as we have already heard. In my view, it is simply not good enough to continue using terms that lawyers and drafters of legislation may find helpful—it might help them fit things in with other bits of legislation and other conventions—but which causes harm and distress to those we are all trying to help. I believe there is a real and welcome opportunity to change the narrative and discourse in a positive way, and this amendment is a way of taking that opportunity.

[Lord Cashman]

My Lords, it is a great pleasure to support this amendment. Language is crucial. Several times during the day I question whether I am of sound mind, and I think that the concept of unsound mind is extremely dubious. I welcome the amendment from the noble Baroness, Lady Tyler, because it seeks focus and clarity, substituting for “is of unsound mind” the words,

“has any disorder or disability of the mind”.

I believe that the Royal College of Psychiatrists has supported this approach. The BMA also suggests that there should be a different approach because the term “unsound mind” reinforces stigma and discrimination, and equally it is outdated. Its continued use merely perpetuates negative stereotypes of vulnerable people, particularly when we are trying to get over those stereotypes in order to get people to speak more openly at the beginning of their problems—our problems—with mental health issues. Therefore, it is a pleasure to support this amendment.

--- Later in debate ---

[Baroness Watkins of Tavistock (CB)]

It might be complex to find the right nomenclature, but I heard the noble Baroness, Lady Tyler, say that this was a starter for 10. I cannot see why we have to regress to 1959 language in the Mental Health Act without further exploration of whether we could redefine the term about perhaps affecting the mind, to take in that very small minority of people with severe physical illness that occasionally affects the mind. We have worked so hard to destigmatise both learning disability and mental health that it seems very sad that we cannot work a bit harder at this point on this issue.

[Lord Cashman]

I want to reaffirm the point made by the noble and learned Lord, Lord Woolf. Surely it is not beyond the wit of drafters and our legal experts, when referring to the starter for 10 offered by the noble Baroness, Lady Tyler, to refer to the European Convention on Human Rights and the jurisprudence arising from the European Court of Human Rights? It seems to me that it is elegantly simple to take such an approach, reassuring the rights that relate to the “unsound mind” in relation to the new definition offered. I hope my intervention makes sense—it is not often best practice to speak on the hoof on such legal matters. I hope that noble Lords will forgive me if I have not made sense.

HIV Prevention Services: Public Health Funding

Lord Cashman Excerpts

Thursday 30th November 2017 Lords Chamber

Asked by

[Lord Cashman]

To ask Her Majesty’s Government how reductions to the public health grant since 2015-16 have affected access to sexual health services and HIV prevention services, particularly in London, for (1) men who have sex with men, and (2) people from black and minority ethnic groups.

[Lord Cashman (Lab)]

My Lords, I beg leave to ask the Question standing in my name on the Order Paper and refer to my entry in the register of interests, particularly as patron of the Terrence Higgins Trust.

[The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)]

My Lords, the UK is one of the first countries to witness a substantive decline in new HIV diagnoses in gay and bisexual men. Between 2015 and 2016, new HIV diagnosis fell by 21% across the UK and by 29% in London due to reduced transmission of HIV. New diagnosis in heterosexual black, Asian and minority-ethnic groups fell by 16%, mostly due to changing migration patterns.

[Lord Cashman]

My Lords, I thank the Minister for that response. Great progress has been made and I pay tribute to all those concerned, but there is concern at the cuts seen in HIV support services and sexual health services across the United Kingdom, not least in the two areas with the highest prevalence of HIV, Lambeth and Southwark, through to Oxfordshire, Portsmouth and Bexley. How are the Government working with local authorities in England to ensure that such services are fully funded and meet the needs of local communities at risk of HIV? Furthermore, what steps are they taking to ensure that people living with HIV have access to support services that fully meet their needs?

[Lord O'Shaughnessy]

First, I pay tribute to the work of the Terrence Higgins Trust and its leadership in this area in making progress in the UK in dealing with the HIV/AIDS epidemic. The delivery of open access to sexual health services is mandated for all local authorities, which are funded to do so by the public health grant. It is incredibly important to point out that over the last four years there has been a 500,000 increase in the number of attendances at sexual health clinics, and more testing and treatment is taking place. That is starting to show in the reduced number of diagnoses, as well as in other factors. It should also be pointed out that as regards looking after those suffering from the consequences of HIV/AIDS, the Care Act 2014 is extremely clear that the legal framework for social care applies to adults, including those who live with HIV.

Older Persons: Human Rights and Care

Lord Cashman Excerpts

Thursday 16th November 2017 Lords Chamber

[Lord Cashman (Lab)]

My Lords, I refer your Lordships to my interests in the register and to my date of birth. I congratulate my noble friend Lord Foulkes on securing this important debate and on his excellent report. Of course, the noble Lord, Lord Balfe, will remember that I was one of the co-rapporteurs on the framework directive of 2010 from the European Parliament on combating discrimination on access to goods and services on the grounds of age, disability, sexual orientation or gender. That is still resting and blocked by Governments who do not want to take the necessary action—so there needs to be taken at national level on this important issue.

The reality is that we are failing many older people when they need us most. The Care Quality Commission’s annual state of care report of 2017 found that only 2% of adult social services were rated outstanding: 78% were good, 19% required improvement and 1% were rated as inadequate. Before we congratulate ourselves, let us remember that the 1% represents 303 locations and approximately 16,000 individuals whose care was inadequate.

The report also, importantly, reveals wide variations in quality ratings between different types of homes and services. Community social care services were rated the best overall when compared with other services. Domiciliary services and residential homes received similar ratings. However, nursing home services received the worst ratings, with 68% rated as good, 28% as needing improvement and 3% as inadequate. Within these stark statistics are hundreds and thousands of vulnerable adults whom we are failing.

I am pleased to be reminded by the noble Lord, Lord Haskel, of the issue of human rights that is predominant in this Motion. That is why I turn specifically to the issues of human rights and discrimination and other issues faced by older people—in particular, people living with HIV. The Terrence Higgins Trust report, Unchartered Territory, surveyed nearly 250 people living with HIV across the UK, all of them aged over 50. Some 58% of respondents were defined as living on or below the poverty line. Over one-third of individuals living with HIV were reliant on social security payments. Some 84% were concerned about future financial difficulties and a third of respondents were socially isolated. Some 79% were concerned about memory loss and cognitive impairment in the future and how they would cope with managing multiple health conditions.

The challenges are many and varied. There is a difference in needs and experience, depending on whether an individual was diagnosed before antiretroviral drugs were available or after. Individuals diagnosed before treatment was available were more likely to have more additional health conditions. Social care is not currently meeting the needs of people living with HIV as they grow older because they face the prospect of managing multiple long-term conditions that are made more complex by their interactions with HIV. Even those who have been able to access social care have faced discrimination from social care professionals due to their HIV status. This discrimination is fuelling myths and stigma around HIV by treating people living with HIV differently from other social care users.

The Minister and his department will also need to address discrimination faced by older LGBT people. Care providers need to recognise and respect LGBT identities and should ensure that LGBT identity is not marginalised, nor rendered invisible, and that LGBT elders are not outed deliberately or inadvertently. There are human consequences to this. Unfortunately, the problem, as evidenced in the Stonewall/YouGov research, Unhealthy Attitudes, found that a quarter of health and social care staff had never received any diversity training at all. Some 72% had not received any training on the health needs of LGBT people and, shockingly, only a quarter of staff had received any training on trans people’s healthcare. The training of health and social care staff in understanding and engaging with the particular needs of LGBT+ people is an important and deliverable objective to improve the quality of life of these people.

Time does not allow me to offer the House further examples, but I ask your Lordships to imagine what it must be like to once again have to validate your life, your love and your relationships at a time when you are vulnerable and when these have been, and should remain, the one constant in your life.