Care Bill [HL]

Debate between Lord Turnberg and Baroness Hollins

Monday 10th June 2013 Lords Chamber

[Lord Turnberg]

My Lords, after that tour de force by my noble friend Lord Campbell-Savours, there can be hardly anyone who does not believe that the training of healthcare assistants should be mandatory. Indeed, most of the public would be surprised to know that they are not trained or may at least get through without any training whatever.

I strongly support the amendments. They are a slightly less strict version of Amendment 16 from the noble Baroness, Lady Greengross, in that it focuses heavily on the mandatory nature of the training, and that is of course the basic requirement. It omits the need for statutory registration, but the case for mandatory training is incontrovertible; I cannot see anyone believing that it is not.

I hope that the Government are open to this proposal. It is a valuable step in the right direction, even if we cannot have registration at the moment. I sincerely hope that the Minister will be open at least to this proposal, which has such merit and such strong support from almost everyone; I do not know of anyone who argues against it. I do hope that he might see this sympathetically.

[Baroness Hollins]

My Lords, my interest is as the parent of two adult disabled children who receive publicly funded care. I did not speak to the earlier amendment on the need for the regulation of health and social care assistants, but I strongly believe that some such staff are currently poorly served by the lack of an adequate professional framework. Many have poor pay and variable conditions of work, and perhaps poor protection for themselves. They also have varying access to training, supervision and education.

To give one example, a care assistant was employed to work with an autistic person without receiving any autism-specific training, even though it was specified in a support plan. One would hope for some basic mandatory training that also specified what future training might be needed to support specific people with specific needs. That seems to be common sense.

My noble friend asked clearly for mandatory training in basic standards of care, and that these candidates should then be registered as suitably trained. It is a neat solution to the problems that we are facing and it makes very good sense. I have one more example: in the interests of more integrated health and social care, care assistants are often required to support disabled or elderly people to access healthcare, but they are not very good at doing that. The confidential inquiry into the premature deaths of people with learning disabilities found that it was often the lack of persistence of people who were supposed to be supporting learning-disabled people that led to a failure in follow-through of their healthcare investigations and treatment.

I have a question about how personal assistants employed directly by people who are in receipt of direct payments would fare under such a system. Disabled people would need assurance that the personal assistant applying to work with them also had basic skills. One would hope that disabled people employing personal assistants would be reassured by the knowledge that someone had been registered as having a certificate of basic standards of care. I add my support to these very good amendments, particularly Amendment 23A.

Health and Social Care Bill

Debate between Lord Turnberg and Baroness Hollins

Monday 27th February 2012 Lords Chamber

[Baroness Hollins]

My Lords, I support the amendment, particularly because it draws attention to the point that often patients experience prolonged psychological harm after an incident, something that is not well understood across the whole of the medical field. Such psychological harm is often overlooked. However, there is plenty of evidence that an honest and prompt apology can do so much to help the person and their family going forward. It is fair to say that delaying a response is very much like denying a response. The timeliness of a response is critical.

[Lord Turnberg]

My Lords, As someone who taught medical students for many years that it is very important to be absolutely open and candid with your patients, and that, if something has gone wrong, to explain it in full to the patients and their relatives—explaining that that is not necessarily an admission of guilt in some way—I am very keen on the sort of sentiment that is being expressed in this amendment. I am particularly keen on the GMC imposing on doctors the duty of being open. I am all behind the sentiments of this amendment. I have some anxiety, though, about how this can be put into law. How can you legislate for someone to be candid? How will it work? How do you know that someone has been candid or not? There is a great deal of subtlety about this candour and about putting it into law as a duty on every occasion. I am slightly apprehensive about the amendment, even though I support everything about the principle.

Health and Social Care Bill

Debate between Lord Turnberg and Baroness Hollins

Tuesday 22nd November 2011 Lords Chamber

[Lord Turnberg]

My Lords, I will speak to Amendments 103, 104A, 106, 135A, and several of the others in this group. Clause 20, new Section 13M, highlights integration of services as something the Commissioning Board should “exercise its functions” to secure,

“where it considers that this would—

(a) improve the quality of those services”.

That is all well and good, but by itself it seems insufficient. Integration is of course difficult to pin down. We have heard quite a bit about that this evening, and I will not repeat those remarks. I know what I mean by integration, so I will give you my particular understanding, for the purposes I want to talk about, using the term to mean a seamless service for those patients, usually elderly and with multiple diseases, who need both hospital and community care, and flit between the two.

It is unfortunately the case that the integration that is needed between health and social services has seen so many failures and been so elusive, despite many wasted words. We have an opportunity here to correct these failures, so I was somewhat disappointed when the Minister said in the debate on 2 November, when we were discussing the role of the Secretary of State, that the Government were,

“not in the business of dictating the processes”—

and that—

“integration is neither a necessary nor a sufficient condition of a good outcome”.—[Official Report, 2/11/11; col. 1334.]

Surely if integrated care is a good thing—and I think few will deny that—then we must give a lead on how it might be achieved. We cannot ignore the process, and must at least try to see what conditions are necessary for successful integration. We should not go around simply saying it is a good thing, without showing how it might be achieved.

There are many examples out there that we can build upon. We are not entirely in uncharted territory. The noble Baroness, Lady Cumberlege, mentioned Assura Cambridge and services in Torbay in our last debate, and other noble Lords spoke of Kaiser Permanente, Northern Ireland, personal health budgets and information sharing, as valuable means to an end.

We also have the excellent report from the Nuffield Trust, Integration in Action, that analyses successful integration being carried out in four places across the world, including in Scotland. We are not working in a vacuum, and we could and should take advantage of all this information, and incorporate some of those ideas in the Bill without waiting for yet further work.

Of course, not everything can or should be put in the Bill, but we should see where we can strengthen it, by including more pointers to how we can improve the present, very unsatisfactory, position. Let me give some examples, leaning heavily on the Nuffield Trust report. First, the Commissioning Board should point the way by developing commissioning for bundled payments, and local tariffs for key conditions. I think that is possible. At the moment, fees for service for episodes of hospital care, as we have heard, work against integration with community service. That is something that the board should seek to redress quickly.

Secondly, we should design the national tariffs that we have heard about, which incorporate a full care pathway across the health and social service divide. Monitor and the board should work together to develop a pricing strategy that provides the incentives for integration. They should also develop ideas about how outcome measures, which are admittedly difficult to quantify when we are talking about a complex system like integrated care between hospital and social care, can be used to promote integration across the whole pathway of care. Contracts based on those measures can encourage providers to respond to the need to integrate. There is nothing here that obviates competition between providers, which I am sure will please my noble friend Lord Warner.

We will come later in the Bill to Monitor, but it too should link improvements in outcomes, including the patient’s experience, to the way it regulates integration. Then, there are several measures that clinical commissioning groups and local authorities should be encouraged to develop by the Commissioning Board. One huge area is of the improvements we desperately need in the flow of information between hospitals and community. Too often we rely on phone calls on the day of discharge, which is inefficient and fails most of the time. We should have an IT system which allows information to be shared across the divide. It only requires a competent programmer to produce the programme, and a safe system for preserving patient confidentiality and data protection. I am sure that that is not beyond our capacity.

There is also the need for joint funding and integrated governance arrangements, which we have had some discussion about. This is much easier said than done, but it can be done. We have seen it in action here and there and we must spread the good practice.

There is also the need for people to make the whole thing work on the ground: for example, liaison officers whose sole responsibility is to ensure that patients pass seamlessly across the divide, and nurses and doctors who move without constraint from one sphere to another. The example of specialist district nurses is a good one. They follow patients from hospital to the community and back, and are very much appreciated. Unfortunately, they are a threatened species and are disappearing, largely because neither the NHS nor local authorities will fund them. We must get around that problem.

Of course, much of what is needed depends on a change in the mindset of those working at the coalface in hospitals and the community. If through the Bill we can change the conditions from those that inhibit collaboration to those that encourage it, we can begin the process. The amendments bring a greater sense of the need to focus more strongly and urgently on the duties and responsibilities of the board in putting integration more firmly on the map as a way of improving outcomes. I support them strongly.

[Baroness Hollins]

My Lords, I will speak to Amendment 203A in my name and those of my noble friend Lady Finlay and the noble Lords, Lord Patel of Bradford and Lord Patel. I will speak also in support of Amendments 135C and 135D, tabled by my noble friend Lady Finlay.

The Bill seems to favour the commissioning of services through the any-qualified-provider model rather than being concerned primarily with commissioning an integrated model of care. Amendment 203A would introduce a duty on clinical commissioning groups to commission multiple providers of health services competing to deliver a section of the care pathway only where they can demonstrate to the NHS Commissioning Board that the approach is beneficial to patients. Integrated care pathways are particularly important in complex, long-term conditions such as serious mental illness or challenging behaviour, for example in someone with learning disabilities who is also on the autistic spectrum.

There have been attempts in the NHS to deliver integrated care pathways, with varying degrees of success. The introduction of a plurality of providers in mental health services in recent years is already showing signs of fragmenting complex care pathways in some instances. The disaster of Winterbourne View is just one example of how commissioning one provider to deliver part of a pathway without planning, commissioning and co-ordinating the whole of an integrated pathway can be an expensive and tragic mistake.

The further introduction of competition between providers has the aim of reducing the cost of provision while maintaining and improving the standard. This is a noble aim on which we may all be able to agree. However, commissioners must evaluate whether the aim is being achieved, recognising that care pathways vary hugely in different conditions and even for different patients. The variety of provision needed means that we cannot easily—if at all—prescribe a rule to cover all situations. Of course, the health service exists to serve patients, not providers. It is in this light that we must consider proposals to introduce competition between providers, and it is because of this that the burden of proof must be on those who favour increasing competition to show that doing so would benefit patients.

The risk is that many providers will compete to provide more profitable parts of a pathway, cherry-picking the parts they would like to offer, perhaps only to the least complex patients, thus leaving unmet the less easy to cost and define but still essential parts of the pathway. The importance of an integrated care pathway cannot be overestimated. The comfort patients take in knowing that their entire provision is being dealt with in a coherent, joined-up way may be put at risk under an any-qualified-provider system. As always, it is the most vulnerable patients whose needs may remain unmet.