Mental Capacity (Amendment) Bill [ Lords ] (Sixth sitting)
Steve McCabe Excerpts(5 years, 3 months ago)
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Caroline Dinenage
I think it would be helpful if I began by setting out how we got to where we are, for the sake of clarity, although I know that many hon. Members know this. The case of MIG and MEG and P widened the understanding of the scope of deprivation of liberty safeguards with the Supreme Court decision that:
“A gilded cage is still a cage”.
Even though the cared-for person was happy in their situation, it was still a deprivation of liberty and required a safeguard. The acid test set out by Baroness Hale in Cheshire West had two limbs: first, is the person subject to continuous supervision and control, and secondly, is the person free to leave? We can see that test running through this clause. We cannot directly challenge or go against Cheshire West, as it is the Supreme Court’s articulation of article 5, and our Bill must be compliant with the European convention on human rights. That is why deprivation of liberty continues to be defined by reference to article 5 of the ECHR.
We are confident that the exceptions in subsections (2) to (4) represent existing case law. The clause defines deprivation of liberty in that way, and the subsections are consistent with and drawn from existing case law—for example, as I have detailed, subsections (2) and (3) are based on the Cheshire West acid test. It is unlikely that there will be a mismatch between our clause and the High Court’s view; it may be that the clause is subject to litigation in future, but we are confident that the Government’s approach of providing for situations that would not constitute a deprivation of liberty will give sufficient flexibility for the meaning of the clause to develop alongside case law as that evolves.
Much of the discussion has emphasised how incredibly complex a legal matter this is; the clause must be drafted incredibly carefully to ensure that it is legally compliant. We have worked with other Government Departments such as the Ministry of Justice to develop the clause. We listened to stakeholders and peers during the progress of the Bill through the House of Lords to understand their requirements for a definition and drafted the new clause in a way that would achieve what they wanted legally. Since drafting it, we have shared it with stakeholders to explore its impact. We are consulting a wide variety of organisations to gather case studies, which we will use in the statutory guidance.
Steve McCabe (Birmingham, Selly Oak) (Lab)
I wonder whether the Minister can explain how, if there was consultation with stakeholders, my hon. Friend the Member for Worsley and Eccles South has that impressive list of organisations with such grave reservations. That suggests the consultation was a bit inadequate.
Caroline Dinenage
The decision to put the definition in the Bill was made in the House of Lords. We had to work carefully on the definition. That information has been shared with stakeholders only in the past couple of weeks. The definition is where we have been working most latterly.
Stakeholders have agreed to work with us and to bring forward case studies that we can put in the statutory guidance that will make it very clear how the Bill will work in every instance and for all the different types of vulnerable people we have discussed. That is what we need to provide clarity. Those case studies will demonstrate how the exceptions will apply in different settings and scenarios, provide clarity, and aid practitioners in identifying when one of the exceptions applies. We are working with stakeholders to co-produce that guidance to ensure that it is clear, unambiguous and of real help to those who use it. It would not be appropriate to include that kind of detail in primary legislation. As I have tried to articulate, the new clause needs to be precise and to fit with evolving case law.
Mental Capacity (Amendment) Bill [ Lords ] (Third sitting)
Steve McCabe Excerpts(5 years, 3 months ago)
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Steve McCabe (Birmingham, Selly Oak) (Lab)
I beg to move amendment 51, in schedule 1, page 12, line 40, at end insert—
“(h) the cared for person has access to an Approved Mental Capacity Professional”.
This amendment is designed to probe that the responsible body could not authorise arrangements for the deprivation of liberty under Clause 15 if the cared for person does not have access to reasonable support and consideration by an Approved Mental Capacity Professional.
It is good to see you in the Chair once again, Mr Austin. I share with my hon. Friend the Member for Worsley and Eccles South a grave concern about the care home arrangements in the Bill generally. Earlier in the week she made a persuasive case for the Minister to look again at the whole set of arrangements. I continue to worry that there is a potential conflict in the way they will operate, which may not be in the best interests of the people whose interests should be at the front of our minds.
I hope that I shall be able to explain my reason for tabling the amendment sufficiently well to persuade the Minister at least to consider my concerns. Paragraph 15 of the new schedule AA1 that schedule 1 would insert into the 2005 Act requires a number of conditions to be satisfied, including with reference to the
“determinations required by paragraphs 18 and 19”.
However, under proposed new paragraph 18, the assessment
“must be carried out by a person who appears”—
they need only appear—
“to the relevant person to have appropriate experience and knowledge.”
I do not quite know how that would be determined if it were challenged in a legal setting, but I would have thought that those who are giving that responsibility would want a little more assurance than the mere appearance of appropriate experience.
Dr Paul Williams (Stockton South) (Lab)
Are experience and knowledge enough without having the skills?
Steve McCabe
I defer to my hon. Friend’s much greater expertise in the area, but my gut instinct is to say, “Absolutely not.” I would have thought that skills were an essential third part of the equation.
The person need only appear to have the appropriate knowledge. Proposed new paragraph 15 also requires that appropriate consultation be carried out and so forth, but it reads to me like a checklist. The Minister made it clear to the Committee on Tuesday that she does not want a checklist or tick-box approach to assessment or to decisions to restrict a person’s liberty—the fact that she is absolutely against such an approach was probably one of the most reassuring things that we heard from her. However, we also heard that the Law Society has expressed concern about the relatively limited situations in which a cared-for person has access to an approved mental capacity professional; it recommends that having that access should be the default position in the majority of cases.
I concede that my amendment is very poorly drafted. The Minister will have no difficulty in pointing out its deficiencies in that respect; I am sure that the people who advise and assist her could do a vastly superior job of drafting it. However, the key issue that I am trying to raise relates to the anxiety of my hon. Friend the Member for Worsley and Eccles South that a cosy or somewhat collusive arrangement could develop if the care home manager has too much influence over who is engaged to carry out these activities. Before the responsible body authorises the arrangements, I want it to be completely satisfied that all the conditions have been fully complied with and that the vulnerable person has had access to an appropriate AMCP.
I am prepared to accept that there may well be circumstances—the Minister drew on the experience of her relative, who has sadly passed away—in which access to an approved mental capacity professional does not necessarily require extensive involvement. For example, if there is already an abundance of information and evidence to support the decision, it seems a pointless exercise to engage someone in an extensive role. I assume that is part of the thinking behind the Minister’s efforts to streamline the process. I would be the first to concede that point, but we need to be absolutely sure that the person who is engaged has the appropriate experience, knowledge and—as my hon. Friend the Member for Stockton South says—skills. That is surely key to being able to determine whether any of those conditions are appropriately met, other than simply through a checklist or tick-box system.
Alex Cunningham
Age UK agrees with my hon. Friend’s point and proposes an extension to it, through the involvement of an AMCP every time a family member objects, or if the cared-for person has no family members to object on their behalf. Does he agree with that position?
Steve McCabe
Absolutely; I agree entirely. That makes more sense than the way I have been saying it.
I accept that the amendment is clumsy and not well drafted, but I hope that it is clear that, more than anything, we need to hear—all the better if it happens before our proceedings conclude—and then see in black and white a cast-iron guarantee that the arrangements will not be used in a way that ends up being detrimental to the interests of the person about whom we should be most concerned. That is the purpose of the amendment. We can have some confidence that all those conditions have been appropriately and properly satisfied only if we have confidence that a professional with the appropriate experience, knowledge and skills, who is valiantly independent and capable of looking at it in the round, has been a key component of that decision.
Barbara Keeley
I thank my hon. Friend for moving the amendment. The Committee has already considered the principles that he has discussed, but I am glad to have the opportunity to return to them, because the role of the AMCP is a big part of the schedule, which I am sure we will come back to.
The aim of the amendment is to ensure that all people subject to the liberty protection safeguards have their case considered by an approved mental capacity professional. On Tuesday morning I discussed a range of cases where we thought that it was crucial that the approved mental capacity professional should review the case. I was talking about specific cases, but an AMCP review would be beneficial in all cases, because it would bring independent scrutiny from a professional with experience in such matters. We will talk about the issue of skills shortly, which comes into it as well.
An AMCP review can only be a good thing. It would ensure that even lower risk cases than the ones I spoke about were properly scrutinised, so that cared-for people would be at less risk of being inappropriately deprived of their liberty. That is what it is all about, really; that is what we on the Opposition side are doing. I am sure that we and the Government are of one mind on the important role that approved mental capacity professionals can play, which is why we will support Government amendment 9 when it is put to the Committee, and why I hope that they will support our amendments 37, 38 and 39.
Caroline Dinenage
I thank the honourable—I seem to be test-driving someone else’s teeth today, Mr Austin. I thank the hon. Member for Birmingham, Selly Oak for raising the issue and facilitating an important discussion. I have absolutely no doubt of his dedication and good intentions in the matter. I wish to offer him some reassurance, because the Bill already requires that an approved mental capacity professional carries out the pre-authorisation review where an objection has been raised. In such cases, authorisation cannot be granted unless the pre-approved mental capacity professional is 100% satisfied that the authorisation conditions are met. Amendment 9 would strengthen this provision, as the hon. Member for Worsley and Eccles South mentioned.
Should an approved mental capacity professional not complete the pre-authorisation review, it would be completed by someone who is not involved
“in the day-to-day care of the cared-for person…in providing any treatment to the cared-for person, or…who has a prescribed connection with a care home.”
We believe that this would ensure that the pre-authorisation reviewer is sufficiently independent. We expect that the review would be completed by professionals such as social workers, nurses or physicians. The hon. Member for Birmingham, Selly Oak talked about the use of the term “appropriate experience”, which is set out very clearly in extensive case law.
Steve McCabe
I am grateful to the Minister for that. Why does the wording suggest that the person should “appear” to have the appropriate experience? That does not sound quite as precise to me. Perhaps I am having difficulty comprehending this, but “appears” seems to suggest that there is an element of doubt or vagueness about the situation.
Caroline Dinenage
The hon. Gentleman is questioning aspects of legal terminology, on which I am not a huge expert. I am happy to get back to him on that in due course.
The hon. Gentleman referred to my personal family experience. I shall not share my life story, but my uncle’s situation is only the most recent experience that I have had of the whole system. I have far more than one family experience of this, which is why I am very keen to ensure that the Bill not only offers as much protection as it can, but works effectively and is as streamlined as possible. I have seen the effects of the delays not only in my constituency office, but in my personal life.
We have to be super careful not to denigrate in any way our care home staff, which I have spoken about before. So many of them work with great professional integrity. We have to be super careful about saying that a care home cannot be trusted not to interfere in the way the judgment is made. Clause 21 sets out clearly that the review would have to be completed by somebody who is not involved
“in the day-to-day care of the cared-for person…in providing any treatment to the cared-for person, or…who has a prescribed connection with a care home.”
The amendment would move away from having a targeted system, which allows authorisations to be in place more quickly, and would effectively recreate the current DoLS system. We cannot allow that to happen.
The hon. Gentleman talked about detriment to the interests of the individual. At the moment, the biggest detriment to the interests of 125,000 individuals is that they are sitting on a backlog. Some 48,000 have been sitting there for more than a year, which I am sure is not his intention. I cannot support the amendment and I ask him to withdraw it.
Steve McCabe
I am prepared to concede that the Minister has offered some reassurance—as a doubting Thomas, I would like an awful lot more. To be terribly honest, I am not that convinced. “Appear” is not a technical legal term; it is a description of the professional who would review a cared-for person’s situation for determination. Clause 18 sets out that the
“assessment must be carried out by a person who appears to the relevant person to have appropriate experience and knowledge.”
There is nothing too technical or legal about that. I say as gently as possible that if I were the Minister, I might go back to my officials and have another conversation about that in order to establish exactly why that wording has been chosen.
The Minister knows the Opposition’s view. She knows the view of quite a number of important organisations that are involved in this work day in, day out. It is probably better if I agree to withdraw the amendment now and take it on trust that the Minister will look further at our concerns. I therefore beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Paula Sherriff (Dewsbury) (Lab)
I beg to move amendment 32, in schedule 1, page 13, line 46, at end insert—
“(aa) a determination made on an assessment in respect of the cared-for person as to whether the person’s capacity is likely to fluctuate, and”.
This amendment requires that an assessment of whether a person’s capacity is likely to fluctuate is included within the initial capacity and medical assessments, and therefore seeks to ensure that fluctuating capacity is reflected in the care plan of the cared-for person.
Mental Capacity (Amendment) Bill [ Lords ] (Fourth sitting)
Steve McCabe Excerpts(5 years, 3 months ago)
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Caroline Dinenage
That is what we must guard against. It cannot be done in the Bill, because coverage has to be extensive; that is exactly where the regulations that run alongside the Bill come into their own. They will set out how, if someone is working for a care home in a different location but run by the same provider, they will be excluded. They will also take a broader view, encompassing things such as agency staff, volunteers and other areas where people may have very reasonable concerns, as well as, of course, everybody who is employed in the care home.
Another point I want to stress is that the amendment would put hospital trusts, clinical commissioning groups and local health boards in a position where they are unable to arrange for someone in their organisation who is separate from delivering care and treatment to complete the pre-authorisation review. They would instead have to organise someone external, which to me seems a wildly unnecessary and bureaucratic exercise. We trust our NHS staff with our lives every single day. I am sure that is an unintended consequence and that Opposition Members are not saying that we cannot trust our NHS staff to complete those reviews. That is when I talk about unintended consequences of amendments to Bills.
Steve McCabe (Birmingham, Selly Oak) (Lab)
This is a genuine question: what will the arrangement be for inspecting the work of the people who carry out the reviews? The Minister says that we trust our NHS staff, but we have a whole series of inspection and review processes to ensure that decision makers are complying with the law as intended. I think I asked a similar question the other day about the Care Quality Commission in relation to homes, which she said that she would look at. Will there be some similar oversight or random review process of the work that these people do? That would be one way—not a guaranteed way—of picking up whether there was an unsuitable relationship. At the moment, part of the fear is that we could end up in a situation where these people are set free to do this work, but without any guaranteed oversight of how they carry it out.
Caroline Dinenage
I laughed when the hon. Gentleman said, “This is a genuine question,” as if all the others he has asked have not been. I am sure that is not what he intended to suggest.
Steve McCabe
If the Minister will forgive me, it is just that she looks as if she does not believe me sometimes.
Caroline Dinenage
I think that might just be my natural resting face. I understand what the hon. Gentleman is saying, but it depends who we are looking at. If the pre-authorisation review is being conducted by a local authority for a care home, the oversight of the senior members of the local authority would apply, as well as the Care Quality Commission, which deals with the quality of care homes. If it is something like a hospital, people will monitor other people’s work as happens already within hospitals, CCGs and health boards.
The Bill says that somebody who is involved in the direct care of a particular person cannot mark the homework of another person. In something as big and broad as a local health board, a CCG or a hospital trust, which can be enormous, exclusively saying that there could not be two people, who have never met each other before, looking at each other’s work seems to me a huge leap.
Amendment 36 is designed to prevent anyone with a prescribed connection to an independent hospital from conducting pre-authorisation reviews. I am sure that we can all agree that the pre-authorisation review is critical to the effective operation of the liberty protection safeguards in providing independent reviews of proposed arrangements that may deprive people of their liberty. We are talking about the most precious and vital of our human rights. The reviews have to be conducted by someone independent, who is not involved in the day-to-day provision of care or treatment of the cared-for person. That provides the necessary degree of separation to ensure that the model is compliant with the European convention rights.
By requiring authorisations in independent hospitals to be considered by an AMCP, regardless of whether the individual objects, we add a further level of security and build on other safeguards within the model. The AMCP will meet with the person, complete any relevant consultation and review assessments to decide whether the authorisation conditions are met. They can effectively veto proposed arrangements, if they feel that the proper conditions are not met. AMCPs will be professionals, such as experienced social workers, learning disability nurses and psychologists. Their practice will be regulated by and they will be accountable to their professional bodies—in answer to what the hon. Gentleman said earlier.
Barbara Keeley
I absolutely agree. My hon. Friend makes such a good point.
The Minister in the Lords, Baroness Stedman-Scott, said:
“We are clear that our intention is for approved mental capacity professionals to meet with the cared-for persons in almost all cases.”—[Official Report, House of Lords, 15 October 2018; Vol. 793, c. 371-72.]
That qualification—“almost all cases”—creeps in again. Our proposal would go a little further and require AMCPs to meet the cared-for person in every case that they review. This is a crucial part of reviewing an application. It cannot be right that the role of the independent reviewer should be limited to simply reading a set of papers and certifying that what is contained within them meets the requirements to authorise a deprivation of liberty. That would be no safeguard at all.
I have mentioned the case of Y v. Barking and Dagenham, which saw a young man held in an inappropriate care setting for more than two years. One major failing of the local authority and the independent social worker in that case was to simply accept the assertions made by care home staff, which led to nobody challenging the changes in Y’s condition, denying him the safeguards he so badly needed.
There are, so far as I can see, only two objections to requiring the AMCP to meet the cared-for person. The first is that it might be an excessive burden on the cared-for person. My response to that is simple: we are not asking for the AMCP to carry out a protracted, in-depth cross-examination of any cared-for person. It need not take hours or involve directly checking every minute detail of the authorisation record with the cared-for person, which would be burdensome in itself. We would not want to implement a system that requires somebody to go through a lengthy experience like that. However, that is not the same as not wanting the AMCP to meet the cared-for person, which could be for only a few minutes.
Steve McCabe
Does my hon. Friend share my surprise that these words have actually been included in the Bill? We have heard quite a bit from the Minister about the things she has not wanted to add to the Bill because she has not wanted to send the wrong signal or be too rigid in her approach. Does my hon. Friend agree that, if the Minister’s argument is that there could be genuine circumstances where it is not necessary to meet the person and the phrase would apply, that would be a matter of professional judgment that could be spelled out in the code of practice? By putting it in the Bill, the Minister succeeds in giving a clear signal that she expects there to be lots of circumstances where the person will not be seen.
Barbara Keeley
That is really worrying.
As I was saying, the meeting could be for just a few minutes to confirm that the cared-for person appears to present with the behaviours that are described in the application for deprivation of liberty. A meeting, no matter how short, could confirm or deny what is written in that application—whether a person is visibly happy or unhappy with arrangements and whether the arrangements appear to be proportionate.
To give a hypothetical example, physical restraint is not unheard of in cases under the deprivation of liberty safeguards—we know of many cases where restraint is being used. It might not be unreasonable to look at a level of physical restraint on paper and feel that it is needed to prevent harm to others, but seeing that person in the flesh may make it clear that the subject of the application is underfed and would not present a significant physical threat. Cases such as that would perhaps be rare, and I do not want to suggest that care providers would seek to over-restrain people as a matter of course, but the Minister and I, and many hon. Members, understand that it does happen. In such a case, the meeting with the cared-for person would tell the AMCP whether the arrangements were overly restrictive.
A second objection might be that meeting a cared-for person would involve extra cost. As it stands, the responsible body decides whether an AMCP should be brought in to review a case, so responsible bodies, including local authorities, must be properly resourced to bring AMCPs in on all cases where they are needed. We will touch on resources later in the debate. The reason that the meeting is important is simple: it may be that the cared-for person is not completely as they are described on paper or by other people that the AMCP meets in the process of their review.
I return to the case of X, whom I discussed previously, to illustrate why that is so important. For hon. Members who cannot remember that far back in our discussion—we have had several case studies—X was a 99-year-old woman residing in a nursing home. Daily, if not hourly, she was objecting to where she was. She wandered up and down the care home objecting to the arrangements that had been put in place. Of course, nobody in the care home had bothered to identify that X was objecting to the arrangements and that, as such, she would require a deprivation of liberty safeguards application to be made.
The Government’s refusal to accept some of our earlier amendments on approved mental capacity professionals means that X would not have received an AMCP review, given that nobody had identified an objection. If an AMCP had been appointed, however, it would have been critical that they met X, because anything else would have led them to simply accept the word of the nursing home, which clearly felt that X was content with the arrangements, despite the evidence to the contrary.
Meeting the cared-for person would allow the AMCP to stress-test the other elements of the application that they are reviewing. It would provide them with primary evidence, against which they can hold everything else they are given. I hope that the Minister agrees that that is important—indeed, that is undoubtedly why the Bill contains provision for approved mental capacity professionals to meet most of the cared-for people whose cases they are reviewing. Our amendment would simply extend that slightly to ensure that nobody falls between the cracks.
As we have discussed, the AMCP will not be involved in the majority of pre-authorisation reviews. They will be involved only in higher-risk cases where extra safeguards are needed. Given that the AMCP is being brought into the process because the cared-for person is at risk of being inappropriately deprived of their liberty, it seems perverse not to require that they at least meet the cared-for person.
The Bill provides for the approved mental capacity professional to
“meet with the cared-for person, if it appears”
to them
“to be appropriate and practicable to do so”.
Steve McCabe
I beg to move amendment 48, in schedule 1, page 17, line 30, leave out “12 months” and insert “3 months”.
This amendment is designed to encourage reviews and appropriate authorisation by making it harder to detain someone for such a lengthy initial period.
The Chair
With this it will be convenient to discuss the following:
Amendment 49, in schedule 1, page 18, line 24, leave out “12 months” and insert “3 months”.
Amendment 44, in schedule 1, page 18, line 24, leave out from “less” to end of sub-paragraph (1)(b).
This amendment limits the period of renewal of any authorisation to twelve months.
Amendment 50, in schedule 1, page 18, line 25, leave out “3 years” and insert “6 months”.
This amendment would limit renewal periods to a maximum of 6 months.
Steve McCabe
It is a pleasure to see you in the Chair, Mr Pritchard. I should probably begin by saying to the Minister, just so there is no doubt, that these are genuinely probing amendments. As the Minister will know, Sir Simon Wessely recommended much shorter periods of detention in his original proposals regarding the Mental Health Act 1983, and of course there have been strong arguments—which the Government appear to have resisted—for this legislation to be more fully considered and developed in conjunction with that Act.
A recurring criticism of the operation of mental health legislation is that too many patients are only considered for discharge during preparation for a tribunal hearing. Effectively, the concern is that once a person is captive, as it were—once that person is detained—the authorities are content to leave them there. Under the Bill, a vulnerable person can be deprived of their liberty for three years, as opposed to the previous maximum of 12 months. Given some of the anxieties and concerns about the arrangements in the Bill that we have discussed, both on Tuesday and today—the sense that there may be conflicts of interest, which mean that a person’s interests will not always be safeguarded, and that some of the guarantees do not look as strong as we would like—those rather lengthy periods of detention become an added cause for concern.
I am struggling to understand the justification for having a renewal period of three years, other than on the grounds of cost; I hope the Minister can make that clear to me. She may tell me that it is to cover situations in which the person’s condition is well established and unlikely to change. I presume that if that is the case, what she means is, “We can foresee this situation carrying on, and therefore there is not much point in having further intervention or authorisation regarding the detention arrangements.”
However, what about a condition such as dementia? As I understand it, dementia is a progressive condition, so a person with dementia experiences changes over time. It could be that as a person’s dementia progresses, they need less restrictive care because their condition changes, but it is highly unlikely that that sort of change in what they need would be detected. If that person was already subject to a three-year order, who would be looking to say, “It is obvious that Mrs B’s condition has moved on, and the arrangements that were made 12 months ago can now be altered”? The likelihood is that if that person needed less restrictive conditions, she would be causing less trouble in the establishment that she was living in. She would be one of the patients or residents who was of least concern to the staff, so the improvement in her condition that would merit a lessening of the restrictions on her freedom would be completely missed, because the staff would know perfectly well that she was there for three years. That is how that would be viewed.
I notice that the wording on first renewals says “12 months or less”. What proportion does the Minister consider will be for less than 12 months? What proportion of renewals that can be for three years does she think will actually be made for less than three years? For how long are people normally deprived of their liberty under the present arrangements? What does she think will be the average period under the arrangements she proposes?
Caroline Dinenage
I thank the hon. Members who have tabled the amendments on authorisations up to three years. I stress that this was a recommendation of the Law Commission, in particular for people with long-term progressive conditions from which they are unlikely to recover. It was suggested because many people and their families told the Law Commission, throughout its extensive consultation and work, that they felt that starting the process from scratch every year was unnecessary and cumbersome.
I should also stress that the three-year authorisation period starts only after there have been two one-year authorisations, and the periods set are maximums, not minimums or targets. The Bill does not prevent a responsible body from approving an authorisation for the period set out in the amendment if that is appropriate. Furthermore, the responsible body is required to specify a continuous programme of reviews. If a person’s circumstances change significantly, the authorisation will be reviewed and may be found to no longer be valid. That could easily be the case with somebody with dementia, as has already been highlighted. In that way, I believe that the provision actually brings in additional safeguards.
I hope that has provided clarification and I ask hon. Members to withdraw the amendments.
Steve McCabe
My amendments were probing amendments, so I do not wish to push them to a vote. I hope the Minister will reflect again on what I said about monitoring how the detention periods are used, because I fear there is a greater risk here than people may have anticipated. I beg to ask leave to withdraw the amendment.
Barbara Keeley
Can I just make a couple of points? There is near unanimity in the sector that three years for renewals is too long. Even the Alzheimer’s Society is worried about the impact it could have. The power on renewals lies with the managers of independent hospitals or care homes, who are people with a vested interest in renewing the authorisation and keeping the cared-for person as a client. In the amendment, we suggest a 12-month period, which would allow the renewal process to be built on the all the other assessments that cared-for people undergo annually as part of their care programme. That would avoid the process placing an excessive burden on them.
Mental Capacity (Amendment) Bill [ Lords ] (First sitting)
Steve McCabe Excerpts(5 years, 3 months ago)
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Caroline Dinenage
I thank the hon. Gentleman for that interesting question. His medical background makes him a very valuable member of this Committee—as is everybody else, of course. There have been a lot of high-profile cases involving independent hospitals recently, and we have to pay attention of them. We are talking about a very tiny cohort of vulnerable people here—slightly less than 1%—but they are very important, given that they are extremely vulnerable. Given the nature of the concerns that have been raised about independent hospitals, we felt, and the Lords agreed, that it is important to ensure that additional protection is there from the outset, whether or not the person objects to their care.
Caroline Dinenage
I will just get to the end of my sentence.
The Government amendment already clarifies that AMCPs can review authorisations in other relevant cases—for example, if circumstances are complex or if particularly restrictive practices are used.
Steve McCabe
I am grateful to the Minister for giving way; I did not want to interrupt her flow. I want to clarify the answer she gave to my hon. Friend the Member for Stockton South a second ago. How many people reside in independent homes, as opposed to independent hospitals? I would have thought that the greater proportion are in independent homes, which is all the more reason why we should have concern about them.
Caroline Dinenage
With deprivation of liberty safeguards or liberty protection safeguards, roughly 80% are in care homes, 20% are in hospitals and—I know this will add up to over 100%, but it is there or thereabouts in each case—about 1% are in independent hospitals. We have to avoid recreating the painfully inadequate DoLS system we have at the moment. Where something is straightforward and simple, we do not want to take the power and decision making out of the hands of families, loved ones and those trusted to help people in decisions about their care.
We have put in this clause about independent hospitals because Members from both sides of both Houses have had particular concerns. I know that the hon. Member for Worsley and Eccles South shares these concerns with me. That is why we felt that the clause was particularly important.
We know that situations can be complex and incredibly far-ranging, which is why we intend to use this code of practice to capture the full scope of circumstances to which it may apply. We will set out in detail the circumstances that may trigger a review by an AMCP. I am keen to take input from all Members from across the House on this document.
Amendment 38 relates to the involvement of approved mental capacity professionals in arrangements for 16 and 17-year-olds. We understand that many 16 and 17-year-olds would benefit from the additional scrutiny of an AMCP. This is why the Government amendment clarifies that relevant cases should be referred to an AMCP.
Alex Norris (Nottingham North) (Lab/Co-op)
It is a pleasure to serve under your chairmanship for the first time, Mr Austin. It always feels a bit risky to speak before one’s Front Benchers. Let us hope that I do not re-write Labour party policy and cause it to have to be unwritten two minutes later.
This is a really serious issue, as has been said. It is exceptionally impactful for individuals and the health and social care system. The Minister rightly notes the backlog that has built up in the 10 years since the DoLS regulations were put in, that it has been five years since the critical Cheshire West judgment, and that the system is cumbersome. It is right for us to look at that.
As played out on Second Reading, we have significant concerns that this legislation is rushed. We will frequently come back to the point on the code of practice, because it feels as though we are dealing with half the information. We are putting significant arrangements into law, knowing that we will be relying on another code of practice. I am glad to hear of the legal basis for that code of practice, but would like to see it alongside the Bill. Otherwise, how do we know whether these arrangements are really suitable? We do not know what the counterpart arrangements in the code of practice would be. I certainly have fears that the process is rushed, that the arrangements are a little bare, and that we are expecting to fill them out with the code of practice, which we will not get to see during these proceedings, so there is a risk that we will not achieve what we are trying to.
I remember the Cheshire West judgment well. When I looked it up last night, I could not believe that it happened in 2014, five years ago. I was the lead member for adult social care and health on my local authority, Nottingham City Council. I got one of those concerned calls from the director of adult social services that one gets periodically, saying, “We have a problem. Oh, goodness me!” We reacted, as I suspect every other upper-tier local authority did, by saying, “There is a legal risk, which has been tested in case law, that for this case load, we, the local authority, have not been complying with our responsibilities in law, which is very serious.”
Again, we did what I suspect everybody did, which was to traffic-light the case load—to sort it into red, amber and green—to indicate which cases we thought matched most closely the circumstances of the judgment and therefore where the risk was greatest, where there was less risk, and where we thought there was probably no relation. We matched our assessment capacity against that, so that we could get on with ensuring that we were complying with the law, as we would be expected to do.
Assessment capacity is not an infinite resource. It is not a matter of putting in an extra bit of money and gaining more assessors. Assessment capacity across social care and social work in general is increasingly stretched. Local government has been an exceptionally difficult place to work for eight years, so that was a really challenging exercise.
It has been some time since I led that brief in Nottingham and was in local government, but there were certainly times when I felt that the traffic light system was no longer a way of trying to remove an initial risk; it had become the way in which local authorities would have to operate with stretched resources. They would ask, “Where are we most at risk of challenge? Where are we least at risk of challenge? That is how we will match up our resources.” That is not a satisfactory way to operate. Today and in future weeks, it behoves us to ensure that whatever arrangements we come up with go past that and ensure that we operate in the best interests of the individual. That is all we are concerned about, and why I still have concerns.
I am sure we will come back to the subject of impact assessments in future sittings. The impact assessment is very clear about what it would take to develop a series of people who could make the assessments, but there is no sense of who will resource those individuals, whether we have enough of them, how we might find them and how we will grow them for 10 years’ time.
Steve McCabe
Does my hon. Friend share my concern that so far, we have heard no reference to resources associated with this legislation? The Minister said at the outset that she was concerned about the backlog, but it is reasonable to argue that the backlog developed partly because of the shortage of local authority resources. It is difficult to see how capacity to grow professionals will develop if that same starvation of resources continues.
Alex Norris
I share that view completely. On my first day here, if my hon. Friend had stopped me and said, “You’ve just come from Nottingham, where you were the adult social care lead. What was your situation with DoLS? Why did you have a backlog? Are the regulations too cumbersome?” I would have said that they probably were, but that that was about our assessor capacity, because there have been eight years of growing demand in social care, while the council has experienced extraordinary reductions in resources. That toxic cocktail meant that we were increasingly stretched to the point where we really struggled to keep up with our responsibilities. There is concern that, while we could write the best legislation, if we do not understand the context, we will not deliver what we are trying to.
Alex Cunningham
My hon. Friend spells it out very clearly. I get very anxious when I see parents shut out. People come to see me when children are being taken into care—though I know that that is not necessarily directly applicable to this Bill. They are often in tears or do not understand the system; they are not being properly consulted. Anything that we can do in the Bill to give protection in this specific area is very important, so I welcome what my hon. Friend just said.
Mencap confirmed in its briefing that:
“We believe that there are some situations in which the LPS system will not be the appropriate framework to authorise interventions. For example, where young people’s care arrangements include physical restraint, we believe more scrutiny would be required and should therefore be undertaken by the courts.”
Those are the protections and safeguards that we need to consider while providing care to under-18s. My local authority of Stockton-on-Tees has raised its own concerns that including 16 and 17-year-olds in the legislation is likely to contribute to increased workforce pressure in any given local authority. One area that it has particularly flagged is the possible impact on foster carers. Would this lead to a reluctance among foster carers to come forward? Has the Minister considered what happens for other people who care for children who are not with their families? The measures proposed in our amendments go a long way to providing the protections needed. They are the very least of what we should be doing to protect vulnerable young people.
Although I have spoken mainly about 16 and 17-year-olds being included in the Bill, their access to an AMCP and the development of other protections, I support the notion that access to a genuinely independent AMCP should be standard—not the exception—for every person. I do not think that the Government amendments go far enough. Why would that not be standard? Are there financial reasons? My hon. Friend the Member for Nottingham North has already started the conversation about that. Is it a case of expense or resource? Will the Government make sure that we have not only the resources in the system to deal with this, but the training and even the career development for people to move into this area?
AMCP work is not inexpensive and there is no doubt that anything in the Bill that involves local authorities, commissioning groups or health boards and their teams is bound to have a considerable financial impact on them. If it were left to me and other Opposition Members then local authorities, commissioners and health boards would have even greater responsibilities on them, and therefore even greater increased cost. We must not lose sight of that. I am sure that there will be other opportunities to talk about resources and what already works, but for now I would welcome hearing from the Minister not just about the protections that she sees as necessary to the Bill, particularly for young people, but how she will ensure that the various bodies involved in delivering them will have the financial and staff capacity to deal with the work they need to do.
Steve McCabe
It is a pleasure to serve under your chairmanship, Mr Austin. I want to make a brief contribution, particularly on amendment 37.
If I may say so, the Minister was rather dismissive in her contribution. It has become evident in the past hour that the real challenge for the Bill will be to provide an affordable and worthwhile set of arrangements that guarantees that people who genuinely need care and protection get it, but that protects individuals’ liberties at the same time. We do not want to end up putting the wider establishment’s interests first and the individual’s second.
The Minister said that she was anxious not to put too much in the Bill, because that might expose it to challenges about what had been left out. Conversely, the Government cannot put too little in the Bill and ask us to rely on a non-existent code of practice. As legislators scrutinising legislation that will have a massive impact on the liberty and human rights of some of the most vulnerable people in our society, we need to ensure that the Bill is fit for purpose; I notice that Sense, an organisation with a lot of experience of many people who will fall within the Bill’s remit, takes the view that it is not. We need to be certain that we have the balance right, rather than tipping it in favour of the authorities or institutions—the people with power, effectively—against the interests of vulnerable people.
I know that the Minister’s intention is to streamline the process, but if she succeeds in streamlining it by flouting the legitimate liberties of some of our most vulnerable people, it seems to me that she is exposing the system to some risk. Disability Rights UK fears that one of the Bill’s dangers is that it
“takes the rights of disabled people backwards.”
Mr Dhesi
My hon. Friend is making very powerful points. Does he agree that there needs to be greater democratic accountability and responsibility? If a clinical commissioning group or local health board decides that a cared-for individual should be looked after in an independent hospital, it should be the responsible body. It is important that we have that accountability and responsibility in the whole process.
Steve McCabe
Yes, I agree.
I happily accept that every member of this Committee is committed to trying to do the right thing by very vulnerable people—there is no doubt about that. However, it is easy to rush such a Bill, particularly at a time when the Government are a bit distracted by other matters. The argument may seem simple on the surface: “Oh, we have a bit of a backlog, but let’s not concentrate on how it developed—maybe it was resource-driven. Let’s focus on the fact that we have a backlog and find a way of streamlining things to get that down.” When taking that approach, it is easy to gradually step away from the essential safeguards.
Sometimes these things take time. I do not want there to be unnecessary repeat authorisations. The Minister mentioned that to me recently and I accept that it is just pointless bureaucracy, but it is possible to try too hard to limit it. One of the reasons why protections and safeguards are built in is to stop us from trampling over people. It was a long time ago now, but I should confess that in my dim and distant past I was once a social worker, and I know what happens when people are under pressure. The case load of an average social worker these days is unbelievable compared to 30 or 40 years ago, and they are under enormous pressure to get things done with insufficient resources.
Barbara Keeley
I very much accept that point. Clearly there are difficult family circumstances and sometimes contact is not allowed. All the Opposition are saying in amendment 37 is that those cases where the family is denied access are more risky, and there should be the possibility of an AMCP review. We are not saying it should not happen—we know it does happen for a variety of reasons—but the risk of another Steven Neary case is clear once parents or other family members are banned. Once family members have their contact reduced or taken away, that becomes a high-risk case.
Steve McCabe
Does the hon. Member for Halesowen and Rowley Regis not make the argument for the Government to spell out more clearly the circumstances in which to consider these matters? Surely, that is exactly the sort of thing that both courts and professionals would be asked to take into account. He makes a valid point and I agree with him. His point is an argument to be more specific rather than more vague.
Barbara Keeley
I agree with my hon. Friend that that argument makes the case for us. In amendment 37, we suggest that the Government adopt in the Bill the process for assessing risk that social services departments up and down the country currently use on the DoLS application backlog. That is what they are doing and that is why that important amendment should be taken forward.
In response to the points made about amendment 39, it broadens out the terms of objection that would trigger an AMCP review. As I showed with examples, it is not always about the location. Just being able to raise objections about location is not enough. People often object to forms of treatment. There are some very difficult cases, such as eating disorders. There are often difficulties around the treatment.
I gave the example of an older person receiving palliative care who did not want dialysis. Medical people might find it hard, but there are cases where somebody does not want a treatment but wants the course of their disease to progress. In the cases I have mentioned, people were forced into situations that they did not want and where they did not have a basis to object. I believe that there is a case to broaden the grounds of objection to include not just location but the other points we have put forward in the amendment.
I just wanted to finalise those points and pull together what my colleagues have said. We will push our amendments to the vote at the appropriate time.
Mental Capacity (Amendment) Bill [ Lords ] (Second sitting)
Steve McCabe Excerpts(5 years, 3 months ago)
Public Bill CommitteesRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Caroline Dinenage
The hon. Lady has legitimate concerns. Making the responsible body the independent hospital was a recommendation in the Law Commission report. Amendment 19 changes the responsible body in cases where a CCG or a local health board is responsible for commissioning the care of people for the assessment or treatment of a mental disorder.
Steve McCabe (Birmingham, Selly Oak) (Lab)
I was reflecting on the comment made by my hon. Friend the Member for Worsley and Eccles South about the risk of the relationship being too close, cosy or convenient. Has the Minister considered giving the CQC a wider brief to investigate what happens between the various parties over a range of authorisation decisions in any given period? If a relationship that could be regarded as unhealthy was developing, that would presumably be an easy way of highlighting that.
Caroline Dinenage
I thank the hon. Gentleman for his suggestion; we will definitely take it into consideration. I fully understand where the concerns about independent hospitals acting as a responsible body come from. We must be careful not to stigmatise all independent hospitals. Every time we have such debates, we hear horror stories, but then I always get emails from parents who feel that their children’s lives have been saved by such hospitals. We must make preparations to care for those who are most vulnerable and at risk.
Barbara Keeley
We welcome this amendment, which gives clarity on arrangements in Wales, so that there is uniformity with England through the equivalent to continuing healthcare arrangements.
Amendment 3 agreed to.
Steve McCabe
I beg to move amendment 47, in schedule 1, page 11, line 17, at end insert—
“(d) the arrangements are in the cared for person’s best interest,
(e) less restrictive options have been considered,
(f) appropriate weight has been given to the cared for person’s feelings and wishes as best as these can be determined.”
This amendment is designed to pursue the issue of a person being deprived of their liberty as a last resort and only if it is in their best interest and a reasonable effort made to determine their wishes and feelings.
In suggesting these additions to the clause, I will return to the matters I raised this morning, because it seems to me that it is crucial that we in this Committee are as confident as any Committee ever can be that the arrangements will prove to be for the benefit of and in the best interests of the vulnerable person, and not for the convenience of the agency or the authorising body. It seems to me that, as the pressures grow on various professionals, the temptation is to interpret legislation for the convenience of the agency, as opposed to the interests of the individual. Consequently, it would be helpful and send an absolutely clear signal about the Government’s intentions if the Minister were to include in the clause a statement that the authorisation must be in the person’s best interests. That would make it crystal clear that there could not be any room for doubt or any other agenda or issue to intrude.
I recognise that paragraph 12(c) of new schedule AA1 to the Mental Capacity Act 2005 says that the arrangements must be “proportionate”, and I guess that the Minister will tell me that my fears will, therefore, not be realised, but I was thinking about that during the break and wondered whether “proportionate” could be interpreted as “suitable” rather than “necessarily in the best interests of the person”. It is quite possible in a hospital or a local authority setting to make proportionate arrangements that are suitable.
I am sure every member of the Committee deals with housing cases in local authorities every day of the week, where the local authority says that it has been proportionate in its decision about allocating a property, particularly given the constraints on the properties it has. It will certainly be a proportionate decision, but whether it is necessarily in the best interests of the person is open to debate. I simply say to the Minister that I am not wholly convinced that the two terms are exactly the same. Likewise, I do not know that, in a situation where “proportionate” meant “suitable”, it would necessarily indicate that all other less restrictive options have been properly considered, examined and then excluded. I am thinking of an elderly person who suffers a degree of confusion, or a brain-injury victim. If there is a lack of home care or day care in the area in which they reside, there may be a temptation to go for another option regarded as proportionate based on those considerations, rather than on what is in the best interests of the person, and to rule out more coercive options.
In such a situation, it might be perfectly possible for that elderly person or brain-injury victim to be properly and well cared for with the support of a dear relative, if that relative had access to realistic respite care to give them a break from time to time, and if the cared-for person had their care supported by reasonable access to home care and day care services. If that were the case, it would be wrong to restrict that person’s liberty not because less restrictive options had been considered and ruled out, but because the available care options in the area were inadequate and nothing had been done to try to address that.
That would be a classic example of a decision being made to suit the immediate economic interests of the agency or the environment in which the person happened to reside. It would not be about what was wholly in the best interests of that person. It would certainly not be because appropriate consideration had been given to less restrictive options. It would be proportionate, because in that situation “proportionate” was interpreted to mean “convenient” or “suitable”, rather than anything else. That is why I raise this matter.
Alex Cunningham
I am interested in my hon. Friend’s argument. It shows why, regardless of which part of the organisation or process we are dealing with, it is essential that there is an independent person involved in the process, whether that is to deal with a private hospital or a care home. There must be an independent person who can be an advocate and supporter for the person in care, rather than it being left to a care home or independent hospital to decide what is best for them.
Steve McCabe
I agree and I think that will be a recurring theme. As I tried to indicate this morning, the divide is between a person’s precious liberty and the need to prove good care and protection for an individual. The whole reason we are here discussing this Bill and the Minister wants to change existing legislation is that it is thought not to be adequate and to provide appropriate independent overview and scrutiny. I certainly agree with that.
James Morris (Halesowen and Rowley Regis) (Con)
I have a lot of sympathy for the points the hon. Gentleman makes. One of the underlying principles of the independent review of the Mental Health Act 1983 that was published just before Christmas was that we need to move towards a more care-led Act. That is reflected in some of the deliberations in this Committee.
Steve McCabe
I absolutely agree. From time to time we encounter horrendous examples of terrible practices by people who should never work in certain settings—things that are utterly inappropriate—but by and large, the people who work in care and helping professions do it as a vocation. They genuinely care about the people they are trying to look after, and they have nothing but the best intentions. That is my experience. None the less, there is a tendency for the individual to be lost in the management of any kind of care system. The bigger the system or the more pressed the resources in it, the more it moves to a procedure-driven model and the less the focus is on the individual. That is the kind of point that the hon. Gentleman raises, and I agree—that is exactly how it seems to me.
Let me move on to the last part of my amendment that the Minister might consider including in the Bill. I am utterly realistic; I have served on one or two Bill Committees in the past, so I know it is very unlikely that the Minister will leap to her feet and say, “That’s it—that’s brilliant! I’m having those.” That that is not on the cards is a severe disappointment to me, but I wonder if, rather than concern herself too much with the technical nature of my suggested additions to the clause, the Minister will reflect on the point I am trying to make about how to ensure that best interest is the first thing that people think about in this process, with less restrictive options and going the extra mile to try to find them, rather than going for restrictive options because they are convenient?
Finally, Sense argued in its briefing on the Bill that the cared-for person—this is the very point the hon. Member for Halesowen and Rowley Regis made—should be at the centre of the Bill, and every effort should be made to establish their feelings and wishes. My fear is that when the measures move from this nice green Government Bill and deliberations in this Committee to the operational stage of legislation, there is a real danger that they will become more about what we do to people, rather than what we do with and for the person concerned.
Caroline Dinenage
I thank the hon. Member for Birmingham, Selly Oak for highlighting the issue, about which I always listen to what he has to say. Of course, he is quite brilliant in his own special way, and he has taken a lot of time to engage with me and to do his homework on the subject, which is close to his heart. I am grateful for that.
I share the hon. Gentleman’s sentiment. As the hon. Member for Worsley and Eccles South said, we are talking about depriving somebody of their liberty, which is our most fundamental human right, so we cannot do it quickly, based on cost, or based on the current system, which Simon Wessely described as a “perfunctory and box-ticking” exercise. It has to be done with people’s best interests, and their wishes and feelings, at heart. Excellent care and the interests of the cared-for person have to be at the heart of everything we do.
In responding to the points the hon. Gentleman made in moving the amendment, it is worth reminding hon. Members that the Bill will not replace the current Mental Capacity Act 2005, but amend it. Best interest decision making remains fundamental to the existing Act, within which the liberty protection safeguards will sit. Before a liberty protection safeguards authorisation is considered, it will need to be decided that the arrangements are in a person’s best interests. That is included in section 4 of the 2005 Act. It must then be demonstrated that arrangements to enable that care and treatment are necessary and proportionate.
I understand the hon. Gentleman’s concern about the words “necessary” and “proportionate”, but the word “proportionate” was chosen because it has a specific meaning in human rights case law. It means that assessors must consider less restrictive options, and cannot base their decisions purely on cost or any other box-ticking exercise. The word “necessary” is used in conjunction with the word “proportionate” in the Bill, which means that the arrangements must benefit the person.
That part of the liberty protection safeguards takes place at the second stage test. I agree with hon. Members that it is fundamental for people deciding whether to authorise a deprivation of liberty to consider whether less restrictive options are available. A necessary and proportionate assessment would also include the consideration of less restrictive practices. Considering less restrictive alternatives is already an important aspect of the wider 2005 Act. In fact, the fifth principle of that Act specifies that decision makers have to have regard to less restrictive options. Nothing in the Bill changes that. Indeed, we will ensure that that is a core part of the consideration of what is necessary and proportionate.
On the matter of wishes and feelings, which the hon. Gentleman talked about so powerfully, it should be noted that they are already part of the first stage of best-interest decision-making under section 4 of the 2005 Act. I can confirm that the Bill does not change that. Wishes and feelings will form a key element of the necessary and proportionate test. During the Bill’s passage in the other place, we tabled an amendment that makes it explicit that regard must be given to a person’s wishes and feelings in relation to arrangements. We tabled a second amendment that explicitly requires the cared-for person to be consulted under the consultation duty. Those amendments were made purely because we agree that the person’s wishes and feelings should be at the heart of the liberty protection safeguards process.
I hope that that provides some clarification and reassurance for the hon. Gentleman. I am certainly not in the business of keeping the Bill as small and tight as possible just for the sake of it; if there are amendments that I feel will materially add to the Bill, I am more than happy to take them on. In this case, I hope that the hon. Gentleman will withdraw the amendment.
Steve McCabe
I was not planning to press it, so I beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Steve McCabe
I assume that the Minister has given quite a bit of thought to this matter already. Does my hon. Friend think that this is one area where it would be extremely helpful for the Committee to be able at least to see what is in the draft code of practice covering this area before the end of our proceedings? If the Minister and her officials have been giving quite a lot of attention to this, there may be some reassurance in the draft code of practice. If there is not—if it is yet to be drafted—it would be close to a dereliction of duty for us to say that that is acceptable on such a crucial point, namely that the person does not even get the opportunity to raise issues about what is being done to them until after it has been done.
Barbara Keeley
I very much agree with my hon. Friend. I understand the Minister’s difficulty with the code of practice. She has told us that it would have to be laid before both Houses, but the difficulty here is that the Government are trying to remove from the Bill provisions that strengthen safeguards, and are thus making those safeguards weaker. As I said earlier, I do not understand why this is happening at all; I do not understand why we would be expected to accept it or to think it was a good idea.
A code follows what is in statute, and sets it out in lay terms and at length, but it would not exist if the obligation in law was not clearly set out. I do not want the Minister to change obligations for information, yet that is what she appears to be doing. I want to make it clear that, for Labour Members, the right to information before authorisation must be on the face of the Bill. It cannot be something added to the code of practice—even if we could see it now, and the trouble is we cannot—because it would not be a right.
There is existing case law about the Mental Capacity Act code of practice. In 2018, in the case of NHS trust v. Y, the Supreme Court said:
“Whatever the weight given to the Code by section 42 of the MCA 2005, it does not create an obligation as a matter of law to apply to court in every case.”
I think that says it all, really.
Paragraph 13 is the right approach in the case of this Bill. Furthermore, a number of Labour amendments, including amendments 17, 40 and 41, which we will come to later, would strengthen the duty on the responsible body to promote appeals.
Alex Cunningham
Again, it is a pleasure to serve under your chairmanship, Mr Austin. This Government amendment—this move to remove paragraph 13 from the Bill—leaves me and others seeking much more information on what exactly is intended. I did not really hear from the Minister what I needed to know. It was a very short introduction to the debate, given the fact that this was long debated in the other place. The Lords brought forward the amendment to the Bill, which is now part of the Bill, with good cause. I am concerned that it has been dismissed quite quickly.
My hon. Friend the Member for Birmingham, Selly Oak talked about the code of practice. It is critical that we have the reassurance that if we are going to have to depend on the code of practice, we know what it will say. Therefore, I ask the Minister whether she will, rather than just depending on dumping this stuff into a code of practice, make a commitment today to come back during our conversations over the next few days or on Report and spell out specifically how we can be assured that the items and protections in the Lords amendment, which is now part of the Bill, will be covered? How will she guarantee that what the Lords achieved with that amendment will be fulfilled on Report?
Steve McCabe
I am not sure whether I have understood this correctly. As my hon. Friend the Member for Worsley and Eccles South outlined her concerns, I tried to understand how someone could ever be confident that their wishes and feelings had been fully taken into consideration if they did not get the information explaining what was happening to them until after it had happened. How is that possible?
Alex Cunningham
It is totally impossible. If someone does not have the information, how can they make an informed decision? Likewise, people who advocate for someone, whether parents, relatives or whatever, cannot do that if they do not have that information. If there is no information, it cannot be acted on.
I made my career out of journalism, public relations and communications.
Alex Cunningham
The Minister is nodding her head, which is very good news. She has given me that reassurance, so perhaps I do not need to continue with this particular line of questioning.
We should be very careful that a communication issue is not missed prior to an authorisation being recorded. Just because somebody cannot communicate in the same way that we can does not mean that they cannot communicate.
Steve McCabe
I do not want to disrupt my hon. Friend’s flow. It is very good to see the Minister nodding her head, but is that the same as an assurance that there will be an obligation? It would be easy to suggest that a person is not very communicative, but that would not be quite the same as acknowledging that the person has some speech and language difficulty. A hard-pressed individual making a rapid assessment might not arrive at that conclusion unless it was absolutely clear that they were obliged to check out that area.
Alex Cunningham
That is most certainly the case. The Minister will forgive me if I mention resources again. If people are hard-pressed, we should perhaps have more resources in the system to deal with that. My hon. Friend is perfectly correct, and I take some comfort from the Minister’s nodding. I do not so much like the bits where she shakes her head, but I like it when she nods. I think that that may indicate that she will be able to address the issue I raised at the beginning of this short speech and come back to us, either here in Committee or on Report, to spell out exactly how the protections will be covered elsewhere if they are removed.
Caroline Dinenage
I hope that what I will say gives the hon. Lady more clarity. Amendment 4 follows the current approach in the deprivation of liberty safeguards system—the DoLS system—which requires information to be provided as soon as practicable after authorisation is granted. We agree that from a legal perspective, that is a clear point at which we will always be able to carry out that duty. Amendment 4 removes the requirement to provide information about the process, which was in existing paragraph 13. This is a matter of drafting, but the paragraph did not list the significant parts of the process about which a person must be informed.
The Bill ensures that the person has the right to representation and support from either an advocate or an AMCP. If there is no appropriate person and the person does not have capacity, there is an effective presumption that an independent mental capacity advocate—an IMCA—will be appointed. Responsible bodies will ensure that the person has representation and support. The Government amendment includes steps to ensure that the cared-for person and the IMCA understand the authorisation and the right both to review and to access court.
Steve McCabe
Can the Minister share exactly what the draft code of practice says on the matter?
Caroline Dinenage
No, I do not have that to hand, but I have explicitly said that we will set out what the draft code of practice will include. I hope that that will give the hon. Gentleman more reassurance.
Caroline Dinenage
I am very happy to discuss the matter further with hon. Members, but the issue is that there is not a watertight trigger point. When we say that information must be delivered at the earliest opportunity, it is very difficult to codify and define that in law.
Steve McCabe
I do not want to get bogged down in legal technicalities, but why is it necessary for the legal trigger point to be after the authorisation has been made? Why could it not be at the start of the authorisation process? That could also be a defined legal trigger point, surely.
Caroline Dinenage
I am happy to commit to going away and looking at the matter again. I understand that it worries hon. Members; if I am honest, it worries me, too. As I understand it, the reason is that the starting point is different, depending on the individual circumstances.
That is the problem we have had with the current Bill, from beginning to end. We are looking to create a Bill that satisfies the needs of somebody like my elderly uncle who was living with dementia, as well as the needs of a 16 or 17-year-old who was born with a learning disability. We want the same Bill to cover the needs of a 30-year-old who has been involved in a road traffic accident and has an acquired brain injury.
It is very difficult to ensure that we cover the legal bases and offer the protection needed by every one of those individuals, with their own personal support requirements. That is why we have to pay close attention to what is legally cogent, and why it is important to ensure that the Bill contains a watertight trigger point.
Barbara Keeley
By moving this responsibility in the Bill to local authorities, which currently have this responsibility, we can ensure that people are more confident about expressing their feelings. The consultation process should act as a crucial safeguard to prevent people from being deprived of their liberty against their wishes. Without our amendments, I am afraid that all too often the Bill will not achieve its purpose.
I turn now to the burden of work that the Bill will place on care home managers, because that is an important aspect. I hope that I have made it clear that I do not think that it can ever be appropriate for a care home manager to have a role in this process, but more than that there is no evidence that care home managers want this role or could carry it out. There is currently a vacancy rate of 11% for registered care home managers—11% of care homes do not even have a manager. That is higher than for any other role in the care sector. Care home managers are overworked in many cases, having to manage care homes that are operating on increasingly narrow margins. They are not experts in mental capacity nor trained to carry out assessments. In short, the role that they may be given is not one that they are prepared for or want.
Given that they are overstretched, we can expect them to make mistakes on occasion—that is understandable. When people are placed in high-pressure environments and expected to do more than they reasonably can or want to do, something has to give. We should not be in a situation where that something is the proper process for the authorisation of the deprivation of somebody’s liberty. It would not be acceptable if the result of the Government’s underfunding of social care was that people had their liberty taken away based on a tick-box exercise by a care home manager who lacks the time and skills to do any more.
I understand that the Government estimate that it will cost just £20 to train a care home manager to carry out this role. I think it was said at a recent meeting of the all-party parliamentary group on social work that it takes years to train a social worker to get to the point of carrying out assessments. Twenty pounds represents perhaps half a day of training. The idea that after a few hours a care home manager will be able to go out and manage liberty protection safeguards is not plausible. These complex issues should be carried out by people who have experience and expertise.
As we heard earlier, local authorities already have teams dedicated to deprivation of liberty safeguards, so it seems a wasted opportunity not to use that resource. Ultimately, it would not even save money.
Steve McCabe
As I listen to my hon. Friend, I wonder if people are a little confused between process and practice and, as a consequence, are doing a disservice to the local authority or whoever the appropriate responsible body is and to the care home manager. Surely, it is the job of a good care home manager to provide and oversee the care and to give regular reports and information that explain how the cared-for person is responding to the care regime that they are receiving—what seems to help them and what may hinder them. That is extremely useful, because the alternative to that is that the person is being warehoused and there is no way of knowing what happens over a period of time. The process is to assimilate that information and think about it in the context of what is in the person’s best interests and where we should go next. By suggesting that the same person should do the same thing—and it is just the same thing—have we not ended up doing a disservice to both groups of people?
Barbara Keeley
I think my hon. Friend is right; that is the case. Ultimately, the point is that it would not even save money. Despite what the Government’s out-of-date impact assessment may say, care home managers will not be able to carry out this role for free. Time spent carrying out these authorisations is time spent not doing other work. Care home managers are not currently sitting around doing nothing all day, so there will be cost implications. When care homes are struggling to remain solvent anyway, these small differences cannot simply be absorbed.
The Bill comes at a time when social care is under enormous pressure. Years of underfunding mean that care homes are hard pressed to keep their heads above water. The brutal reality is that without more funding for local authorities, they will not be able to increase what they are paying to care homes, and that means that some care homes will have to carry out these assessment without any extra resourcing. That will mean that less time is spent delivering hands-on care and more time is spent dealing with this process. This is where the proposed reforms to the Bill would have a real implication for the delivery of social care as a whole. We need to see reform across the board if this is not to become another cost that we expect care homes to bear, pushing more of them into dire financial straits.
It would not be the first time the Government have done that. When they brought in the living wage, they made no effort to support local authorities so that they could pay providers more. When the Government updated their guidance on sleep-in pay, they made no guarantees to providers that they would support them to pay off their liabilities. The care sector cannot afford to continue to pay for Government decisions without being appropriately supported to do so.
Alex Norris (Nottingham North) (Lab/Co-op)
Thank you, Chair: I know you have put in a double shift as Chair today. I think that might help us get to the root of why this room is so warm. We are trying to echo the micro-climate in Dudley, which I believe is quite tropical at this time of year. It is a pleasure to follow my hon. Friend the Member for Worsley and Eccles South.
This set of amendments follows on from amendment 19. When we were discussing amendment 19, the Minister said that she would take under active consideration the issue around independent hospitals; I am very glad about that. I hope that perhaps she will take these amendments in the same spirit, as they extend the same principle.
At the beginning, prompted by my hon. Friend the Member for Birmingham, Selly Oak, the Minister said she felt that independent hospitals would be a particular focus, because the revelations that we have seen on television showed that there is risk there. I suspect that the same risks are built into the care home sector, too, because the preconditions are similar—for example, a financial vested interest, a lack of outside scrutiny and an unhealthy power balance between those who run such schemes and those who are resident there.
The vast majority of the time, the leadership in such facilities is excellent and is geared towards supporting the individual. However, where that is not the case, those preconditions build up that risk. As I say, what we have talked about in relation to independent hospitals also applies here. We need to address a fundamental question. We have said that we believe that the DoLS system does not work, that the backlog is not tolerable, and that we ought to move to more effective arrangements. That view is very broadly shared, but I do not think that anyone would wish, in reaching a system that is more sustainable for the public purse and better for the individual, to downgrade the assessors from qualified social workers with specific qualifications in the area to others—in this case, care home managers. That is not a good way of saving money or getting things done more quickly, and the best way to make that clear is by finishing the process that began in the Lords, as my hon. Friend the Member for Worsley and Eccles South noted, and completely removing the relevant references from the Bill.
There are a couple of reasons why that is necessary. First, finances in care homes are marginal. We might sometimes blanch at the cost, but we know that they can go to the wall quite quickly. As a result, there are subconscious commercial pressures that could colour a judgment, shifting it away from the best interests of the individual and towards the best interests of the care home in general. That, of course, is not what we seek to do.
It cuts both ways. We have spoken about independent hospitals having a perverse incentive either to hold on to an individual when it is not appropriate or to provide a much more comprehensive service than is necessary, but it can cut the other way, too. I am not aware of the picture across the country, but in Nottingham the most complex care packages in a residential setting are hotly sought after and we do not have a mass market for them; the market for more general needs care in my city is quite mature and sustainable, but that is not the case for higher-end care. A different perverse incentive could therefore arise for a care home if there are individuals for whom starting the assessment process or conducting periodic reviews is more trouble than it is worth. Whatever path we take in the rest of the Bill, the issue will continue to be tested in case law, and I do not know of many care homes that would gladly take on the responsibility of being on the other side of it.
As well as perverse incentives either to keep people or to ensure that they do not stay, there is a second point, as my hon. Friend the Member for Worsley and Eccles South said: are care homes really the right responsible body? I did not know—I am disappointed that I missed it in my research—about the £20 training for care home managers in a really important subject. Of course that is not sufficient; I cannot imagine that it could cover anything beyond filling out a form in a legally compliant way. It instantly pushes us towards a tick-box approach, which nobody wants—an approach that is about clearing the necessary barriers to legal compliance, rather than working around the individual’s needs and being person-centred.
As my hon. Friend said, there is a double risk. Some local authorities will identify the risk straightaway; others will not. Those that are feeling particularly hard-pressed will say, “It is our legal responsibility to ensure that somebody does this, but it does not have to be us.” With public sector cuts as they are, there is a series of perverse cost incentives throughout the health and social care system that result in individuals being pushed from one organisation to another; this will be one such incentive. Other local authorities—we have heard some good examples—will say, “Hang on a minute: this is far too important for that,” but portfolio holders and directors of adult social services are under incredible pressure.
Steve McCabe
Is this another situation in which we are in the dark because of the missing code of practice? It may be the case that if the Government have thought about that there will be examples in the code of practice saying how it should operate, what the minimum expectations are to avoid a tick-box approach, what good practice is and what people should aspire to achieve. If we had sight of that—if we had some indication that it was on the Government’s agenda—it might be easier for us trying to scrutinise the Bill, and it would offer some reassurance to the wider public that the fears that have been expressed will not prove well-founded.
Alex Cunningham
During today’s debate I have already raised concerns about independent hospitals, and about care home managers and their potential role in depriving people in their care of their freedom. I know that my hon. Friend the Member for Worsley and Eccles South has addressed that comprehensively, but I hope that I can still add some value to the debate.
Even if there was some way in which the Government could justify the role of care home managers as outlined in the Bill, there is still a huge number of reasons why the sector would struggle to deliver what Ministers want it to. My hon. Friend has talked about the fact that finances in care homes are very much on the margin—they could be bust one day and make a bit of profit the next. However, some care homes do not even have care home managers. In hundreds of others across the country, the level of competence of managers in running care homes is alarmingly poor. We have some of them in my constituency. We have some great managers, and we have some excellent care homes, but we also have some that fall into the “inadequate” or “requires improvement” categories on inspection. It is not good enough for us to consider handing over this level of responsibility to people who might not be competent, or might not even be there in order to carry out the work.
On the CQC website, 2,550 care homes are listed as requiring improvement, with a further 223 deemed “inadequate”. Some of them are very large homes, but let us say that each one has an average of just 25 people in their care. That would mean that some 70,000 elderly people in care are being failed by the system. Leadership in those homes is one of the reasons they are being failed, and CQC reports bear that out time and again.
I know that that is symptomatic of a broken adult care system that has been neglected by the Government. I am sure that the Minister wants to wring my neck when I start talking about resources again, but it is about inadequate resources. Even after allowing councils to hike council tax to boost the social care budget, there is still insufficient money in the system. Profit-taking companies are often failing to provide adequate care, citing as the reason that they cannot afford to do so.
The system is in danger of failing further, as care homes close and the number of people requiring residential support increases. How on earth can the Government justify placing this most important duty on care home managers, asking them to play a central role in depriving the people in their care of their freedom? Given that the system is broken, that thousands of care homes are not anywhere near the required standard, and that in many cases there is no one competent—or no one at all—in the home, who will fill the gaps and deal with deprivation of liberty issues there? There may be other reasons why someone needs to do the work planned for the care home managers. If there is no care home manager, who are the Government expecting to carry out these assessments? Those managers do not want this duty, so what happens if a care home manager says, “I am simply not prepared to do this work; I do not want this responsibility”? Again, who will pick up that work? Will it fall on the local authority, the local GP commissioning group, or the health board?
Steve McCabe
Is not the reality that if the scenario my hon. Friend has depicted comes to pass, we will have a different backlog? We will have gone through this whole exercise and, rather than having fixed this system, we will have transposed one problem for a different one with exactly the same impact.
Alex Cunningham
Indeed that is the case. There are probably thousands of people in the system at this time who are illegally detained, or whose freedom has been denied them; we can do without additional problems of the sort that my hon. Friend describes. I talked about the fall-back position: if there is nobody in the care home who can do this work, and it does fall back on the local authorities or some other organisation, they are already dealing with very strained budgets and an overload of work, so how do we fill that gap? Again, I ask the Minister how she will ensure that these organisations have the resources that they need, even if the duplication that she was describing earlier in the day is sorted out and the systems run far more effectively. I am aware that if our amendment is successful and these duties do not sit with care home managers, the bill for work by these other organisations will be all the greater. Again, how on earth will that be funded?
Of course, the system can work. I cite the case of the north-east of England, where the DoLS system probably works better than in other parts of the country—albeit that local authorities have chosen to take the political decision I talked about earlier. However, that is letting other services down because they feel that they must protect the interests of people whose liberty is at risk. I will return to my point about the north-east a little bit later, as I want to go back to the topic of care home managers. Does not the Minister agree that most of them should be working to improve or maintain their CQC ratings and all that comes with that, rather than carrying out those assessments of individuals in their care?
I intervened on the shadow Minister to talk about charges. Some care homes may even charge a self-funder an administration fee for the assessments. Who says that is fair, right, or proper—Members can use whatever word they like? Who on earth governs that, and who is protecting the person who is having to shell out the cash? What is to stop a care home manager from unnecessarily charging fees for “administration purposes”? Who is there to say otherwise? I said this morning that we need to protect the public purse and the purses of those who live in these establishments; this is another example of that. One of the pieces of written evidence we have received comes from a collective of organisations, including the Registered Nursing Home Association and Care England. It says:
“There is no reason for singling out care home managers for extra responsibility, over their colleagues in other care settings, except for to transfer significant costs from struggling local authorities to struggling care homes. The effect will inevitably be that some providers who continue in the sector…pass on the costs to the affected residents.”
My hon. Friend the Member for Nottingham North discussed that.
So there we are: care home associations do not want the responsibility of assessments; the persons involved will not want the care home to have that responsibility; and we Labour Members, who probably matter less than them, do not want care homes to have responsibility for assessments, so why are the Government continuing to push this? Any opportunity a care home manager has to improve their organisation’s financial outlook is bound to be considered. That is all the more reason why it should not be their job to carry out assessments for a person when they have a vested interest—and a financial interest, at that. The Alzheimer’s Society also has a concern; it argues that we urgently need clarification of the role of care home managers, and how to protect the independence of the person being cared for. That is currently dealt with by best-interests assessors. My council of Stockton-on-Tees has raised concerns with me about the fact that the decision as to the necessity of assessment still appears to rest with care homes.
I thank Angela Connor and Natalie Shaw from the Stockton DoLS team for taking the time to talk to me about their work and how it will be affected by the Bill. They provided me with some follow-up notes, for which I am very grateful, because in one hour they built my understanding more than all the reading that I had tried to do. Like others, they posed many questions. Where is the quality assurance? Who is going to check that what they are doing is both correct and within the law? Despite the obvious conflict of interest, local authorities rely on assessments made by a care home manager, including allowing care home managers to carry out a consultation to determine a cared-for person’s wishes.
Between 2013 and 2018, there was a 5,000% increase in the number of applications under the Mental Capacity Act that my local authority received. Stockton-on-Tees Borough Council created the DoLS team in 2014 to manage the applications. As I said earlier, we are quite lucky in the north-east because there has been a regional arrangement in place that means that mental health assessors are paid a fixed fee of £175 for three assessments—buy two, get one free—and best-interests assessors are paid £175, again for three assessments.
As I mentioned earlier, the number of completions of DoLS in the north-east was higher than in the rest of the regions, and applications are taking a shorter time to process. Dedicated DoLS teams have been established across the region. Independent assessors are used, and that raises awareness with managing authorities. Yet the Alzheimer’s Society tells me that the Bill would remove the post of best-interests assessor; part of their responsibility will shift to care home managers, who I think are ill equipped to perform the role. The DoLS team in Stockton tell me that they believe that the Government’s proposals will lead to a diluted assessment.
I agree with what the Minister said this morning about ending the duplication of assessments, cutting out waste and targeting limited resources where they are most needed, but that must not be done by diluting the assessment process. I am interested to hear what the Minister has to say to address the concerns of so many stakeholders in this area.
The Government’s proposals, under which care home managers, who are held responsible for providing care, are also responsible for assessment, are not in the best interests of the person affected. I do not believe that the Government intended to create this clear conflict of interest. If care managers are not to be removed from the process entirely, I hope the Minister will outline in detail exactly how this serious situation is to be avoided. We may have to rely on information provided later. A code of practice is all very well, but we need the detail now. If we do not have the assurances we require, how on earth can we support the Bill?
Caroline Dinenage
I understand the hon. Lady’s concerns, but she is not 100% correct. Where there are concerns about the care home, it is possible for the local authority, which would normally be the responsible body, to carry out these functions. Care home managers should be able to arrange assessments and identify and provide valid assessments previously completed by the responsible body. Let me say why. This goes to the crux of why care homes and the system face this overwhelming bureaucracy today.
Let us take a straightforward case, such as that of my uncle, whom I spoke about earlier. He was in a care home—he is sadly no longer with us—and he was very happy. We were very happy with him being there. There was a clear medical assessment of his condition and his state on the care home’s books. Why couldn’t the care home manager gather that? If there was no care home manager, or if the local authority—the responsible body—had any concerns about that person, their role, or their ability to fulfil that function, they could do it themselves, as they currently do.
Steve McCabe
The Minister told the Committee earlier that she did not want to put too much detail in the Bill in case that in itself became a restrictive problem. If good care home managers are already involved in and informing the process as part of good practice, why does that need to be specified in the Bill? She is telling us that this happens anyway. Presumably, this could be cited in her code of practice as an example of good practice. The role of the care home manager that she describes is one of informing the responsible person, and using their knowledge and experience, gained through engagement and regular contact with the individual, to help inform the process. Presumably, that is just existing good practice, and it could be included in the code of practice. She may want to follow her own example of not cluttering her Bill by being too specific. This is an opportunity to take something out to help her achieve what she wants to.
Caroline Dinenage
I am grateful to the hon. Gentleman for that kind offer, but we intend to build on the role that care homes already play. Care home managers already daily identify that a person may lack capacity and need restrictions, take part in constructing a care plan, and liaise with mental health professionals. We are committed to supporting them further in doing that, ahead of implementation. We want to make sure that training for the workforce is delivered, and want the development-type model that I have spoken about.
I spoke a lot today about reducing the backlog. That will help enormously in reducing the burden that falls on care homes. They will not have to keep chasing applications that are in local authorities’ backlog in order to get protections regarding the legal right to hold somebody in their care. The care home manager is often in a strong position to identify whether a person objects to the arrangements. Having a role in the consultation allows them to do this.
Mental Capacity (Amendment) Bill [Lords]
Steve McCabe ExcerptsTuesday 18th December 2018
(5 years, 4 months ago)
Commons ChamberRead Full debate Mental Capacity (Amendment) Act 2019 View all Mental Capacity (Amendment) Act 2019 Debates Read Hansard Text Read Debate Ministerial Extracts Amendment Paper: HL Bill 147(a) Amendment for Third Reading (PDF) - (5 Dec 2018)
Steve McCabe (Birmingham, Selly Oak) (Lab)
Coming here tonight, I thought that this was in origin a well-intentioned but flawed Bill, but after listening to the Secretary of State I am not sure we are discussing the same legislation. It is hard to believe that in a free society such as ours, probably more than 125,000 people are currently denied their lawful liberty because of failings in the system. We need to improve the situation, not make it worse.
As with much of this Government’s legislation, the Bill seems to be more about reducing costs than protecting and promoting the rights of vulnerable people. As we have heard, the impact assessment was produced before a raft of Government amendments were made, so there is now a clear argument for producing an updated assessment before we proceed. The attempts to transfer some of the responsibilities set out in the Bill just do not make sense. I am not sure it is wise to transfer any responsibilities for things such as liberty to bodies such as CCGs. They are already very stretched and prone to questionable judgments on delivering equality and fairness in the NHS.
There are real doubts about the protections in the Bill. Access to legal aid is a Catch-22 if a person qualifies for it only after they have been deprived of their liberty. How can that be fair? There is also concern about the length of detentions and authorisations. Sir Simon Wessely recommended that initial detention should be reduced to three months, with a three-month renewal and six-month periods thereafter. Under the Bill, despite what the Secretary of State claims, a person can be subject to an order for three years.
The Bill does not put the interests of the cared-for person at its heart. The existing arrangements explicitly state that deprivation of liberty may be granted only where it is in the best interests of the cared-for person. The Government should make it clear on the face of the Bill that depriving a person of their liberty must be in their best interests, and should come only after the consideration of less restrictive options.
Proposals must ensure the right of a person to object to and challenge arrangements if they so wish, and that they have appropriate support and representation to do so. Access to an approved mental capacity professional is currently available only in limited circumstances. That is wrong: access should be made available in all cases. Scrutiny for pre-authorisation reviews should be extended to all situations in which a person might be considered vulnerable.
All cared-for people in private hospitals should have an independent mental capacity advocate appointed, and all authorisations must be carried out with approved mental capacity professional oversight. Independent oversight is essential in all cases, as cared-for people may not be able to object in the formal sense. Appropriate advocacy must therefore be available. The Royal College of Psychiatrists rightly draws attention to its concern that no one should have their liberty denied because of a mental disorder without first being seen by a qualified doctor.
It is essential that these matters are dealt with properly, which is why there are real concerns about the role of the care home manager. It is wrong that they should make the decision on independent representation. As drafted, the Bill makes the care home manager responsible for carrying out the consultation with the cared-for person, when the main purpose of that consultation is to ascertain that person’s wishes. Nor can it be right that the choice of assessor should lie with the care home. There is an obvious conflict of interest if independent health and care providers are responsible for both providing a service and deciding on that service’s suitability. The Bill allows for managers of independent hospitals to authorise deprivation of liberty when care is being delivered in their hospital. That is plain wrong.
Diabetes: Artificial Pancreas
Steve McCabe Excerpts(5 years, 5 months ago)
Commons ChamberRead Full debate Read Hansard Text Read Debate Ministerial Extracts
Mr Howarth
I am grateful to my hon. Friend for that intervention. He is right in what he says, and I will be covering precisely that point later in my speech.
A recent JDRF-funded trial found that the artificial pancreas is better at helping people to manage their glucose levels than the best currently available technology. People who used the artificial pancreas spent 65% of time with glucose levels in range, which compares with 54% of time for people using a continuous glucose monitor and an insulin pump. Unfortunately, as my hon. Friend mentioned, there are significant regional variations in access to existing diabetes technologies, such as insulin pumps, in many parts of the country. The most recent national diabetes audit, published in July 2018, shows that although the overall uptake of insulin pumps has increased, the proportion of people with type 1 diabetes attending specialist services who are treated with pumps varies from a pitiful 5% to 40% at best.
Steve McCabe (Birmingham, Selly Oak) (Lab)
I do not know whether my right hon. Friend is familiar with a group called #WeAreNotWaiting. They are people who are developing their own equipment, pumps, monitoring system and computers, because they are not prepared to wait for technology that could be made available to help them.
As my right hon. Friend says, the pumps are available but not widely available on the NHS, despite being a leading British technology. Of course, the other problem is that there is no push from the Government for concerted commercial development of these systems in this country.
Mr Howarth
I am grateful to my hon. Friend for that intervention. I am aware of the #WeAreNotWaiting group and as recently as earlier today I had an email from one of them. I will not name them, because I do not have permission to do so.
Mr Howarth
My hon. Friend may have been late, but he is never behind. Of course I agree with him.
In October, I tabled a written parliamentary question to the Secretary of State for Health and Social Care, asking how many patients with type 1 diabetes had been referred for psychological support, psychiatric support, and treatment for an eating disorder or diabulimia in the last 12 months. I was told that the information is not held centrally. I then took the matter up with Knowsley clinical commissioning group, but it turns out that it does not hold that information either.
The lack of psychological support for adults and young people with type 1 diabetes is a real and important issue. It was one of the key points in the national service framework for diabetes when that was first brought into being. Most patients on Merseyside, which is my part of the world, still cannot get the support that they need.
Diabulimia, which is a syndrome, rather than a condition, is an eating disorder present among those with type 1 diabetes. It involves the omission of insulin doses, which leads to high blood glucose levels and the body’s cells being deprived of oxygen and energy. The available research suggests that around 40% of females between the ages of 15 and 30 with type 1 diabetes deliberately induce hyperglycaemia and diabetic ketoacidosis in order to bring about weight loss. Anyone can go on the internet and quite easily find out that if they omit to use their insulin, they can probably lose half a stone in a week, but of course the risks in involved in doing so, including damage to vital organs, should not be taken at all.
According to the charity Diabetics with Eating Disorders, 60% of all females with type 1 diabetes will have experienced a clinically diagnosable eating disorder by the age of 25, and new research suggests that 11% of adolescent males also engage in insulin omission for weight loss. I just want to pause at this point and say a word: although I am describing something that affects type 1 diabetics, it is all part of a wider problem of body image and an obsession with a particular type of weight range. Although diabetics, because of their condition, have a different means of achieving that weight loss, it is an issue that has to be addressed nationally. I know that the fashion industry, for example, has started to make some moves in that direction, but it is a national problem, particularly for many young women who feel that they have to look a certain way to be acceptable. That is, of course, nonsensical, but, nevertheless, it is the way that some of them feel.
Sandie Atkinson, a PhD candidate at Liverpool John Moores University, believes that there is a lot more that clinics can do to reduce the psychological impact of type 1 diabetes and, as a consequence, reduce the prevalence of diabulimia. She says:
“By being empathetic to the issues that impact blood glucose level outside of the realm of an individual’s ability to manage and having realistic expectations of them in light of these uncontrollable factors, individuals might feel less inclined to hide their true condition from Healthcare Professionals. The likelihood of them being more open would undoubtedly be in the best interest of the patients and the NHS at large.”
While conducting her research, those whom Sandie spoke to described the problems that they had in accessing support in clinics. One participant said:
“Eating disorders thrive on secrecy and yet people feel with diabetes they can’t be honest about the expectations of where they are with control so there’s two lots of secrecy there that really does a lot more damage”.
A second interviewee said:
“There’s something about the way that we treat diabetes and I don’t know if it’s maybe because there is some internal stigma, but there’s something needs to be done…I just kind of feel like we’ve got it all wrong…right from the off you should have a psychologist…at least for the first year. I mean the research is all there, suicide risk goes up, self-harm risk goes up, mental health declines…We know this but we’re like, ‘oh yeah, we’ll see you in six months’ time’.”
To progress towards artificial pancreas systems, there are a number of things that the Government must do. The NHS needs to establish a new national framework that encourages innovation. The framework could include some of the following elements: first, a national strategy, with allocated funding, for diabetes technology, allowing all people with type 1 diabetes to self-manage their condition by considering individual medical need and the potential to improve quality of life and psychological aspects of care.
Steve McCabe
If the NHS were to develop that approach, would it not, as well as giving people much more freedom, autonomy and control over their life, produce massively more data—the strongest commodity in the NHS at the moment—which would mean that we could predict this condition, and look at other possible methods of controlling or treating it?
Breast Cancer
Steve McCabe Excerpts(5 years, 6 months ago)
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Westminster Hall is an alternative Chamber for MPs to hold debates, named after the adjoining Westminster Hall.
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This information is provided by Parallel Parliament and does not comprise part of the offical record
Steve McCabe (in the Chair)
This debate can last for up to three hours, but hon. Members are not obliged to fill the entire time.
Laura Smith (Crewe and Nantwich) (Lab)
I beg to move,
That this House has considered the future of breast cancer.
It is a pleasure to serve under your chairmanship, Mr McCabe, and to have been selected to introduce this important debate. I welcome my hon. Friend the Member for Washington and Sunderland West (Mrs Hodgson) and, of course, the Minister. Their presence underlines the importance of this issue. I also welcome everybody in the Public Gallery, many of whom have had personal experience of breast cancer, and all other hon. Members here today. It is important that we demonstrate our commitment to raising the profile of this issue across the party political divide. I am sure we have all been touched by this terrible disease in some way in our own lives.
I pay tribute to the remarkable people up and down the country who raise awareness of breast cancer and fight against it in their everyday lives. I want to take this opportunity to mention Rachael Bland, the BBC Radio 5 Live newsreader and presenter, who sadly passed away on 5 September. She did a remarkable thing by blogging about her experience in “Big C. Little Me.” and bringing down the barriers when it comes to living with breast cancer. Her strength and courage touched many of us, and her family and friends should be incredibly proud of her.
Between 2014 and 2016, an average of 457 women a year developed breast cancer in the South Cheshire clinical commissioning group area, which covers my constituency of Crewe and Nantwich. Sadly, in the same period, an average of 101 women lost their lives to the disease.
Today is World Menopause Day. It may seem odd that I have chosen to start my speech by talking about what might, at first glance, appear to be an unrelated issue, but the reverse is true. Breast cancer is most commonly diagnosed in women between the age of 50 and 65—the age at which women undergo the menopause. Some breast cancer treatments can bring about menopause symptoms, because they reduce oestrogen levels in the body. To make matters worse, women diagnosed with breast cancer usually cannot use hormone replacement therapy, the primary treatment for menopause symptoms, because there is strong evidence that it can increase the risk of breast cancer coming back. Some might ask whether it is really a big enough issue to warrant special attention, but we cannot afford not to pay special attention to it.
It is absolutely vital that we continue the fight to ensure that those diagnosed with breast cancer live, but we must also fight to improve their quality of life. About 70% of women with breast cancer experience severe night sweats and hot flushes, which cause major physical discomfort and anxiety, and affect their confidence. In some cases, they can even lead to serious sleep deprivation. Such problems can persist for many years. The severe and persistent symptoms of menopause are one of the main factors contributing to women discontinuing their treatment. Given that doing so can increase the chance that their breast cancer will come back, we have simply got to take this issue seriously.
What can be done? Professor Fenlon of Swansea University believes that cognitive behavioural therapy can help to ease physical symptoms, and is leading a clinical trial to assess how feasible it would be to train breast cancer nurses to deliver it. If clinical trials deem it to be effective, it has the potential to improve the quality of life of half a million women living with or beyond breast cancer in the UK, so I urge the Government to provide the NHS with resources to make the programme available in all our hospitals.
That brings me to the next issue I want to focus on: the geographical inequality in treatments and related services. It is important that the advances that I hope we are about to make in this area benefit everyone. The main CCG covering my constituents is NHS South Cheshire. I am proud to say that it was recently rated outstanding based on four pan-cancer measures, including waiting times, one-year survival rates and patient experience.
However, the report by the all-party parliamentary group on breast cancer states that there is a postcode lottery for breast cancer outcomes. All hon. Members will agree that it is simply unacceptable that women in some areas are more than twice as likely to die prematurely as women who are treated elsewhere. My CCG is set to merge with three others in the near future, and I want to ensure that my constituents continue to see waiting times fall, survival rates rise and the patient experience improve. I was shocked to read that women in some areas are one third less likely to have attended breast cancer screenings in the past three years than women living in other parts of the country.
Patients have had issues accessing off-patent drugs such as bisphosphonates, which were originally licensed for the treatment of osteoporosis but were discovered to be effective in preventing breast cancer recurrence in some post-menopausal women. When CCGs were asked last year whether they routinely fund bisphosphonates for that purpose, only 42—20%—said that they did. At the time, South Cheshire CCG said it was not doing so. I hope that the situation has improved, given that the National Institute for Health and Care Excellence has recently published updated clinical guidelines that recommend bisphosphonates. I am currently waiting to hear back from South Cheshire CCG. Is there an opportunity for the Government to make some specific interventions in the NHS long-term plan to prevent more cases of secondary breast cancer?
There is currently little incentive for manufacturers to license off-patent drugs for new uses in breast cancer. Breast Cancer Now is calling on the Government to introduce a catalyst fund in the NHS long-term plan to provide that incentive. That would make it quicker and easier for patients routinely to access cheap off-patent drugs. Breast Cancer Now commissioned York Health Economics Consortium to model how many lives we could save if the best outcomes were reached everywhere. It found that more than 1,100 lives could have been saved in 2016 if all CCGs in England had been able to reduce their mortality rates to match the lowest. Geographical inequality is not just an issue of principle; we have the potential to save lives, and if we save only one life, does that not make it worth addressing?
I would be grateful to hear from the Minister about the steps he is taking to facilitate the sharing of best practice between cancer alliances to reduce those variations. What conversations has he had with the Chancellor and his Treasury colleagues to ensure the long-term funding of cancer alliances?
If cancer alliances are properly to invest in the future of services and plan strategically, we must provide them with multi-year budgets. The APPG’s report on geographical inequality highlights that there are still worrying gaps in data collection, including in relation to the number of people living with secondary breast cancer. It is absolutely essential that we improve the cancer dashboard with more detailed performance data. After all, identifying and understanding these inequalities is the first step towards addressing them.
Universal Health Coverage
Steve McCabe Excerpts(5 years, 10 months ago)
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The Parliamentary Under-Secretary of State for Health and Social Care (Steve Brine)
I am sorry for my musical chairs during the debate, Mr McCabe, but I could not hear everyone from the end of the Chamber—I think it is my age and the heat. I thank the hon. Member for Strangford (Jim Shannon) for, as always, an interesting speech. I congratulate him, especially today—birthday day—on securing the debate in his residence of Westminster Hall. He mentioned that he might still be here in 2050—I would almost hazard a wager with the hon. Gentleman about that one, but I hope we shall all still be here.
Was not 5 July 1948 a pivotal day for our country, with the inauguration of healthcare free at the point of use for all our citizens? Seven decades later, the NHS remains one of our nation’s most loved institutions. The NHS is often described as the closest thing we have to a national religion, and this lunchtime a service in Westminster Abbey proved the point. The NHS is one of our country’s crowning achievements, possibly the crowning achievement—along with the English football team, of course—and it is the envy of people across the globe. When I travel around the world in this job, people are fascinated by and envious of the NHS in equal measure.
As has been said by my shadow, the hon. Member for Washington and Sunderland West (Mrs Hodgson), and everyone else who has spoken today, the NHS is of course nothing without its fantastic staff, who show such a level of Christian compassion—some without even knowing it—day in, day out. More than 1.5 million people work each day to provide the best possible care for our constituents.
The questions that the hon. Member for Strangford asked are important. We are the proud owners of an excellent universal healthcare system, albeit one we continually strive to strengthen, as we must—the best friends are prepared to criticise, and the NHS is not above criticism in our struggle to make it better—but he asked what we are doing to share our experiences. I shall certainly be able to cover that point.
The health of UK citizens is not dependent only on action in the UK. Diseases do not respect borders, and we need to act internationally to protect ourselves as well as to help others. Not only is that relevant when an outbreak hits—recently we had an Ebola outbreak, which I have monitored closely—but we must keep working with other nations to strengthen their capacity to prevent, detect and respond to diseases. UHC is critical to that. Threats such as that of antimicrobial resistance, which the hon. Gentleman mentioned in his opening remarks, can be tackled only through global action.
There is much that we can learn from each other. The NHS has evolved a huge amount since the late 1940s, and the next 70 years will require ongoing adaptation and innovation as we deal with the challenges of 1 million more over-70s—the ageing population—and further reap the rewards of scientific advancements, which have been so central to the NHS in its first 70 years. Other countries develop innovative approaches that we may not yet have considered—it is not all about the great empire of Britain, telling the rest of the world how things shall be—and there are plenty of challenges that no one has yet cracked. We should work together, and we do. It is right that we support others who have not yet achieved universal health coverage to do so, including by sharing our experiences.
We are committed to delivering the sustainable development goals, which the hon. Member for Cumbernauld, Kilsyth and Kirkintilloch East (Stuart C. McDonald) mentioned, including SDG 3. That is crucial to tackling many other health challenges, including the improvement of maternal, newborn and child health, as he said, and specific diseases such as TB, HIV, malaria and—everyone rightly mentioned this—pneumonia, the single largest infectious cause of death in children worldwide.
Universal health coverage is a goal, not a blueprint. Country needs, plans and perspectives are central to our work, and we have no interest in imposing an NHS model. It is crucial for each country to find its own path to UHC, which may entail greater private sector involvement, if that is what the country wishes, or a national health insurance scheme if that is what the politicians are brave enough to do. That is not our choice, but it is the choice in some parts of the world. We cannot just go with our judgment in trying to help other countries achieve universal health coverage.
Poorer, marginalised populations must achieve better access to good-quality essential services without the risk of financial hardship, as we choose in our NHS. Support for UHC must also involve helping countries to achieve sustainable funding mechanisms for their system, whichever they choose. The countries in greatest need deserve our financial support, but the ultimate goal must remain to transition to domestic funding, so that countries can maintain health systems in the long term.
The UK engages on UHC in a number of international forums. We strongly support the World Health Organisation’s focus on UHC through its new general programme of work, and we provide funding through a number of DFID programmes. We engage on this topic at governing body meetings and our annual UK-WHO strategic dialogue. I have a good, open and direct relationship with the head of the WHO, as part of my responsibility for international health at the Department of Health and Social Care. Underpinning the WHO’s success is a strong and effective organisation, and the UK continues to promote reform of the WHO so that it is the best it can be. As the second largest donor to the WHO, we are in a very strong position in that regard.
We promote UHC as a priority in other forums such as the G20 and the G7; I attended the G7 Health Ministers meeting last year in Milan. We were pleased to see strong commitments on health in the recent Commonwealth Heads of Government meeting, including on eye care, which I am passionate about. We will continue to follow up with the Commonwealth secretariat on the implementation of everything that was agreed in London. The high-level meeting on UHC at the UN General Assembly in 2019 will be an important opportunity to share experiences and to drive greater collective action. I will pass on the hon. Gentleman’s request, which I agree with, for us to use our chairmanship of the Commonwealth to further the UHC agenda that we all believe is so important.
My Department has rightly taken on a global leadership role on patient safety, along with our German and Japanese counterparts, to whom I spoke directly at the G7 Health Ministers meeting last year. Hon. Members will know that patient safety is the central mission of the Secretary of State. It is crucial to universal healthcare—as the hon. Member for Cumbernauld, Kilsyth and Kirkintilloch East rightly says, the aim cannot just be universal healthcare but must be good-quality and safe universal healthcare. Providing access but not quality care is not truly delivering on the sustainable development goals. We hosted the first global ministerial summit on patient safety in 2016, bringing together political leaders and experts to galvanise action on this crucial issue. Subsequent summits in Germany and Japan have continued that legacy.
Another key but often overlooked facet of universal health coverage is addressing mental as well as physical health. Again, my Department is taking an international role: we will host the first global ministerial mental health summit in October. The summit will bring together political leaders, experts by experience, policy makers and civil society to share innovative and effective approaches to mental health care, which the Prime Minister has rightly said is one of her main priorities. The Department of Health and Social Care frequently receives ministerial and official delegations from overseas to look at topics as diverse as childhood obesity, on which we lead the world; emergency response, as we often send people around the world; and elderly care.
The international team, which the hon. Member for Strangford mentioned and which I look after, manages the Department’s bilateral and multilateral engagement, working closely with colleagues at DFID and across Government. The team also leads on co-ordinating global health strategy across Government and on the health implications of trade and of the UK leaving the European Union.
The hon. Gentleman asked about our support for low and middle-income countries. The UK has a number of programmes with those countries. They are largely led by DFID, although a number draw on my Department, the NHS and Public Health England, for which I have ministerial responsibility. The UK supports the aim of countries working towards universal health coverage, with priority given to ensuring that poorer, harder to reach populations achieve better access to good-quality essential services without risk of financial hardship.
We apply a health systems strengthening approach to all health investments. That includes addressing global health security issues such as antimicrobial resistance; scaling up nutrition interventions, which are about building up country resilience; improving reproductive, maternal, newborn and child health; and targeting specific diseases such as HIV, TB and neglected tropical diseases. One of the first things I was able to do in that space was to speak at the family planning summit organised by DFID over the road at County Hall, which was backed by Bill and Melinda Gates, about our record in driving down the teenage pregnancy rate in this country. Of course, getting reproductive health right often helps developing countries to make their health systems more robust and sustainable.
The hon. Gentleman mentioned the delicate subject of male circumcisions and HIV. He is right to say that circumcision is practised across many parts of Africa to prevent HIV. The WHO and the UN consider male circumcision to be effective in HIV prevention, where there are heterosexual epidemics and high HIV and low male circumcision prevalence. However, the practice provides only partial protection. The procedure should not be seen as a green light to risky behaviour; it should be one element of a comprehensive HIV protection package. It would be remiss of me not to mention that I get a lot of letters on this subject. A number of campaign groups in this country and around the world make arguments about the human rights elements of the matter, especially when children undergo circumcision surgery, and its impact later in life. It is important to recognise all those facts, but the hon. Gentleman is right to mention it as part of the toolkit used in certain countries, Tanzania being one of the most prevalent.
We provide support directly to countries, work through the WHO and scale up targeted, cost-effective preventive and treatment interventions through global initiatives such as the global health fund, Gavi and the global financing facility. We are the largest donor to Gavi, which provides developing countries with pneumococcal vaccine to protect against the main cause of pneumonia. Between 2010 and 2016, 109 million children received the vaccine; we estimate that saved about 760,000 lives.
The health partnership scheme is another good example of how the UK can use our expertise overseas. Since 2011, we have trained 84,000 health workers across 31 countries. The scheme relies on volunteers from the NHS who help to support the training of staff overseas and benefit themselves through gaining new skills and motivation. Last October, the Minister of State, Department for International Development, my right hon. Friend the Member for North East Bedfordshire (Alistair Burt), who I work closely with across Government, announced the new £30 million programme with the catchy title “Stronger Health Partnerships for Stronger Health Systems”. It will run for five years from 2019 and will support partnerships between leading UK institutions and those in developing countries.
One of the benefits of being the Minister in these debates is that sometimes I can mention the good things that happen in my constituency. Hampshire Hospitals NHS Foundation Trust, which covers the Royal Hampshire County Hospital in Winchester and the Basingstoke and North Hampshire Hospital, has two very good international links, including with Yei in South Sudan, where a number of medical professionals from that trust have worked on antibiotic resistance studies, looking at the bacteria that can cause pneumonia. In collaboration with the Rotary Club in Winchester and the Brickworks, which is a Winchester-based charity, it has secured funding for textbooks to repopulate a midwifery and lab training institution and funding to build schools for South Sudanese refugees in Uganda, so that refugee children can continue their primary and secondary education. There will be examples in the constituencies of Members throughout the House of health professionals using such expertise as part of their upskilling, but also to help those less fortunate than us.
The UK offers development opportunities for the medical workforce globally. The medical training initiative allows overseas medical specialists to train in the UK for up to two years, to see our system close up, so that they can return to their home country and apply their skills and knowledge to the benefit of their population. Of course, that benefits the NHS by providing extra staff, who we desperately need, and enhances the clinical capacities of health systems in low and middle-income countries. We estimate that just over 3,300 overseas doctors have taken part since 2009. I know the House will be interested in that positive programme.
We are passionate about tackling AMR, and we are committed to doing so. My Department is working across Government with a wide range of stakeholders to refresh our AMR strategy, which rightly gets a lot of attention in the House, with a view to republishing it at the end of 2018. I know that the hon. Member for Strangford will be interested in that. One of the ambitions we set out in response to Lord O’Neill’s independent review of AMR, which was established by George Osborne when he was at the Treasury, was to halve healthcare-associated gram-negative bloodstream infections. We are focusing on E. coli infections this year, but we are also collecting data on Klebsiella and Pseudomona pathogens.
I think there will be a lot of interest among Members in the refreshed AMR strategy. Health Question Time seldom goes by without AMR being mentioned. AMR is important. As the chief medical officer, who is busy in other ways today, has said, it is one of the greatest threats, if not the greatest threat, that our world—not just our healthcare world—faces.
We welcome all new research that contributes to our work to tackle AMR—especially great research such as that produced by Queen’s University Belfast, which the hon. Gentleman mentioned. There are a number of funding opportunities, and high-quality proposals are always welcomed. He rightly mentioned that people from Queen’s were at the House yesterday. He and I met them together—we had our photo taken with them—at an excellent Breast Cancer Now event, which was a great chance to hear about some of the incredible research that is being done on that disease in our United Kingdom.
Great research projects often start with relatively small grants from charities such as Breast Cancer Now, which act as the building block for other researchers to jump on board and get with the plan. That is very important. This is not all about the Government starting research projects; it is about institutions such as Queen’s being world-renowned. The lady I met yesterday was clearly on top of her game. She deserves great credit, and I thank her and all her colleagues at Queen’s for the work they do for our country.
We have strong join-up across Government. My Department, DFID, Public Health England and the Foreign Office in particular take a “one HMG” approach to global health, which was recently praised by the Independent Commission for Aid Impact. That includes regular meetings between Ministers, and a co-ordination group of senior officials meets very regularly to look strategically at our international activity and some of the programmes I mentioned. It includes joint delegations to WHO meetings and daily contact between our officials. It also includes joint working on projects such as the UK public health rapid support team. That is a partnership between the Department of Health and Social Care, Public Health England and the London School of Hygiene and Tropical Medicine that, at countries’ request, deploys people rapidly to some of the poorest parts of the world to investigate significant disease outbreaks and support capacity building. I mentioned examples of times when that has been invaluable, such as during the Ebola crisis.
In concluding, let me return to the incredible achievements of our NHS over the past 70 years, during which time life expectancy has leapt. Its staff work tirelessly to ensure that it remains the best in the world. We are committed to ensuring that it provides universal health coverage in the UK for generations to come, but we do not keep it all to ourselves—we are desperately keen to go on sharing our knowledge to help other countries do the same, so that people around the world can benefit from the incredible privileges we have in this country.
Steve McCabe (in the Chair)
Mr Shannon, would you like to make some concluding remarks?
Oral Answers to Questions
Steve McCabe Excerpts(6 years, 3 months ago)
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Steve Brine
I thank my hon. Friend for his work in this job on this subject. The Secretary of State was in the other place to listen to Baroness Jowell’s speech, and I read it and watched it back. It was a moving and brave piece of work. We take this matter seriously. My colleague Lord O’Shaughnessy has the report, which we are going through line by line, and he and I will jointly chair a roundtable on the subject in the next few weeks.
Steve McCabe (Birmingham, Selly Oak) (Lab)
Will the Secretary of State give an assurance that any accountable care organisations that he establishes will not be able to use commercial confidentiality excuses to evade scrutiny under freedom of information legislation?
