Committee (4th Day)
Clause 80 : Reviews and performance assessments
74: Clause 80, page 67, line 19, at end insert “including their integration with other relevant services”
My Lords, in the unavoidable absence of my noble friend Lord Warner, I shall move Amendment 74 and speak also to Amendment 75.
These two amendments give an opportunity to put into the Bill further emphasis on the importance of integration. Amendment 74 requires reviews by CQC of regulated health providers to cover the integration of those services with other relevant services. Amendment 75 does the same for reviews of local authority adult social care services. They are a clear reminder in the Bill that when CQC carries out such reviews it will have to pay attention to the issue of integration of services for the benefit of patients and service users.
I shall not detain the Committee today with yet another speech of a kind that I have made many times before on the importance of integration of health and social care services from the point of view of patients, service users and their carers. We all know how important that is. The Committee is familiar with the arguments and, more importantly, so is the Minister. Indeed, the Chancellor of the Exchequer, no less, acknowledged this in his announcement in the comprehensive spending review in regard to joint budgets. The announcement has been widely welcomed, although caution has been expressed about how these budgets will operate in practice.
The amendments are a modest attempt to give some practical effect to the aspiration for integration which we all share. I hope the Minister will say that it is a good idea, “Let’s do it”, and get us off to a cracking start this afternoon. I beg to move.
My Lords, I declare an interest as a chair of a NHS foundation trust and as a consultant and trainer with Cumberlege Connections. I am happy to support my noble friend Lady Pitkeathley’s Amendments 74 and 75, which rightfully push the CQC into the direction of integration of services. I also sympathise with the amendments of the noble Baroness, Lady Greengross, Amendments 76ZZA and 76ZAA, to which she will speak later.
My Amendments 74A, 76ZA and 76ZB and my opposition to Clause 80 stand part go to the core of the purpose of CQC and its approach to performance assessment in health and social care. Inevitably, recent events at that regulator in relation to Morecambe Bay and before that at Mid Staffordshire will readily come to mind. There can be no doubt that the current leadership of CQC faces a major challenge in changing the culture of the organisation and its approach to inspections. It has much to do to restore both public confidence and confidence within the NHS about the way in which it operates. That is why this clause is so important.
Clause 80 substitutes Section 46 of the 2008 Act and provides that the CQC’s duty to conduct periodic reviews, assess performance and publish reports of such assessments, which are henceforth to be known as “ratings”, is to apply in respect of any regulated activities and any registered service providers as may be prescribed in regulations. In addition, where regulations so provide, the CQC must also review and assess the performance of the provision and commissioning of adult social services by English local authorities. CQC is to be given responsibility for determining the quality indicators against which services and providers will be assessed. This may include measures of financial performance and governance if the CQC deems this appropriate. Different quality indicators, methods and frequency in periods may be used for different types of cases. The CQC may also review the indicators of quality and method statement from time to time as it sees fit.
Let me say at once that I support the broad intention of these clauses to make the CQC responsible for rating providers and local authorities. I say again that one should not underestimate the task. It is important that the CQC is not put under undue pressure to rush to change the way that it operates and to introduce new ratings without proper pilots being done and without having enough time to do it.
I refer the noble Earl to the Nuffield Trust’s work. As he knows, the Nuffield Trust was commissioned to carry out a review for the Secretary of State into the possibility of rating providers of health and social care. It argued that the new ratings must be given adequate time to work together with a range of stakeholders in developing a system which enables both patient choice and professional leadership to drive up standards of quality. That is vital. Yet I am concerned by the document issued by the CQC recently that indicates that it is to start inspecting and regulating NHS acute hospitals, in the ways that it set out in that document, from October 2013. Indeed, from December 2013, it will begin to rate NHS acute trusts and NHS foundation acute trusts, aiming to complete them before the end of 2015.
Have Ministers put pressure on the CQC around the timing of those ratings? Secondly, does the noble Earl not think that there is a risk that the CQC will be forced to rush into a new system without proper consideration? I remind him that the chairman of the CQC has recently made a number of statements. First, he has said that the approach to inspections by the previous leadership was wrong; it was wrong to go for generalist inspections. He also says that the culture of the organisation was wrong. Given that there are about 1,000 people employed by the CQC, although I am not absolutely certain, how on earth is the culture going to change in a short period of three or four months? I just do not think it is going to happen.
I have great admiration for the current leadership of CQC, but the risk is that it is going to be forced into a new system too quickly and it could fall over. As a result, its credibility will be very much damaged. Let us face it; it is almost starting from a negative position. I must confess that I am surprised that such an ambitious timetable has been set.
Who will be assessed? As I have already intimated, the clause provides for the Secretary of State to draw up regulations laying out exactly which services the CQC will rate. They are likely to be hospitals, GP practices, care homes, domiciliary care services across both the public and privates sectors and local authorities. Will the noble Earl confirm that? Will he say why this is not specified in the Bill? Does he not consider it important enough for Parliament to decide which bodies should be assessed, and to do so in primary legislation rather than through regulations?
I asked at Second Reading whether clinical commissioning groups are to be assessed. If not, why not? The Bill allows for local authorities to be assessed for their performance in the commissioning of adult social services, so I cannot really see why NHS commissioners—the CCGs—should not be similarly covered. The same logic then applies to NHS England which, after all, has been given a massive commissioning budget in relation to specialist services. If it is appropriate for local authorities to be assessed for their commissioning responsibility, surely all health commissioners should be similarly assessed. That must apply to NHS England because otherwise I do not see who will hold it to account for the mammoth amount of resources it will spend on commissioning specialist services.
I am particularly interested in local authority assessment, particularly in the way that services are commissioned. Can the noble Earl tell me whether this is intended to be a priority for the CQC? He will know that there is real concern about the practices of many private sector providers in social care in using zero-hour contracts and allocating only 15 minutes with each client. It is vital for the CQC to be able to investigate the way in which local authorities commission those services. We will come to this in Clause 5 but it would be very useful if the noble Earl could confirm that the commissioning responsibilities of local authorities will be a priority for the CQC.
Turning to the inspection approach and the rating system to be adopted, according to the recent document issued by the CQC:
“Our inspections of hospitals will vary in terms of the things they look at and the time they take, but they will take as long as is needed—typically 15 days, with an average of 6-7 days on site—to make a thorough assessment of the quality and safety of care. In the vast majority of cases, inspections will be longer and more thorough than our current approach of a small team of inspectors being on site for one or two days. Our inspectors will spend more time talking to people who use the service, to staff, senior managers and members”.
That is very welcome. I am sure that that is the right approach. The noble Earl will know that there has been a problem with short-scale inspections, which take just one part of a service and do not really give a measure of the scale of services being provided.
We then come on to the rating of services, which I have raised with the noble Earl. As far as I can see, the intention is to follow the Ofsted approach of rating from 1 to 4, with 1 being outstanding, 4 being a measure of inadequacy, 2 being good and 3 being satisfactory but needing to improve. That is an approach. But the noble Earl will be aware that the Nuffield Trust has argued that,
“the Government and CQC must be alert to the possibility of aggregated ratings which reflect high general standards of care but conceal individual failures within organisations”.
It goes on to say:
“For hospital trusts in particular, which operate across multiple sites and provide a range of complex services in different wards and units, it is important that service-level assessments are easy to find and understand”.
This is very important because the CQC is going to follow the Ofsted example. Outstanding hospitals will be inspected only every three to five years and good hospitals every two to three years. So a hospital could be rated as outstanding and then not inspected for five years. The problem with that is that we all know that services can go up and down and that changes in leadership can have an impact on the quality of an organisation. We know there are examples in education where schools or colleges have been rated 1, have not been inspected for five or six years, and some of them have gone down to 3 or 4.
I am more concerned about the public’s confidence in such a system. Where a hospital has been rated 1, within 1 there will probably be some inadequate services; if something goes drastically wrong, the whole rating system will come into serious question. What I am asking for is a much more sophisticated, balanced approach to rating these institutions. That is why it would be right that before any substantive programme comes into being there should be pilots, which should be fully assessed. I hope that Parliament would have an opportunity to debate them as well.
Finally, I come to my Amendment 76ZA. My understanding is that part of the criteria which will form the ratings judgment by CQC will be whether staff would recommend their organisation to patients. I am sure that that would be a very valuable component of the ratings. I have been contacted by the Chartered Society of Physiotherapists, which says that, perhaps, we should go even further and actually consider staff health and well-being. That seems to make a great deal of sense. Sickness absence in the NHS is a major problem. The sickness absence rate for the winter among healthcare assistants has been very problematic. I do not expect the noble Earl to agree to my amendment, but I hope he will give some comfort that CQC, in looking at the way staff feel about their organisation, might be able to develop some kind of indicator of the way staff are dealt with. Health and well-being might be a very good way to do this.
Overall, we wish CQC well. I am concerned about the pressure being put on it to come up with a new system before it has time duly to consider it. I hope the noble Earl will agree to an amendment around pilots.
My Lords, I shall speak to Amendments 76ZZA and 76ZAA in my name. I thank the noble Lord, Lord Hunt, for the support he expressed earlier. On Amendment 76ZZA, we know that one of the major problems identified in the Francis report was the inadequate handling of complaints and concerns. This issue has not been addressed in the Care Bill. My amendment would enable the Care Quality Commission to introduce more rigorous complaint systems across all care settings. I hope the Minister will consider this because it is very important to get this right now. This is about the way in which a registered service provider or a local authority will handle complaints and concerns, and it is very important.
Amendment 76ZAA is about continence care. I declare an interest as chair of the all-party parliamentary group on this subject. It is hardly spoken about, but it is terribly important; people just do not recognise how many people have some problem with continence. The NHS services should have continence care as an essential indicator of service quality. It therefore needs to be established as an essential indicator of high-quality services across the NHS and care settings within the periodic assessments of care standards undertaken by the CQC.
A number of recent assessments have demonstrated that continence care is still a low priority across NHS settings, with poor treatment resulting in escalated and more costly care needs and poorer patient outcomes. This is in spite of the fact that good bladder and bowel control are fundamental to people’s dignity and independence and that NICE has published a wealth of best practice recommendations to effectively assess and treat the condition. The Francis report included an entire chapter outlining the scale of failures in continence care. Given the expected rise in prevalence of incontinence and the impact that poor care can have on patients and the NHS, continence care must be seen as a key indicator of high-quality provision across care settings. An explicit requirement within the Care Bill for the CQC to assess providers for the quality of their continence care would directly respond to the failings in this field which the Francis report identified—the stated purpose behind Part 2 of the Bill. That would encourage providers actively to address how they manage incontinence by assessing their local protocols and policies about the condition, taking steps to improve awareness among staff about incontinence and undertaking internal audits in order continuously to improve care standards.
My Lords, I wish to register my support for the proposals in some of these amendments. The integration of services should always be highlighted. We have a long way to go and, since we are not providing an integrated budget, every encouragement short of that should be given, so I support the amendments that propose this.
The amendments and stand-part question in the name of the noble Lord, Lord Hunt, have to do with the standing of the CQC. CQC has been through a very rough patch, and to some extent, responsibility lies as much here as elsewhere. I remember the debates a number of years ago, when we changed the structure of the regulation that should be provided in this area three or four times within four or five years and always handed the ball on to a new organisation that we thought would solve all the problems. We failed consistently to answer the question: what are the signs that the new organisation will succeed in all the tasks being given to it? We now see that there have been difficulties. Moving with a degree of caution has a great deal to commend it, and I look forward to the Minister’s response to the questions raised by the noble Lord, Lord Hunt.
The rhetoric around the comments of politicians, those in health regulation and the press continually refers to Ofsted and Ofsted-style inspections. I declare an interest, in that I had something to do with founding Ofsted and the type of inspections that in due course developed. Ofsted is a rather a different beast, and these comparisons do not help. For example, the chief inspector is independent of the control of the department, which seems not to be the case in the plans for the future. That means that the relationships with the Minister and Secretary of State will have to be very carefully managed. I am not sure that sufficient thought has been given to that. That is part of the case for asking whether Clause 80 should stand part of the Bill.
The other pressures being put on CQC have to do with financial assessment. These are additional responsibilities for which CQC is hardly prepared. There is a need for specialist staff and specialist abilities to decide whether companies providing care at all levels have the ability to continue sustainably to do that—but that does not, as we have seen in other forms of financial regulation, come easily to regulatory bodies. This has to be looked at very carefully, along with the pace at which change is introduced into the practices of CQC, which is under, we hope and expect, good new management.
My Lords, the need for the specialist staff referred to by the noble Lord clearly lies behind the tabling of Amendment 76ZB. It is precisely why we need to pilot the proposed system.
My noble friend on the Front Bench referred to the system being created as a new system. We were told that we were going to get a new system in 2009. I sat on the third Bench behind my noble friend—the noble Earl was on the Front Bench on this side—and pointed consistently to the deficiencies in the system while it operated under CSCI and the inevitability of further problems arising under the new structure that was being created. Indeed that is precisely what has happened.
It seems to me that it can only get worse. The report of the Select Committee on Public Service and Demographic Change sets out the scale of the problem that confronts us in future. It prays in aid the Office for National Statistics updating its projections up to 2021 based on a recent release of data from the 2011 census on the ageing population. It says that, by 2021:
“There will be 24% more people aged 65 and over”,
“39% more people aged 85 and over”.
It goes on to say that by 2030 there will be,
“will be 51% more people aged 65 and over”,
and that the population over 85 will have doubled. This means, to put it bluntly, that a lot more people will go into a lot more nursing homes throughout the country. Therefore, we have an absolute responsibility to make sure that the structure that we establish on this occasion is fit for purpose.
At the moment, I understand that there are 2,400 nursing homes catering for approximately 220,000 residents. That is going to increase, and I am still not convinced that the structure that this new so-called CQC is to set in place will be fit for purpose for taking on that task. Nor has the structure been defined in the legislation, as my noble friend has referred to. When I say fit for purpose I am reminded of the comments made by the noble Earl when we met on the last occasion to discuss this Bill, when he talked of a new broom at the CQC. As I understand it, it is not a new broom but an old broom with a new handle, because the person who is now running the operation is in fact the same person, I am told—and the information is available on the internet for anyone to read—who was responsible for the structure, which we are now debating, which has failed miserably over the past four years and is the subject of the complaint.
Mr David Behan, who runs the new operation, prior to his current appointment at the Care Quality Commission, was director-general of Social Care, Local Government and Care Partnerships at the Department of Health. As the director-general—and I read these words very carefully, because I do not want in any way to misrepresent the position—he had lead responsibility for the social care aspects of the Health and Social Care Act 2008, which created the CQC, the very organisation that we are having to review today because of its total failure and the scandals that have been drawn to our attention in the national media over recent years. I understand that he should have been aware of the Act’s requirements for the CQC to perform its functions for the general purpose of encouraging the improvement of health in social care services. This failure is implied in the Department of Health capability review, which in effect admits that the Department of Health was not sufficiently challenging and strategic in the way it supported the CQC.
David Behan is not new to social care regulation. Before taking up his appointment at the Department of Health, he was chief inspector of social services at the Commission for Social Care Inspection—CSCI—the organisation that we criticised in 2009 when the Act was going through on the basis of its failure in this particular area. I remember Ministers going to the Dispatch Box—Labour Ministers, yes—reading briefs produced by civil servants, in which they repeatedly assured us, as they did in personal correspondence to us, that the new structure that was going to be set up would work. It has not worked. It has been a complete and utter disaster area, which is why we are now faced with problems in this particular area that are reflected almost daily in the national press.
There is a very reputable organisation called the Relatives & Residents Association. Before anyone seeks to discredit its operations, it is worth pointing out that it is quoted in the most recent report by the House of Commons Health Select Committee. Its comments are prayed in aid in the committee’s criticism of the CQC. On 18 May 2009, in a letter to me following my criticism in the House, it affirmed its view. Four years ago, it said:
“we are concerned that … inspectors judge homes as delivering an adequate standard of care even when they are failing to meet national minimum standards for care homes”.
We were assured that that was going to be stopped. It has not been stopped under the structure that was established. The letter continued:
“the overall number of inspections of care homes has reduced. Homes that are failing to meet minimum standards are now inspected less often than used to be the case”.
We know that over the past 10 years, there has been a steady decline in the inspection of care homes nationally. We were told when the Act was passed in 2009 that it was going to be a risk-based system with a minimum of one inspection every three years. We know what a disaster that has been. We need an absolute minimum of unannounced inspections of care homes of at least twice per year, irrespective of the grading and irrespective of the ratings that have been applied to a particular home, because we all know that the management of a home can change over months, weeks or even overnight, and the home may drop in ratings dramatically as standards of care fall, depending on the financial considerations of the management of those homes.
The 2009 letter to me, four years before we stand here now, continued:
“requirements made by inspectors for action to improve care homes are often not met, there is little evidence of systematic follow-up by inspectors and requirements left unmet from one inspection to the next are common”.
That has happened over and over again over the past four years, and I am convinced that it will carry on happening until we set clear targets and a requirement of two unannounced inspections annually with a proper rating system, which is precisely why I support the amendment tabled by the noble Baroness, Lady Greengross, on the need for a pilot system for inspections.
I would now like to place on record the latest views expressed by the Relatives & Residents Association about what it believes the new structure should be. I do so because I understand that under the provisions of the Bill, the CQC will itself, following consultation with Ministers and others where necessary, be taking decisions on those very important areas. What does the Relatives & Residents Association say? I think that what it says should be implemented. It calls for the,
“reinstatement of regular twice-yearly inspections of all care homes to ensure compliance with regulations and standards. This case and others show that CQC needs to listen, record and act quickly on complaints which show older people are not receiving”,
the quality of care they should receive.
I add at that point that we are talking about complaints. I could never understand why we established the CQC without a proper complaints remit. According to the Relatives & Residents Association, people ring up to complain about the fact that the CQC is not dealing with complaints. The CQC says, “We do not deal with them, you have to go to the local authority”. The structure is wrong. The CQC should be the body that deals with those matters and should be given that responsibility. The association calls for investment and more and better training of all care home staff, with vastly improved training in leadership skills of care home managers and operators and up-to-date inspection reports which are easy to understand, with any action required by the provider clearly highlighted. It also wants to see:
“Care homes focusing on individual care rather than putting pressure on staff to complete daily tasks such as dressing and feeding.
Statutory registration of all care workers”—
a matter that we were dealing with on the last occasion we met as a Committee—
“by a professional body which can set standards for competence and hold individual care workers to account for their own practice.
The reinstatement of specific standards for care homes for older people”.
That might seem a particularly substantial agenda. However, if the Select Committee’s views on the ageing population are true and there is going to be a vast expansion of the care business in the future, more and more homes will have to open to deal with that increased population. We should be setting in place in this Bill a structure that is capable of dealing with that expansion in care. If we do not, we will be back here again in five years’ time arguing about a deficiency in the system. If I am still alive, I will be on my feet again complaining about the fact that the Bill we introduced in 2013 miserably failed. That is the route that the Government have set out to go down. Unless they make the resources available to address this, the CQC will inevitably fail again.
My Lords, I had not intended to speak in this debate and will do so briefly. We need to allow the CQC time to settle down under its new management. We should also remind ourselves of the rest of the history, because it is important to put it in context.
I was the deputy chair of the National Care Standards Commission, the first organisation that brought together the inspectorates for homes under the previous Government. It was also the previous Government who, after two years, made the decision concerning the organisation—which had been quite successful. It had established a baseline of inspection. It had integrated the inspectorates, which several other organisations which had tried to integrate the different teams had failed to do. Like other noble Lords, I would also cite CAFCASS in that regard. The commission did all of that. We should remind ourselves that it was only a year later that the previous Government announced through a newspaper, not directly to the staff, that the organisation would be merged with CSCI.
The merger took place and I think that it was extremely successful. David Behan was involved in ensuring that it went well. CSCI then took on the starring system which was put into place and was having some success. By that time, we had closed 400 poor establishments. The work was continuing in terms of co-operation when it was again decided that there should be a restructuring, this time to bring the inspectorate into health.
I think that we have two lessons to learn. The first is not to restructure yet again on a political basis. If there is good leadership and the lessons have been learnt, let the organisation settle down. The second lesson is clear. If you are going to inspect anything, you need to have the expertise within the teams to carry out the inspections. Again under the previous Government, it was a sort of theory that if you had somebody other than a nurse looking at nursing, a social worker looking at a social work establishment or a teacher looking at teaching—indeed, you usually did have teachers looking at teaching; that always seemed to be an exclusion—then you could get a better answer than if you had a professional do it.
I think that the present leadership at the CQC has learnt that lesson and understands that you need the professional expertise to know what you are looking for, although that should certainly be cross-checked by independents. I hope deeply that we will be able to keep that steadiness, because I understand absolutely what happens to organisations when they are in constant flux and change.
Perhaps I may make one other point while I am on my feet. I support anything that we can do about integration. We have singularly failed to reach some complex conclusions about how health and social care can truly be put together for the benefit of those who are the recipients of that care. We should ensure that we put into the Bill whatever we can about integration. I would support all of that.
I endorse what the noble Baroness, Lady Howarth, has just said because I am firmly of the belief that it will take time to find all the appropriate people for the move which the CQC has clearly said it would make, from generic to specialist inspectors. I am sure that this will make a huge difference to the outcomes of inspections. I, too, think that we should give this organisation time. From what I have seen, it has the drive and the initiative to make sure that things improve enormously.
My Lords, this has been a very useful debate and in addressing this group of amendments, it might be helpful if I began by setting out why we believe this clause is necessary.
At the moment, there is no straightforward way for members of the public to get a clear view of performance in hospitals and care homes, nor is there a measure to help drive up performance, so we believe that a new system is needed to give patients and the public a fair, balanced and easy to understand assessment of the quality of care provided. Clear ratings on performance will help to incentivise providers to improve their services, as they will be able to see how well they are doing. One of the central principles behind this clause is that it will enable the CQC to develop the new performance assessment system—informed by the views of stakeholders, of course, but nevertheless independent of government. In its report into ratings, the Nuffield Trust said:
“While there is a legitimate role for … government … to influence priorities, the process should largely be sector-led including the public and users”.
I am rather pleased that we did not debate this group of amendments on the previous Committee day because the CQC has, in the mean time, published a consultation on changes to the way in which it regulates, inspects and monitors care. I draw that to the attention in particular of the noble Lord, Lord Campbell-Savours, whose points I will address in a moment. This consultation, A New Start, sets out the commission’s initial thinking on the timetable for implementing ratings. The consultation document also sets out some detailed thoughts on how the CQC will rate NHS acute hospitals. I take the point made by the noble Lord, Lord Sutherland: this rating process will have to have some fundamental differences from that followed by Ofsted. However, the ratings will be based primarily on inspection judgments. They will be informed by a series of indicators, using data already available and the findings of other bodies such as those from accreditation schemes, clinical peer review and the judgments of other regulators. The CQC will be consulting on this model more fully later this year.
Noble Lords have raised concerns about the ability of a rating system to reflect the complexity of NHS acute hospitals. I assure the Committee that both the CQC and the Government are fully alive to this risk. The CQC is committed to producing ratings at a level which recognises the complexity of NHS services and is useful to people who use them, as well as those who commission NHS care. It is therefore proposing to provide ratings for certain individual services, such as emergency and maternity services, as well as for each hospital.
A rating will also be provided against each of the CQC’s key questions. They are: is the service safe? Is it effective? Is it caring? Is it responsive to people’s needs, and is it well led? This will mean that where the evidence is available, a trust would have five ratings at three different levels—for the individual service level, for the hospital site and for the whole trust. I am sure that noble Lords will agree that this is an ambitious aim, and one that seeks to reflect the complexity of the organisations that provide care.
The Government will draw up regulations that will enable the CQC to develop the programme of performance assessment in the manner outlined in A New Start. The consultation is the first small, but important, step in the process of developing a robust system of performance assessment of providers of health and adult social care. The first ratings of acute hospitals will appear at the end of this year: I will come on to the timetable in a moment. This will be another significant step in developing a ratings system, but it will not be the end of the journey. The Government are clear that the development of ratings will be a process of continuous evolution.
Amendments, 74, 75, 76ZA, 76ZZA and 76ZAA set out areas that the CQC must or could consider as part of its performance assessment of providers. These amendments would mean that the CQC would be required to include or consider the specific issues raised as part of its methodology. The Government share the view of noble Lords on the importance of the issues they have raised through these amendments. I am sure we can all agree that they are useful ideas. However, I hope that they will equally accept the importance of the central principle that we believe should be adhered to: that the CQC should be given freedom to develop its own methodology for the new performance assessments. The clause is deliberately designed to be flexible in that sense. I therefore hope that noble Lords will be content to withdraw their amendments, in the knowledge that the CQC is ready and willing to listen to all good ideas as it puts its final plans together.
The noble Lord, Lord Hunt, has also tabled Amendment 76ZB, which would require the CQC to undertake a pilot of its new performance assessment system and require the evaluation report to be approved by Parliament. The Government agree that the CQC’s new performance assessment methodology should be subject to evaluation. This is why, in our response to the Francis inquiry, Patients First and Foremost, the Government made the commitment that:
“The Department of Health will commission an independent evaluation of the operation of the new ratings system, and this will inform future adaptations”.
The amendment would give Parliament a power of veto over the methodology which the CQC develops for performance assessment. This is not desirable as it would constrain the freedom of the CQC to act on the findings of its consultation with stakeholders. I therefore hope that noble Lords will be content not to move that amendment.
Amendment 74A would require the CQC to undertake performance assessments of commissioners of healthcare services, specifically clinical commissioning groups and NHS England. The wording of Clause 80 could enable the CQC to undertake reviews of local authority commissioning of adult social care services. The absence of a similar requirement for healthcare commissioning therefore requires an explanation. The requirement for the CQC to review healthcare commissioning was removed by the Health and Social Care Act 2012 on 1 April 2013 when primary care trusts were abolished. This is because the function of supporting the development of the commissioning system for healthcare in England has become the responsibility of NHS England. NHS England’s role is to determine how the performance of healthcare commissioners, including clinical commissioning groups, is assessed and managed. There is therefore no need for the CQC to carry out a virtually identical role. I trust that the noble Baroness will be content to withdraw her amendment, but I would like to address the particular points raised.
I do not quite see the logic of that, because in a sense NHS England has a vested interest in ensuring that all is well with the CCGs. It is not an independent body in the way that the CQC would be.
The other question is about NHS England itself. It is a massive commissioner of specialist services. If a local authority is to be assessed, I still do not see why NHS England ought not to be subject to some kind of independent assessment. It could have a huge impact on where specialist services are going to be provided in future. We know that Ministers are no longer prepared to answer questions about lots of things that NHS England does, so there seems now to be a gap in the architecture.
Ministers most certainly are willing and able to answer questions about what NHS England is doing, and will continue to do so. Parliament, of course, will be entitled to keep NHS England’s performance in the spotlight; that architecture was built into the 2012 Act very deliberately. I do not accept the noble Lord’s point about clinical commissioning groups, because it is for NHS England to assure itself that the commissioning system for healthcare in England is working properly. There will be a high degree of transparency in that regard. The performance management role of NHS England will be right there, and I think that the proof of that will emerge over the coming months.
Perhaps I could cover the individual points raised by noble Lords. The first point was raised by the noble Lord, Lord Hunt, and echoed by the noble Lord, Lord Campbell-Savours, about how we expect the CQC culture to change in a relatively short time. I say to both noble Lords that I firmly believe that the CQC is already very much a changed organisation. It has a new leadership team in which I have full confidence. It has a new board—which, incidentally, the noble Lord, Lord Hunt, may be interested to know will include Kay Sheldon—and I think it has a new attitude to openness and transparency, as its handling of the Grant Thornton report demonstrates.
On 16 July, the CQC’s chief inspector of hospitals, Professor Sir Mike Richards, will start in post, so that is very soon. By September the CQC will be publishing a list of hospitals that it has the greatest concerns about, and it will be using its new surveillance system to develop this list. The CQC is committed to learning from the past and pressing ahead rapidly to improve for the future. I agree with the noble Baroness, Lady Howarth, that the CQC needs stability.
On the question of the surveillance system that the Minister just referred to, what about the proposal that keeps coming up all the time of two unannounced visits per year for every care home within the United Kingdom? Why can that at least not be set down by the Government as a requirement, irrespective of all the other recommendations and decisions that the CQC comes to over its new so-called surveillance system?
It is not for Ministers to do that. I say that with great respect to the noble Lord. In saying that, however, I also highlight the ability of the CQC to flex its inspection frequency in accordance with information received. The noble Lord will know that organisations such as local Healthwatch, and indeed local authorities themselves, are able to alert the necessary authorities through Healthwatch England, which, as noble Lords know, is an integral part of the CQC, to any problems that may be flagged up. The CQC will be consulting in future on its proposals for care home inspections, and I do not doubt that a difference of view will emerge about the frequency of those inspections. I am the first to say how important it is that the inspections take place, and I totally take the point that those assessments should not be allowed to drift in any way. However, for better or worse we have an independent body known as the CQC, which should be allowed to act accordingly. The noble Lord, Lord Campbell-Savours, took us back to the 2008 Act. I would say to him that, in agreeing with the noble Baroness, Lady Howarth, Robert Francis was clear in his report that the system should not be significantly reorganised.
I fully agree with the point raised by several noble Lords that the CQC under new leadership should be given the time that it needs, both to improve the performance of its current functions, such as registration, and to embed the new functions, such as ratings. The noble Lord, Lord Hunt, asked whether Ministers had put pressure on the CQC. No, absolutely not. We are clear—I am looking at the noble Lord, Lord Sutherland —that the chief inspector should be an independent post in itself. The chief inspectors are appointed by the CQC, not by the Government or the Department of Health, and we think that this is appropriate.
The noble Lord, Lord Campbell-Savours, asked why the CQC does not have a complaints remit. Again, going back to earlier debates under the previous Government, all organisations in healthcare were aware that the Healthcare Commission—as it then was—provided independent review of individual complaints cases. This seemed to act as a perverse incentive not to investigate thoroughly at a local level. In other words, it is arguable that providing an independent stage through a separate organisation had actually worked against effective local resolution of complaints, because NHS organisations were aware that the Healthcare Commission would ultimately undertake the work. So there was less willingness to take ownership of the problem at the source of that problem. A lot of duplication also emerged from that, with the Healthcare Commission tending to carry out investigations even where the work had been done at local level. That was not a good use of public money. I remember that the Parliamentary and Health Service Ombudsman and the Local Government Ombudsman fully supported the decision to remove handling individual complaints from the regulatory body.
As for the evolution of these ratings, the Government do not expect the CQC to have fully developed ratings for hospitals by the end of this year. That would be unrealistic. The initial ratings will not be a final product. They will instead represent the first stage in an ongoing development process. The Government expect that CQC will improve its methodology over time, and one of the most robust ways to do that is to continually test the methodology in the field. The new Chief Inspector of Hospitals will spearhead the new approach to assessing hospitals, using his clinical expertise to develop an effective approach for rating. I direct noble Lords to the CQC’s consultation document A New Start, which sets out all these plans in some detail.
CQC plans to commence rating providers of acute care from December, with the aim that all these providers receive a rating before the end of 2015. It will begin to develop ratings for mental health trusts during 2014, and for other NHS trusts, such as community healthcare and ambulance trusts, during 2015-16. Why do we not specify in the Bill who will be assessed? The answer in the first instance is that this Bill consolidates the existing regulation power in Section 49 of the Health and Social Care Act 2008, to allow the CQC to have the flexibility to focus on providers of most interest to the public. That is important in defining the scope of the new performance-assessment system through regulations. We are giving the CQC increased flexibility to focus its assessment on those providers and services that are of most interest and concern. We must avoid overloading it with the task of assessing the entire system. We wanted to focus, first, on services where an assessment and subsequent rating are likely to provide the most benefit to everybody.
The noble Lord, Lord Hunt, asked about the commissioning responsibilities of local authorities, and whether they would be a priority for the CQC when it conducts its ratings. The CQC has a duty under the Health and Social Care Act 2008 to carry out reviews of local authority commissioning, but the policy position agreed with the Department of Health is that, for the time being, local authority commissioning performance and assessment will be led by councils as part of wider moves to devolve responsibility for improvement in the sector, underpinned by strengthened transparency and accountability to local people. The policy position is still under consideration. Therefore, the clause gives the Secretary of State the power to define in regulations the scope of the performance-assessment system. Until it is agreed to what extent there will be a need for reviews of local authority commissioning, the policy will be kept out of scope in the regulations.
I hope that I have answered most if not all the questions. Naturally, I shall reply in writing to any noble Lords whose question I omitted.
Perhaps I may ask for clarification on one further point relating to complaints. Amendment 76ZZA does not propose that the CQC should handle complaints, which was the gist of the Minister’s response. Rather, it proposes that there should be a clear and transparent method of handling complaints within each trust and relevant area. The role of the CQC is to open up that window, very much in line with the Francis report, so that we can know that complaints will be handled at the appropriate level and in the appropriate way.
I completely understand the noble Lord’s point. He will remember that in the registration requirements for providers of health or social care, the existence of a complaints system is one factor on which the CQC will need to satisfy itself. On the quality of the complaints-handling system within that provider, my answer is that it is a powerful point and an important area, but in the end it is one on which we should let the CQC decide as it develops its methodology. I do not in any way dismiss the noble Lord’s suggestion, but it is one for the CQC to take forward.
My Lords, this has been a wide-ranging and well informed debate. It has focused on anxieties about the role and competence of the CQC. The anxieties seem to focus on questions about whether the job of the CQC is doable at all, doable in the very short timescale, or doable with current resources. Suggestions about how to address the anxieties and concerns have included piloting new structures, but there has been much support for the CQC being given time to improve its strategy and performance—although with strong reservations from my noble friend Lord Campbell-Savours. I am grateful for the support for my amendments on integration, and sorry that the Minister was unable to accept them. Given the concern and strength of feeling about the CQC, I am sure that we shall return to this matter on Report. For the present, I beg leave to withdraw the amendment.
Amendment 74 withdrawn.
Amendments 74A to 76ZB not moved.
Clause 80 agreed.
Amendment 76A had been withdrawn from the Marshalled List.
Amendment 76B not moved.
Clause 81 : Offence
Amendments 77 and 77A not moved.
Clause 81 agreed.
Clause 82 agreed.
77B: Before Clause 1, insert the following new Clause—
The provisions enshrining the new duties and responsibilities for local authorities in Part 1 shall not come into force unless and until a comprehensive and sustainable solution has been provided by the Secretary of State to address the funding of existing care and support commitments for local authorities and those arising from this legislation.”
My Lords, we now come to the beginning of the Bill and the very important Part 1, sensibly postponed until after the Chancellor’s Statement last week on the spending review.
I declare my interest as president of the Local Government Association. The LGA has drafted this amendment and, as with many other Bills, has provided invaluable analysis and briefing for parliamentarians, alongside its direct negotiations with central government on behalf of local councils. Indeed, I commend the LGA’s new publication, Rewiring Public Services, which was launched yesterday and sets out a radical agenda for local services, including social care services.
The provisions in Part 1 have been widely welcomed. They will update and reform the adult social care system. They will support greater integration of health and social care and, on the issue of paying for care, the Bill’s provisions will redefine the relationship between the state and the citizen. Some of these changes will lead to future savings in the cost to the public purse of providing adult social care.
However, achieving later savings means spending more today, and some elements of the Bill mean a shift in the cost of care from the individual to the state. Therefore, before your Lordships’ Committee embarks upon its consideration of the important changes contained in Part 1, it seems important to consider the financial position from which we are starting out.
There is compelling evidence that rising costs of care are leading inexorably towards a crisis in funding for the local authorities which are trying to meet the needs of an ageing population. Before we can assess the practicalities of extra activity and extra spending for social care, it is necessary to be clear how existing care commitments can be paid for, as well as how extra costs arising from the Bill will be funded. Decisions on funding need to be taken before, or at least at the same time as, the policy decisions. Therefore, Amendment 77B—and I am very grateful to the noble Lord, Lord Tope, who has added his name to it—seeks to postpone implementation of Part 1 until the Secretary of State has addressed the crucial issue of how the costs of social care and support will be met in the years ahead.
What we now know from the Chancellor’s Statement last week is that the spending review includes genuinely helpful steps to fund key measures contained in the Bill. Following productive dialogue between central government and the LGA, the plans set out in the spending review make it clear that significant extra funds will be available from the NHS to assist with the costs of local care services. As well as needing reassurance that all extra costs for local authorities resulting from the Bill really will be covered, there remains the greater underlying concern that the financial foundation on which the new position is to be built is not secure. Over the past three years, adult social care budgets have reduced by 20%. In a number of areas, to cope with the funding cuts it has already been necessary for councils to raise the bar before regarding older people as eligible for help from the council. Accordingly, despite growing numbers of older people, fewer people are now being helped because their needs are assessed as moderate, not substantial, even though earlier support can prevent the need for higher costs later.
The Association of Directors of Adult Social Services notes that the bulk of this reduction has been made up by efficiency gains. Many adult services directors believe that they can go a bit further; for example, through better procurement, shifting activity to cheaper settings, subcontracting provision to the private sector, and so on. But the scope for further efficiencies clearly now is much reduced. Demographic pressures, with a 3% growth every year in numbers of older people, mean that savings are predicted to be immediately cancelled out by the cost of meeting increasing demand. The cost of just standing still is estimated at another £400 million a year. Efficiency savings alone cannot keep pace with these budget pressures.
Local government funding from central government has taken a huge hit with a 33% reduction over the period 2011 to 2015, prior to the additional 2% cut made in the Autumn Statement for 2014-15 and now the further 10% reduction in funding for 2015-16 announced in the spending review. Many of your Lordships will be aware of the frightening prediction that, unless the funding arrangements can be sorted out, local authorities face the so-called Barnet graph of doom. This shows how social care costs could absorb almost all local authority resources by 2019-20, leading to massive reductions in a whole range of existing local authority services. Already increasing costs, alongside a growing ageing population, are stretching adult social services to the limit. The funding issue really needs to be addressed before we consider a reform system for social care. Analysis by London Councils suggests that the combined effect of inflation and demographics means that there will be a potential £421 million additional cost pressure on adult social care in London by 2015-16. That is before any reforms are implemented.
The new spending review includes some really helpful measures for adult social care and health. The £3.8 billion pooled budget for health and social care services, with a continuation of the existing transfer from the NHS to social care that emerged from the 2010 spending review, is enormously important. Some of that transfer includes additional funds for the measures in this Bill. The new costs to be covered include resources to accelerate the transformation of services, provision of support for carers, capital funding for projects to improve integration locally and help for councils to organise themselves to implement this legislation. Costs are also coming down the line to support the scheme of local authority assistance for equity release by home owners who defer repayments. The extra funding in the spending review is greatly welcomed. I believe that the Government have listened to the concerns expressed by the LGA and others, and recognise the importance of providing sustainable funding for adult social care.
However, it is not clear that the sums add up. London Councils has helpfully spelt out that very significant costs arise from the legislation covering paying the care costs for people who have spent up to the cap of £72,000 and/or have become eligible for support because the means-tested threshold is being raised to £118,000; assessing the increasing number of self-funders coming forward as a result of the reforms; monitoring each individual’s care accounts and progress towards spending up to the cap; assessing carers’ needs for support and making extra carers grants; setting up new safeguarding boards for adult services like those for children safeguarding boards; and promoting integration with health services, fulfilling a new duty to provide information and advice on care.
In its new analysis released this week, London Councils has found potential total additional cost pressure of £1.3 billion for London local authorities by 2019 as a result of introducing the new measures. Approximately £877 million of this will be as a direct result of implementing the capped cost model for care and raising the eligibility threshold over the first four years. If these figures are right, the Government’s estimates of providing £1 billion per year to fund the cost of the reforms for the whole country will clearly be inadequate. London Councils’ analysis has found that the reforms nationally over the four years will be in the region of £6 billion, on average £1.5 billion per year, with cost pressures heavily weighted in the first and fourth years of implementation. It seems very likely, therefore, that the additional burdens on local government will not be matched fully by extra central government support.
I think we all appreciate the hazards of going boldly forward without real clarity on whether councils can afford to meet both their existing and their new commitments for social care. This amendment provides the opportunity for greater clarity as we set out to consider the details of Part 1. I conclude by asking the Minister the following questions. Have the Government fully assessed the likely costs of the nation’s adult social care for the years ahead? If so, do they accept that there is an alarming growing gap between resources and demands? Do the Government consider that their new funding plans are adequate both to cover the extra costs of implementing the Care Bill’s measures and to fill the funding gap already looming so dangerously, and, indeed, that funding allocations will reflect different costs and population pressures in different parts of the country? In relation to the existing funding gap and to any inadequacies discovered in the financing of the extra spending in this Bill, what contingency plans are in place if actual costs prove more than expected to prevent the already hazardous position becoming quite untenable? Until these questions are answered satisfactorily, it seems wise to hold back on implementation of Part 1 of the Bill. Accordingly, I beg to move Amendment 77B.
My Lords, I rise briefly to support this amendment as a mere vice-president of the Local Government Association. Very few Members of this House were here a week or so ago when the noble Lord, Lord Bates, sponsored a debate on the increasing complexity of legislation and, indeed, the increasing volume of legislation. It is a shame that more noble Lords were not there. In that debate, the noble Lord referred to a recent report from the Office of the Parliamentary Counsel, which pointed out that when the Queen came to the Throne in 1952, after 740 years of legislation we had 26 volumes of Halsbury’s Statutes; we now have 74 volumes. In 1952, the average Bill was 22 pages long; it is now 122 pages long. In 1952, there were 29 statutory instruments; last year there were 3,328. This is an astonishing increase even on 2008, when there were just 1,325. On that last statistic, I can bear witness as a member of the Secondary Legislation Scrutiny Committee. Indeed, my postman particularly asked me if I could do something about the volume of secondary legislation.
We have reached a point where we need to think seriously about the volume of legislation and its complexity, and whether we can carry on imposing new burdens and responsibilities, not least on local authorities. It would be fine if all this additional legislation was actually removing some of the red tape and bureaucracy that previous legislation had provided, but we know that it is not doing so and that it does not do so. We need to do one of two things. Either we genuinely reduce the volume of legislation and the additional responsibilities that it places on all sorts of bodies, or, as the noble Lord, Lord Best, suggests, we have realistic costing of what these new responsibilities entail and ensure that resources are available. If we do not, we remain in a cycle of despair and decline where we expect others to deliver new responsibilities, which they are just not able to do. We also raise the expectations of clients and users, who believe that things will change, when in all honesty they probably will not. That, I think, is a cycle of despair and decline, and it is the reason why I support this amendment.
My Lords, I rise briefly, as yet another mere vice-president of the Local Government Association, to bring a slightly different dimension to this debate. The noble Lord, Lord Best, pointed out that local authorities are finding a variety of different ways of delivering services. I have been looking at some of those and listening to messages about them. One issue is that they are delivering cheaper services, which often means commissioning them from providers which will then deliver them at a different level of quality. I declare an interest as a provider in the charity Livability, which delivers services to the disabled, the elderly and some children from residential care.
We need to know whether we are prepared to open the debate. Have the Government as a whole given thought to discussing with the community at large what we really can and cannot afford for the future? The noble Lord, Lord Campbell-Savours, raised the issue of the numbers of inspections. When I was involved in inspections, one issue was that you could deliver as many inspections as you had funding for. Now you can use that funding in a variety of different ways to get better options but, at the end of the day, resources count and, unless we know how far the resources will go, it is pointless to try to descend into the abyss, as the noble Lord, Lord Bichard, said.
If we are going to take this forward, we have to know what level of quality people are prepared to accept. Then, when there are failures in organisations, people are not blamed, because the failure is not necessarily one of individuals or even of groups but of the corporate whole simply not having enough resources to work across the whole piece. Until we start that debate, we will not be able to intervene in discussions about criticisms of local authorities giving only 15-minute slots to people when they have only enough resources for 15-minute slots. In residential care, we are taking away some of the extra services because there is no more money them. We are reducing staffing in various institutions because there are simply not enough resources.
I am not denying that because of the deficit we have to look at funding; I think we do. However, we have to open up the debate. Otherwise, we raise expectations in the country of what we are entitled to. I sat in this Chamber until 11 o’clock last night discussing the Children and Families Bill, and we were having exactly the same discussion. We all want these wonderful things. I want things in this Bill, but somehow we have to decide on some priorities between them all. Whatever we say, we cannot go on expecting to get the same out of the same.
My Lords, I support this amendment in particular. I declare an interest as the president of Mencap. There is no doubt that the services that we are able to provide are being severely cut back because local authorities simply do not have the money to support those services. Where we used to get, say, £15 an hour, we now get £12 an hour. The implication is that we can lower the standard of our services, but we are not prepared to do that. Therefore, we will end up reducing our services and, as a result, people with learning disabilities, their families and their carers will suffer. This is exactly the situation at the moment. Local authorities will try to provide the services, but they are making it much more difficult for voluntary organisations such as Mencap.
My Lords, I shall refer to the report of the Public Service and Demographic Change Committee. Members of the House who have not read the report should do so because it is a fascinating document. It is probably one of the best documents to come out of the House of Lords for many years. On the question of Dilnot, to which I am opposed but I shall explain that later on in the Bill, paragraph 193 states:
“The major gainers will be the relatively better-off, who will be protected from depleting their housing assets”.
In other words, potentially we will be spending in the longer term money that could have been raised in taxation. We are losing that revenue at a time when the same report refers to the deteriorating ability of the state to help people who are in need of medical services. It refers to the fact that the number of people aged over 75 is expected grow from 5.4 million in 2015 to 8.8 million in 2035. It refers to the fact that the demand for hospital and community service spending by those aged 75 and over is, in general, more than three times the demand from those aged between 30 and 40. We have higher demands from the elderly, more people falling into the groups that are liable to want the services historically provided by local authorities and the state, and yet, at the same time, with these Dilnot proposals, over a period of time we will be handing back money to the taxpayer to which, in my view, the taxpayer has no right.
The report says that the number of people in England with three or more long-term conditions is predicted to grow from 1.9 million in 2008 to 2.9 million by 2018. It is forecast that the number of people in England and Wales aged 65 and over with dementia—we all know the care requirements of people with dementia—or moderate or severe cognitive impairment will increase by over 80% between 2010 and 2032 to 1.96 million. The report goes on to say that it is estimated that by 2022 the number of people in England aged 65 and over with some disability will increase by 40% to 3.3 million.
As I understand the amendment of the noble Lord, Lord Best, he is simply saying, “Hang on a minute, before we start spending money, we should take stock of what is available in the longer term. Can the state afford to pay all the bills that are to come? Has that work been done?”. I hope that the noble Earl will seek to give the Committee those assurances because if the work has not been done and the predictions of some have not been taken into account, it may well be that the amendment of the noble Lord, Lord Best, is relevant. Let us defer much of this expenditure until we have sorted out the budgeting.
My Lords, I had thought that I would not respond to the amendment of the noble Lord, Lord Best. However, I feel I must because there seems to be a missing voice in this debate—the voice of the thousands of people who use social care, over 70,000 of whom receive some form of direct payment. Ten years ago, when direct payments were successfully introduced and allowed disabled people to live independently in this country, we were proud to be employers. We were able to employ RPAs at a good rate, with holiday pay, and we were able to advertise. We were equal to those who employed individuals in their own companies. Ten years on, many cannot even give holiday pay and cannot advertise. They fall back on costly social care services or enter hospital as a result of not being able to employ assistants.
We, too, want to know the costings before new services come into effect. Disabled people may have to accept these services and find that they lose choice and control over their lives. So please do not forget the voice of those who say, “We, too, wish to know that the money is settled. We, too, need a voice to remind people that, in order for us to employ or control our services, we must feel that we can do this with equality and dignity and do it absolutely properly”. Otherwise independent living will become just a memory.
My Lords, the noble Lord, Lord Best, is right in his analysis. He is pointing towards a financial problem that we all know is there and will continue to be there, not least in the current situation, for a number of years to come. The noble Lord, Lord Rix, is right about the consequences of this within the community. I declare an interest as president of Alzheimer’s Scotland and I know that the same applies to its sister body in the rest of the UK. There is a shortage of cash, which means that services are being provided more cheaply or, of greater relevance, are not being provided and are being squeezed. That is the analysis.
I do not think I can vote for the amendment as it stands. What is driving this difficulty is not the profligacy of this Government, previous Governments or local authorities—we can all tighten our belts and are doing so—but the reality of changing demography. My favourite statistic is that since the start of this Committee stage our statistical life expectancy has increased by 27 minutes. We cannot cash that in individually, but that is the reality. That is the driver of the difficult position we are in.
Ministers are often between a rock and hard place, and none more so than now. However, in the light of these facts, the Government have not reviewed the priorities of public expenditure across the board—I hope the Minister will persuade them to do that—and how many things can we afford to do with the population that we have. That means looking at priorities across departments. I do not just mean health and social care. It is inevitable that we will have to do this. The sooner the Government—the previous Government were not good at this—are prepared to say that we must undertake a review of priorities in view of the changing nature of our society, the sooner we will begin to move forward. In the mean time, I am in favour of keeping pressure on the Government by introducing a Bill of this kind because there is no doubt that that will sharpen the appetite of the voters for how change should be devised in the future.
My Lords, I declare an interest as a vice-president of the Local Government Association and as a member of Newcastle City Council.
Forty years ago, as the newly-appointed chairman of the social services committee in Newcastle, I had to come to terms with the impact of Sir Keith Joseph’s reorganisation of the health service which came into force that year. Among much else, that involved the transfer of responsibility for public health from local government, where it had largely resided for over a century, to the NHS, taking with it paramedical services such as chiropody and bath attendants. The area health authority, as it turned out, was so limited in its resources that, for a period, we as a council felt it necessary to fund the continued provision of those services by the health authority. At the same time, we hugely increased social care provision, doubled the home help service and trebled the number of meals on wheels. I am sad to say that now those services are roughly back to where they were in 1973 as a result of the pressure on the authority’s budget. Now, in a step on which the Government are to be congratulated in principle, public health largely returns to its local government home and the concept of a holistic approach to social care, involving both local government and the NHS, is enshrined in the Bill.
It is unfortunate that the previous Secretary of State, in his shadow capacity, walked out of cross-party talks which the Labour Government had initiated to address the issue of care and its cost, and that it has taken three years to produce the proposals that we are debating. However, it is even more unfortunate that during that time not only has demand risen inexorably, but local authority funding has been severely and deliberately reduced by a greater extent than any other area of government expenditure. It is sad, but not untypical, that the Secretary of State for Communities and Local Government should not only have acquiesced in, but actively promoted, this perverse order of priorities with all it has implied for key services, including those that we are debating in this Committee.
As we have heard, the Local Government Association avers that adult social care budgets have been reduced by £2.6 billion, or 20%, over the past three years, with additional dire impacts on other services, such as leisure and housing, which should contribute to health and well-being and which are threatened with virtual extinction as local authority services by the end of the decade. The noble Lord, Lord Best, reminded us of the London Councils report and its estimate that the cost of the reforms—which, I repeat, we welcome in principle—will amount nationally to an average of £1.5 billion a year over the next four years. Apparently, the greater amounts will be spent in the first and last years of those four. London itself will be facing a bill of at least £877 million as a result of implementing the proposals.
Of course, this, in part, reflects the increasing demand from different client groups. We largely talk of the elderly, but there are other significant groups. The noble Lord, Lord Rix, has reminded us about people with learning disabilities, and there are also people with physical disabilities. These two groups are growing as medical advances have enabled them to live longer. The quality of their life, of course, is the subject of much concern and that imposes additional strains on the budget. It is another example of incremental demand that needs to be met. In addition to that, there are people suffering from mental health problems. The increasing demand so far has manifested itself as between something like 10% and 14% in these different categories. It is clear that inflation and demographic trends alone will push up the cost, as the noble Lord, Lord Best, has indicated, by some £421 million by the beginning of the next spending review period.
There is also a serious question about the amount and timing of the funding designed to assist transition to the new regime, given that this welcome increment was announced in the spending review for 2015-16, but work will have to begin before then if we are to make progress at that time. It would be helpful to know, given that part of the rationale for the changes is that a whole-systems approach is likely to be more cost effective, just what savings the Government anticipate will be made and over what timescale by each of the two principal partners—local government and the health service—and in the case of the latter, by which of its several components.
Given the huge problems currently experienced in A&E—in contrast with the position under the previous Government when 98% of patients were seen within four hours—and the emerging problems that we have read about in the past few days in general practice, how confident can we be that the basic funding projected for both partners is adequate, even before taking into account the scale of change envisaged? How do the Government respond to the comment on the spending review of the Foundation Trust Network, which warns of,
“a further major squeeze on NHS front line services as £4 billion is diverted from the NHS budget to social care”
in 2015-16? It points to fact that trusts,
“are, in many cases, struggling to meet the rapidly rising demand created by an ageing population”.
The concept of pooled budgets is welcome, but given the number of parties to the commissioning process, with local authorities joined by clinical commissioning groups commissioning hospital services and NHS England, currently the national Commissioning Board, commissioning general practice and mental health services, how will this pooling work in practice?
Moreover, the Minister’s letter of 27 June makes it clear that,
“to stimulate real change, £1 billion of the £3.8 billion”,
which is the sum that the Government are investing in the change and allocating to pooled budgets,
“will be linked to the delivery of outcomes. So local authorities and the NHS will only benefit from this investment if they show commitment to integration and take action which makes a difference on the ground”.
Perhaps the Minister will explain what is meant by this. What outcomes are we talking about? How will they be measured, by whom and when? Will money paid up front, as presumably it would have to be, be clawed back if the outcomes are deemed insufficient? If so, given that we are talking about pooled budgets, by whom, when and from whom?
We are anxious that progress should be made in addressing the urgent need to transform the provision of social care and promote the essential joint working of health and social services in the interests of those who need such care and indeed of their carers. The whole House is united about the desirability of these objectives. I hope that the Minister will be able to respond positively to the concerns expressed by the noble Lord, Lord Best, and other noble Lords in this debate, and I offer a suggestion which could help to allay at least some of those concerns while facilitating an early start on fulfilling the aspirations set out in the Bill.
I join my right honourable friend Andy Burnham in calling on the Government to demonstrate their commitment by utilising part of the £2 billion NHS underspend that the Chancellor siphoned off in his March Budget. Some £1.2 billion could be used in the next two years to help tackle the current crisis in social care and smooth the way to the new system, which we all welcome, by relieving the pressures it will face.
I know very little about local government other than that I work with it in the health sector, but I wonder whether, with the pressure that is on all of us with the cuts and the absolute need to reduce things, local authorities have looked at every opportunity. All I know is that since our income in an NHS trust has been looked at more carefully, we have had to have a look at the cost improvement programmes that we can deliver. We had never done that before, but we have delivered so many of those, improving costs by £17 million in the last year.
I am not making a criticism as I have no idea at all, and I know that we can all bemoan the fact that we have less money and all the rest of it, but until we know that we have done everything that we can, and got right down to questioning if we could do things differently, then we perhaps need to look at ourselves as well. Forgive me if you have already done that.
Perhaps I might respond to the question that the noble Lord is asking about what it means to integrate social care and local authority stuff. This is why I worry to death about this amendment. If this part of the legislation does not happen, the whole system will be in much worse straits than it is now. We have an issue about our local authority cutting back on some of the places in nursing homes, which means that we do not have the opportunity to put patients who no longer need to be in a hospital in the place where they ought to be to receive care.
At some stage or other, all of us have got to work together and say, “How do we do this?”. For lots of different reasons, not just the bed space, it is much cheaper for an individual to be in a care home bed than in a hospital bed. If we cannot resolve it between ourselves, and we cannot do it on our own as providers, local authorities cannot do it on their own, and neither can the care sector generally, then I wonder if we are ever going to get there. People perhaps need to start to look at how we might achieve this by being a bit tighter in other things.
My noble friend is right to draw attention, as many of your Lordships already have, to the need to integrate the provision and to avoid the sort of cost-shunting that can arise if organisations are kept separate. That is the point of the pooled budget: you look not just at the straightforward provision of care by one or other partner, or both partners, but at what will perhaps reduce the need for care in other ways. As I say, other local services such as leisure and adequate housing, in conjunction with the public health agenda, may very well reduce the demand for particularly expensive forms of care, as I am sure we all agree.
Of course, local government’s track record is not uniform, but it is right to say that local government has proved over the years to be the most efficient part of the public sector. There has been a huge improvement programme in local government, recognised by the shortly to be lamented Audit Commission, and others, over the years. The LGA in particular has sought, through a whole series of policies, including the very extensive and successful use of peer review, to engender new approaches and more cost-effective ways of dealing with a range of problems, including those in the social care arena.
I was about to conclude by drawing attention to another figure, which has just emerged today. It is a rather startling figure: £9.8 billion of uncollected VAT—10% of the total take—according to today’s Guardian. That dwarfs the amount that the Government are putting into the new arrangements. Just as local government needs, together with its partners, to engender the utmost efficiency in the mechanisms that it develops to provide services and make them cost-effective, as my noble friend suggests, so on the revenue-raising side central government has a massive obligation to ensure that it collects the taxes—instead of cutting the resources going into HMRC, which is responsible for collecting VAT, by a further 5% in the spending review.
We do not consider the cost of £3.8 billion and the welcome money that the Government are going to provide to be the last word in these matters. There will have to be a continuing process of establishing programmes that are effective and cost-effective. Looking at the totality, there is scope within the system to prioritise this area, providing that the Government take the right decisions—across the piece, not merely on the narrow front of health and social care but considering the implications for other services and functions of government—and collect the money that they are due anyway and which would relieve the huge pressure on these services and others.
I have a good deal of sympathy with the concerns expressed by the noble Lord, Lord Best, but I share the view of the noble Lord, Lord Sutherland, that it would not be right to hold things up. We must get on, but in doing so we must be realistic about the challenges that will be posed to those responsible for delivering these services. I look forward to hearing the Minister’s response to the various questions that have been raised in the debate.
My Lords, I do agree with the spirit of this amendment. It is critical that care and support generally, and these reforms in particular, are fully funded. Without adequate funding, they will not deliver the benefits we all want to see. However, let me reassure noble Lords that we already have full procedures in place to ensure that there is proper funding for social care.
The first and very basic point is that the Government set spending plans for all areas of public expenditure at once during a spending review. This ensures that decisions can be taken about the future funding requirements of government as a whole, rather than assessing each part piecemeal. The noble Lord, Lord Sutherland, spoke about the review of priorities being a task of government. I agree, and that is exactly what spending rounds are designed to do.
Secondly, we have the new burdens doctrine in place, which requires that,
“all new burdens on local authorities must be properly assessed and fully funded”.
That ensures that all new funding pressures, including those that result from this Bill, are fully funded. I can tell the noble Lord, Lord Best, that our commitments are in line with the new burdens doctrine, the costs have been identified in the impact assessment, and the funding in the spending round will support local authorities to deliver on current and future commitments through to 2015-16. To answer the noble Lord, Lord Campbell-Savours, yes, the work has been done.
It is only right that the Government take spending decisions for all areas of public expenditure at once. This ensures that future spending plans are drawn up which are coherent and consistent across all public services. This is exactly the purpose of a spending round, the latest of which concluded last week, as noble Lords know, and set spending plans for 2015-16. Fundamentally, this settlement delivers the funding required to ensure that service levels in the care and support system can be protected and are able to deliver on all the commitments in this Bill.
However, with additional pressure on the system, we must ensure that the Government, the NHS, local government and care and support services are all working together to offer the best possible services for patients while also addressing the growing demand on the system that the noble Lord, Lord Best, rightly referred to. That is why we have announced in this year’s settlement a £3.8 billion pooled health and care budget to ensure that everyone gets a properly joined-up service, so that they get the care and support they need from whoever is best placed to deliver it, whether that is the NHS or the local authority.
In 2014-15, the NHS will transfer £1.1 billion to support social care with a health benefit. The pooled fund will include £2 billion more through the NHS in 2015-16. But this money will be given only on the basis that services are commissioned jointly and seamlessly between the local NHS and local councils. I hope that that helps to answer the question posed by the noble Lord, Lord Beecham.
Before the noble Earl moves on, perhaps he can answer this question. Is he saying that the statistics that were used in the report by the Committee on Public Service and Demographic Change were known to the department and were all taken into account, and that the calculations the department made were based on those statistics, which were well sourced, when the budget for these areas was decided upon by the Government?
The statistics that the Government relied upon were official statistics and, I think, were exactly the same as the statistics used by the report to which the noble Lord referred. Of course, that report takes us forward 10 and 20 years. I am not pretending that the spending round has done that—it never does and I think it is safe to say that it never will. But we did look forward in a rigorous way to the pressures on the system in 2015-16 and based our assessment on the statistics that are officially issued.
As all plans will be jointly agreed by the NHS and local authorities in the pooling arrangements that I referred to, that in itself will provide a strong guarantee that the money is spent in a way that delivers on the priorities of health as well as of care and support. Not only will this fund help to deliver joined-up services, it provides the necessary funding for all the commitments and duties set out in this Bill, and the growth in demand from an ageing population and growing number of disabled people—I say in particular to the noble Lord, Lord Rix, and the noble Baroness, Lady Campbell. In particular, funding worth £335 million has been set aside for the introduction of the cap on care costs and the extension of deferred payment agreements.
With some of the biggest users of the NHS being those who also use care and support services, the drive towards better integration in the system is absolutely essential. This is not just to create a more efficient service, but because the individuals and families who will benefit the most are often those who fall between the cracks of the two systems, being pushed from pillar to post and not getting the care and support that they should.
The investment in integrated services will back the wider moves towards supporting people at home, reducing unnecessary admissions to hospital and focusing more on prevention and support in the community. All of this will improve care and help to reduce burdens on the system. Local areas will work together to draw up plans for the use of this money, ensuring that it is spent on health and care services. All plans will include a commitment to protect care and support, which will guarantee that care and support services receive the investment that they need.
Pooling budgets and producing joint plans have all kinds of advantages. Importantly, they will help to drive down costs in the acute sector by tackling expensive pressure points in the system, like A&E; by improving prevention services; by reducing unplanned hospital admissions; and by allowing people to stay in their homes and live independently.
The noble Lord, Lord Best, raised the point about regional variation and questioned whether the funding allocations would adequately address that. Funding for social care is distributed to local authorities according to relative needs formulae, which ensure that local variation is taken into account. I am satisfied that that was done during the spending review.
The noble Baroness, Lady Howarth, pointed to the risk that, if we are not careful, funding pressures could mean commissioning cheaper and poorer quality services. We are all alive to that risk and we want to avert it. We recognise that the last spending review provided local authorities with an extremely challenging settlement. That is why we took the decision then to prioritise social care and we have done it again in the spending round. I hope that the announcement last week, together with this Bill, demonstrates our commitment to funding social care and promoting quality in care and support services. We took the decision to provide extra funding to help local authorities maintain access to services. As I said, that includes £1.1 billion in 2014-15. Local authorities, however, should be looking at how they can transform care by innovating and exploring new ways of working. Many local authorities are already doing this; I will mention a few examples in a moment.
The noble Lord, Lord Beecham, asked me how the pooled budget arrangements would produce the kind of outcomes that we all want to see. I think the key point here is that this pooled health and social care budget will benefit by its very nature both care and support and the NHS. It will safeguard those funds in the process and it will, as I have outlined, help to save money by keeping people well for longer. It will be given only on the condition that services are commissioned jointly and seamlessly between the local NHS and local councils. I have already explained about having all the plans agreed together, so that we can ensure that the NHS’s priorities are also met and that this money, as it delivers on the priorities that are important to the NHS—I have mentioned a few—will be used effectively.
My question was not about the purpose of the pooling, which I think we all share. My question was rather more detailed. If part of the funding is to be based on outcomes, how and when is that to be judged? If the outcomes are not achieved, how will the money be reclaimed? All this is something of a mystery as matters stand.
The details of the payment-by-results system will be worked through. We are working with our partners in the sector including the LGA and NHS England to ensure that the system is designed with a view to incentivising integration. Further details of those arrangements are in course and we will announce them as soon as we can.
The kind of things that we will be looking for are, for example, the results that we have seen in places such as Cheshire West and Chester. The pilots, the whole place community budgets, showed that savings from integration could be substantial if implemented effectively. A business case needs to be presented. In that context, the pilot suggested that, once proposals are fully implemented, the net savings that could be achieved over five years are considerable.
Cheshire West and Chester has made savings of £26 million, with £3.8 million for Greater Manchester, £190 million for the Triborough authorities and £90 million for Essex. These savings are being identified. It gives us confidence to say that there is real potential to save money across the country, as shown by the pilots and other reviews, such as the Audit Commission review. Oxfordshire recently announced that it was nearly doubling the amount of money in its pooled budget for older people. That is a significant move.
I agreed with much of what the noble Baroness, Lady Wall, said. Savings are eminently possible without detracting from quality, by slowing and preventing the development of care needs or the onset of health conditions, or the loss of independence. We hope and believe that preventive care can increase the quality of life for individuals. A proactive stance by local authorities will deliver that. At the same time, preventive care will provide longer-term financial savings to the public purse. For the first time, Clause 2 creates a clear legal duty on local authorities to ensure the provision of preventive services.
I come to the point raised by the noble Lord, Lord Campbell-Savours, about the Dilnot package. I do not view the Dilnot package in the same way that he does. I do not see funding reform as being about protecting people’s inheritances. It is about providing hard-working people with peace of mind about how much they will pay for their care. Deferred payments will ensure that people will not have to sell their homes in their lifetime to pay for care. That will prevent distressing sales of houses and provide everyone with breathing space to make decisions and choices about what happens to their home. In the long term, the scheme is broadly cost-neutral to government, because the deferred payments will be repaid. Everyone will benefit from these reforms, but they will particularly help people with modest wealth who are most at risk in the current system of losing their entire home and savings.
Delivering on these transformational changes to health and care is the only way to secure the long-term sustainability of services, both for the NHS and local authorities. I would be firmly against delaying this —I think we would be heavily criticised if we did. The noble Lord, Lord Bichard, referred to the burgeoning weight of regulation during the past 60 years and one cannot argue with the statistics that he produced. This Bill serves to consolidate more than 60 years of legislation; it will repeal provisions from more than a dozen Acts of Parliament. Reducing the complexity of the statute and rationalising burdens on local authorities are our key aims in this context. I hope that, for the reasons that I have outlined, the noble Lord, Lord Best, will feel sufficiently reassured to be able to withdraw his amendment.
My Lords, I am deeply grateful to all noble Lords who have spoken: to the noble Lord, Lord Bichard, for pointing out that we cannot keep loading responsibilities on local authorities and others without willing the means to pay for those things; to the noble Baroness, Lady Howarth, who said that we cannot go on like this; and to the noble Lord, Lord Rix, who explained the position from the Mencap perspective—it could have been that of many other charities which are facing very tough times because local authorities cannot keep up the level of support that they used to have. The noble Lord, Lord Campbell-Savours, produced more impressive statistics, not least in relation to the people with long-term conditions and dementia who are living in the community and need to fund their care needs. The noble Baroness, Lady Campbell, brought us the users’ voice, pointing out that funding cuts have already meant people losing some of the control and choice which had been increasingly expected with use of direct payments and so on.
The noble Lord, Lord Sutherland, pointed out that the culprit is not local government or central government but demography, and that we need to make some choices as a result of those demographic pressures. However, in his view, one of those priorities is clear: it is that we should go ahead with this Bill. The noble Lord, Lord Beecham, also felt that it would be unwise for us to delay things, even though he accepted that cuts mean that social services in Newcastle have returned to the position that they faced in 1973 in terms of the resources available. He pointed that it is local government that has shown itself best able to be more efficient in these difficult times. We need to remember that. The noble Baroness, Lady Wall, pointed out that local authorities should try to make savings wherever they can, and the noble Lord, Lord Beecham, was right that statistics show that local government is doing just that.
I think that it is fair to say that the noble Lord, Lord Bentham, felt that it was necessary to find additional resources, but he thought that those could be found from the underspend in the NHS or the uncollected VAT or some other source. However, he did not want the amendment to delay the good things that the measures bring with them. The noble Earl, Lord Howe, agreed that we need fully to fund the measures—did I say Bentham?
I deeply apologise, and not for the first time, to the noble Lord, Lord Beecham, one of the most distinguished of the vice-chairs and past chair of the LGA.
The noble Earl, Lord Howe, agreed with everybody that we need fully to fund the new measures and to ensure that the funding for existing care services is there. He expressed to us the belief that the new measures will do just that and they herald a sustainable funding arrangement for the future. He noted that the settlement for local authorities is extremely challenging this time round, but that, in terms of social care, the settlement that we are now pointing towards, with jointly commissioned services, the pooling of the £3.8 billion and NHS and local authorities working together, will in his view prove enough to fund a sustainable care service. Only time will tell whether those calculations prove to be accurate rather than too optimistic. In the hope that the noble Earl’s predictions are correct, and recognising that government really are attempting to make serious change in this Bill to the funding system as well as in so many important ways to the care services, I beg leave to withdraw the amendment.
Amendment 77B withdrawn.
Clause 1 : Promoting individual well-being
78: Clause 1, page 1, line 4, at end insert—
“( ) The Secretary of State, in making regulations or issuing guidelines under this Part, must have regard to the general duty of local authorities in exercising a function under this Part in the case of an individual to promote that individual’s well-being.”
My Lords, I shall speak also to my Amendments 78D and 88L. I am also supportive of Amendment 79, which very much follows the thinking behind my own Amendment 78. I also support Amendment 78ZA, in the names of the noble Lord, Lord Bichard, and the noble Baroness, Lady Tyler. I am sympathetic, too, to the amendments tabled by the noble Lord, Lord Black. I have also added my name to Amendments 78A and 78B in the name of the noble Baroness, Lady Barker. She will speak substantively to those amendments, which we have proposed in a number of Bills going back many years. They try to make sure that, when a regulator is dealing with a religious care home, regulations do not get in the way of the spiritual beliefs of the residents in that home.
Amendment 78 takes us to the very important well-being principle. In its consultation paper which led to the consolidation of the social care legislation that we see in this Bill, the Law Commission proposed that there should be tightly defined processes for determining the scope of adult social care. That follows on from the debate that we have just had. Replies to that consultation persuaded the Law Commission to define the purpose of adult social care as promoting or contributing to the well-being of the individual. That recommendation was accepted by the Government and is central to their new approach to adult social care.
Clause 1 provides for a set of legal principles which govern how local authorities are to carry out their care and support functions for adults under the Bill. Subsection (1) establishes the overarching principle that local authorities must promote the well-being of the adult when carrying out functions under the Bill in relation to that adult. This duty applies both in relation to adults who use services and to carers. The well-being principle applies to local authorities when they exercise a function in the case of an adult. My understanding is that it is not intended to be directly enforceable as an individual right, but to carry legal weight where a local authority’s failure to follow the principle may be challenged through judicial review.
This issue was considered very carefully by the Joint Select Committee, which commented specifically on the role of the Secretary of State in relation to the well-being principle. It took the view that many of the details that will shape the way in which local authorities discharge their functions under the Bill are subject to regulations and guidance issued by the Secretary of State. We will, of course, come on to one example—that is, the regulations in relation to eligibility, which we will debate not, I suspect, tonight but on another day.
The Joint Select Committee referred to Section 1B(1) of the National Health Service Act 2006, which provides:
“In exercising functions in relation to the health service, the Secretary of State must have regard to the NHS Constitution”.
The Select Committee suggested that the Secretary of State should be obliged to have regard to the requirements of Clause 1 on well-being when exercising the functions under the draft Bill. In giving evidence to the Joint Select Committee, the Minister replied:
“We absolutely want the wellbeing principle to apply comprehensively”.
The Joint Select Committee comments:
“We welcome the importance that Ministers attach to the well-being principle. We recommend that the draft Bill should include a provision requiring the Secretary of State, when making regulations or issuing guidance, to have regard to the general duty of local authorities under clause 1”.
We debated this at Second Reading. The noble Earl, Lord Howe, said that,
“Clause 1 is intended to apply at an individual level, when a local authority makes a decision. This individual focus on the specific well-being and outcomes for that person is at the heart of the way that the Bill has been drafted. It is not intended to apply in a more general way”.—[Official Report, 21/5/13; col. 829.]
He went on to say that it would therefore not be appropriate for the Secretary of State to be subject to the same duty, as the Secretary of State does not make decisions at the individual level.
I think there is an element of Ministers almost washing their hands of what actually goes on at ground level in health and social care. We have already seen that in the Health and Social Care Act 2012, and we are seeing some elements of that here. Of course, the Bill places a responsibility on local authorities to promote well-being in the way they implement the provisions of the Bill locally. However, if the Secretary of State were to issue regulations without having regard to the promotion of well-being, there is a risk that those regulations or guidance will conflict with the well-being principle. That would place local authorities in an impossible situation. For instance, if the eligibility criteria issued in regulations by the Secretary of State do not take full account of all aspects of well-being in Clause 1, local authorities may find that people who need support to promote well-being as defined in Clause 1 fall outside the eligibility criteria. I will come on to debating the eligibility criteria, but there are some aspects of the eligibility criteria which would suggest that they do not meet the well-being principles in Clause 1. I hope the noble Earl will think very carefully about this. There is a broad consensus in your Lordships’ House and within the Select Committee dealing with the draft Bill that the Secretary of State, when issuing regulations and giving guidance to local authorities, ought to be operating under the same principle of well-being as those local authorities are. It seems to go straight back to the debate instituted by the noble Lord, Lord Best, in relation to the Government legislating but not giving the wherewithal to local authorities to actually carry out that legislation effectively.
I turn to Amendments 78D and 88L, which are concerned with ensuring that health needs are taken fully into account in decisions taken by the local authority. I fully acknowledge that I have been inspired to do this by the noble Baroness, Lady Campbell. The starting point here is that it is essential to look at this through the prism of person-centred integration. As a starting point, we need to look at ways to put the individual’s and carer’s need for integrated working in the Bill and outline a statutory framework for person-centred integration that will support and incentivise local moves towards more integrated working. There are clearly points of contact here with the scheme which the Minister’s honourable friend Mr Norman Lamb announced recently for local pilots on health and social care integration.
Promoting the individual’s well-being, assessing their needs and those of their carers, deciding on eligibility and the priority for needs to be met, developing them with an appropriate care and support plan, enabling the best use of a personal budget and/or direct payment, and ensuring continuity of capacity during and after a move such as a house move are all processes or stages in which active engagement of NHS professionals or services could have a positive effect on the outcomes for individuals and carers. Integrated approaches by social care and the NHS can inform decisions, expand options, widen choice, retain or restore capability, prevent or reverse deterioration, avoid admission to and accelerate discharge from more intensive support and enable more efficient, equitable and economic use of scarce resources.
These amendments, which aim to ensure that happens in relation to the whole well-being agenda, are entirely relevant to the eligibility criteria. I remind the noble Earl that Mr Lamb, in his foreword to the document that we have received, makes the observation that,
“there needs to be better integration between local authorities and the NHS to remove gaps and build services around the needs of people”.
The discussion document’s only reference is in one paragraph which says:
“The assessment process in the Bill … provides for joint assessments between local authorities and other bodies such as the NHS. Improved integration will ensure that the person does not have to undergo separate assessments and will support better care planning to meet the individual’s overall health and care needs, or to join up whole-family assessments which look at an adult needing care alongside those who care for them”.
Of course, that is welcome as far as it goes, but there is a risk that it depends on an ill-defined concept of better integration and may well fall short of a holistic approach to well-being, assessment, care and support planning, carer support and review. We will come to the draft regulations later. This has a significant bearing on assessments for health and social care integration. The intention is to scrap the present assessment system, based on judgments about degrees of risk to areas of individual capability and exclusion from participation in various aspects of ordinary living. The new model proposes to examine people’s ability to carry out various personal care tasks and undertake a selections of household tasks. The rationale offered is that the new system will be more objective and fairer in its application, but there are some concerns here. First, this is explicitly a deficit-model of assessment, requiring individuals, their carers, relatives and social workers to almost play up or exaggerate the things that they are unable to do in order to qualify for support. In many ways, that replicates the very bad approaches that we have seen in some welfare assessments. It is certainly bad for morale and distorts the overall framework for making decisions. In one sense, one can argue that it reverses efforts over the past 20 years to maximise independence, choice and control and build on the strengths, contributions and aspirations that people can have. I must say to the noble Earl that is has some very uncomfortable reminiscence of the new approach to disability benefits, whereby people are required to prove limitations under the inexpert and unsympathetic eye of ATOL assessors. I hope that is not the approach that is going to be taken in relation to the eligibility criteria. There will be very great concern if that is to be the case.
The noble Baroness, Lady Campbell, has many examples, which I hope she might be able to intervene and provide, of disabled people with high health and social care support needs, who are ready for discharge but languishing in costly high-dependency hospital units because clinical commissioning groups have almost ground to a halt due to decision-making, with arguments about who pays being one of the many reasons for this. It is absolutely essential to ensure that when we debate and take forward the well-being concept, which of course we welcome, not only do we have a situation where the Secretary of State is subject to those principles as well, but the health service plays its part in ensuring a wholly integrated approach. As we come to debate the eligibility criteria, that is going to be a very important factor for our consideration. I beg to move.
My Lords, I support the amendment and in particular speak to my own Amendment 78ZA, which seeks to place the concepts of dignity and respect on the face of the Bill at the outset. I should declare an interest as chairman of the Social Care Institute for Excellence.
A week or so ago I visited a residential home in Edgbaston, Birmingham, and I came away convinced that I could happily live there. I am not sure that they would want me but I was convinced that I could live there if they would have me. As I reflected on that visit I asked myself why I felt so positively, because I do not always feel that way about a visit. The accommodation was comfortable, clean and not overly institutionalised. The staff were skilled and well qualified. There was a rich programme of voluntary recreational activities and a great deal of interaction between the local community and the home. A special school was visiting on a regular basis and there was clearly a bond between the residents and the students at the special school.
All very impressive, but above all, I experienced a place where residents were treated with dignity and with respect by staff who seemed to understand that people’s greatest need at a time when they have to receive some support is not to lose their dignity. Those residents wanted, above all else, to retain their dignity, and so would I.
Recently, we have all seen distressing coverage of care—residential or domiciliary—which falls below anyone’s acceptable standards. Although I am sure that we have all been shocked by the nature and level of abuse and neglect which have been exposed, I, for one, found the most heart-rending thing was the way in which all that had stripped people of their dignity. The fact that someone in a caring profession could treat another person with such a lack of respect and basic humanity—whatever the pressures, and we know that those pressures are considerable—is what I found truly shocking. To see vulnerable people stripped of their dignity is, frankly, devastating.
Dignity and respect are the basic rights which those in care have the right to expect, but they also provide the benchmark by which professionals should be judged as they go about their work. Whatever else carers do, it is simply not acceptable to treat people with a lack of dignity and respect. That brings me specifically to the Bill and my amendment.
Many of us have said on Second Reading and already today that in many respects this is a mould-breaking Bill, much of which is to be welcomed, but because it is so significant it will long be a reference point for those in the caring professions and a place where people look for definitions of good care. They will look for a clear statement of what users and professionals should expect and should be expected to provide. That is why I think that it is so important that we ensure that the Bill captures and articulates boldly what we expect. As it stands, Clause 1 says much that is important, as it is intended to exemplify what is meant by providing well-being. In Clause 1(2), there is even a cross-reference to personal dignity. I suspect that the Minister may well suggest that that deals with the thrust of my amendment, but for me, it is lost in a series of other references. It just does not stand out boldly enough and its impact is diminished.
Well-being is a phrase well used now in the world of health and certainly within the Department of Health. There is nothing wrong with it, but for me, it just does not quite capture the essence of good care. It is also not a phrase in common usage. It does not encapsulate the fundamentals of good care in the way that “dignity and respect” do. My amendment would state boldly at the outset of the Bill that dignity and respect is what we are all about. They encapsulate the cornerstones of good care. They are the foundations on which everything else should be built. Even in an age of austerity and cost-reduction, they cannot ever be compromised, because they are, in many ways, our most basic human rights.
The amendment is really meant to help the Government and the Minister, to enable them to make at the outset that bold statement of intent and expectation. It does not need additional expenditure—that must be a good thing—it just involves us being prepared to state simply and unambiguously what the Bill is about and what good care is about.
My Lords, I shall speak to Amendments 78A and 78B, which stand in my name and that of the noble Lord, Lord Hunt of Kings Heath. These and other amendments which will crop up throughout our discussions have been inspired by the Christian Science movement. I wish to say that I am not a Christian Scientist, but Christian Scientists hold to some very firm beliefs which are of great importance to them. Part of their belief system is that they do not wish to receive medical treatment in circumstances where other people would make a different decision. Therefore, in health Bills such as this, where we are setting out the principles that underlie what we define to be good care, it is not uncommon for me and the noble Lord, Lord Hunt, to put on record again that there is a spiritual dimension to health and well-being and that the way in which that spiritual belief is manifested can be different for minority groups.
One great strength of the Bill is that it takes a principled approach to what we define as well-being rather than attempting to define well-being in a descriptive sense. One reason why I think that that is increasingly important is that we have an increasingly diverse population. Therefore, the meaning of well-being for individuals is becoming distinct and diverse throughout society. The amendments place a duty on local authorities and relevant health bodies to respect the increasing diversity of our population.
There are two other reasons why I am very pleased to support the amendments. Like everyone else in the House, I am greatly in favour of the integration of health and social care. I see the undoubted benefits of that, but as someone who has worked in the field of social care, as opposed to health, all my life, I still carry with me the fear of the medicalisation of disability or of old age. When push comes to shove, when budgets are tight, some of the certainties which surround physical health, in particular, can overtake social goods which are less easy to define. Therefore, it is important that we ensure that we do not allow that to happen. One way to prevent that is by taking the approach of the amendments.
The final reason why I raise the amendments now is that I think that setting that out as they do right at the top of the Bill is a strong reminder to everyone who will refer to the Bill in years to come that the autonomy of individuals is an important part of health and well-being. You cannot have good health and be a fully functioning member of society if you do not have that autonomy, an autonomy which means that, in some cases, you have the right to make decisions which other people would regard to be unwise. It is a point of principle, but one which I think has a great deal of practical application not just for those who are receiving care but for those who are in charge of making decisions about it.
My Lords, I am very sorry that the noble Lord, Lord Warner, is not in his seat. He tabled Amendment 79 to express the strength of feeling of Members of this House who were sitting on the scrutiny committee about the Secretary of State’s the duty to have regard to well-being. Were there room for more than four names to the amendment, there would have been more Members of your Lordships’ House on that list.
To put this in context—and the noble Lord, Lord Hunt, has taken us through quite a lot of this—this Bill was widely consulted. It was probably the coalition’s most widely consulted Bill; somebody might be able to tell me to the contrary. At each stage, people welcomed the well-being principle. Perhaps I may remind the House that in the majority report on the Bill, one of the recommendations was that the Secretary of State should have due regard. When the final Bill was produced, many in the sector approached me, and I suspect many others, to express their disappointment that that was not included in it. When the Secretary of State came to give evidence with the Minister for Care and Support, the right honourable Norman Lamb, he was very positive about it. According to the transcript of the session, Norman Lamb said:
“We absolutely want the wellbeing principle to apply comprehensively”.
The well-being principle is around the change of culture and it puts the person at the centre. It is absolutely critical that that happens, and next week we will debate the whole business of assessment and how we are undertaking it. However, unless the Secretary of State has to have regard to the same principle as local authorities, there is an opportunity for future Secretaries of State when making regulation to disregard well-being and just make regulation in the old way. One thing that sets this Bill aside from many others is that it is written in plain English and throughout its intention is pretty clear.
I ask the Minister if he is able to offer any assurance to the House, to the sector and to those for whom the Bill is written—the service users and the carers—that the Government will think again about the decision not to include in the Bill a duty on the Secretary of State to take well-being into consideration.
My Lords, I apologise for not being able to bound in as soon as the noble Lord, Lord Hunt, sat down. At that moment my papers cascaded to the floor. I rise to support Amendment 78D. For logistical and physical reasons, as my noble Lords can probably hear, I was unable to put this amendment down myself and the noble Lord, Lord Hunt, has done miracles to articulate our conversations in such a lucid manner.
I feel, however, that I must give your Lordships a very clear example of why I believe this amendment is so necessary. Why do health and social care practitioners need this further direction in this amendment?
It is true that health and social care consumers enjoy greater personal control now, which affords a small percentage support to live independently in the community. I am an example of the few who live with complex health and social care requirements and live a life just like any other: pursuing a career, tending the family, or in my case revising legislation.
We remain, however, an exception, rather than the rule. Let me give your Lordships a couple of examples. Just over a year ago, I led a JCHR inquiry into Article 13 of the UNCRDP, a right to independent living. When we launched the findings, I dedicated the report to a disabled young man who had secured optimum control over his own life using social care direct payments. He lost everything within a couple of months, after his support needs changed, due to requiring a tracheostomy. He had graduated from university and was about to start his first job .
The tracheostomy is a significant procedure requiring recovery and adaptation, but he was considered well enough to return home after two months to pick up his life. Despite what he had been through, he was bright and optimistic about his future, and I had no doubts that he would adjust and go back to work.
Five months later, he was still on the same high dependency ward. Had his health declined? No. He remained in hospital because his tracheostomy meant he was no longer allowed to manage his social care direct payments. Without his knowledge, he was passed from social services to his local PCT, which suggested he move to a nursing home for older people. When he and his consultant said no, this file was put in the pending tray. There this young 23 year-old watched patients die, and the noise of machinery made sleep possible only for the very tired or the very ill. It was a life barely lived for days, weeks and months on end.
That situation occurred only due to the inability of local health and social care services to work in an integrated, efficient and effective way. It could not have been a question of funding, as the cost of his care was three times more expensive in the hospital unit. This was not an isolated case. Since then, the unit has experienced an increasing number of cases.
Britain no longer routinely places disabled people in institutions, but that does not mean that it does not institutionalise disabled people through bureaucratic failure, red-tape and a lack of support, precisely because the duty struggles to provide a holistic publicly funded health and social care support service.
I am not a fan of a health model of disability, but so many disabled people are living with considerable health issues. That is why we have to have a clear structure and direction in both health and social care so that they work together equally to produce outcomes for disabled people that enable them to go on living the life that they so long for: a life lived independently in the community.
My Lords, I apologise to the noble Baroness, Lady Campbell. I was so eager to follow the noble Baroness, Lady Jolly, on Amendment 79, and I did not know that she was wishing to speak.
I particularly wanted to follow the noble Baroness, Lady Jolly, in speaking in support of Amendment 79, on which my name appears as well as hers and the noble Lord, Lord Warner, who was unavoidably absent today, and indeed the noble and learned Lord, Lord Mackay.
It will not have escaped the notice of the Committee that we are all members of the Joint Select Committee which scrutinised this Bill. We were very keen to have in Clause 1 the recommendation that when making regulations or issuing guidance, the Secretary of State must have regard to these principles, as must as local authorities.
We put this issue to the Secretary of State and the Minister as the noble Baroness, Lady Jolly, has mentioned, when they appeared before the Joint Committee. They appeared to be very favourably inclined towards it. We were very hopeful that this would be in the Bill. The civil servants were clearly less eager about this, so perhaps it was no surprise that it did not appear. However, we took away from the evidence session the understanding that Ministers were sympathetic to the idea. That is one of the reasons this amendment has been tabled.
Sadly, the official line now seems to be that used by the Minister at Second Reading on 21 May, when he said that,
“the well-being principle in Clause 1 is intended to apply at an individual level, when a local authority makes a decision. This individual focus on the specific well-being and outcomes for that person is at the heart of the way that the Bill has been drafted. It is not intended to apply in a more general way. Given that we do not think it would be appropriate for the Secretary of State to be subject to the same duty, the Secretary of State does not make decisions at the individual level”.—[Official Report, 21/5/13; col. 829.]
Nobody could disagree with the first part of that statement but the second part simply does not follow on, because the Secretary of State’s actions in regulations and guidance determine to a great extent whether local authorities can discharge their duties under Clause 1.
If the Secretary of State asks so much of local authorities without adequate funding being available, they will simply be unable to discharge their duty. Only if the Secretary of State is bound by the same duty as the local authorities can there be any realistic chance that, over time, he will avoid making unreasonable demands of local authorities in the instructions that he gives them. The way that the Bill is drafted, the Secretary of State can simply pass the buck back to the local authorities, which differs from his position in relation to the NHS, where he is required to act in accordance with the NHS Constitution. If it was the Secretary of State’s intention, as he seemed to be saying in his oral evidence to the Joint Committee, to support the well-being principle in practical terms, this amendment should be acceptable, and I hope it will be.
My Lords, I shall speak to Amendments 78E, 87K and 88J, which are in my name. They raise the issue of companion animals—mostly cats, but dogs as well—and the positive role that they can play in the care of elderly, vulnerable and sick people, whose welfare is at the heart of the Bill. I should declare an interest as president of the Printing Charity, as it runs two homes providing sheltered accommodation and financial support and care for people from the printing industry.
Amendment 78E includes the positive contribution of a companion animal to an individual’s well-being in the list of factors to which a local authority must have particular regard in exercising its functions under Part 1. Amendment 87K includes identifying the role of companion animals in the care and support of an individual when a local authority is assessing their needs and those outcomes that an individual wishes to achieve in day-to-day life. Finally, Amendment 88J deals with the issue of companion animals in regulations under Clauses 9 and 10. Taken together, their purpose is to ensure that the benefit which companion animals can provide to well-being, a subject not currently covered in the Bill, is not overlooked by those implementing and interpreting it.
It is estimated that 25% of people over retirement age own one or more pets. For the elderly and vulnerable, the companionship that cats and dogs can bring cannot be overstated. Academic research over many years has documented this. One study by Brooks, Rogers and others, published just last year, highlighted the emotional and practical impact that companion animals offer. Noting that they provide unconditional support and love, as we all know, the study concluded that,
“the policy implications of this study suggest that pets might usefully feature alongside consideration of the usual support systems associated with the management of long-term conditions and in planning how needs might be ... creatively met”.
That, of course, is precisely what this Bill is designed for and what these amendments are crafted to deliver.
Cats in particular can help those who are vulnerable, through age or health, in three ways. First, there is a powerful body of evidence about the contribution of cats to physical health. According to one study published recently in the Journal of Vascular & Interventional Neurology—not a magazine I look at frequently, but it is there—they contribute to a reduction of fatal cardiovascular disease by around 30%.
Secondly, the ownership of a cat brings positive benefits to an individual’s mental health. Research conducted in 2011 for Cats Protection and the Mental Health Foundation among people with a mental health problem found that 76% of people who owned a cat felt they could cope with everyday life much better as a result, and that 87% said it had a positive impact on their well-being. Cats can be especially helpful for depression during the winter period—a particularly important point since, as we now know, this goes on for about nine months of the year. As the Cinnamon Trust, which works tirelessly to support the elderly and their pets, summarises it:
“Pets have the ability to bring happiness and laughter and lift depression. Communication with other people is often easier when a pet is present for reassurance”.
Thirdly, cats make particularly suitable companion animals for those with chronic health problems, including those who are immobile or disabled. I know that this is a charge always made against cat lovers, so I am not forgetting our canine friends. I highlight, for instance, the excellent work of the innovative Dementia Dog Project, which helps to keep people in the early stages of dementia active and engaged with their local community, as well as providing a constant companion to reassure those suffering from dementia in new or unusual situations. This project in particular shows that a dog may aid a sufferer to stay on longer in his or her home—an important ambition that many noble Lords have highlighted in this debate—and may even slow the onset of this terrible disease.
Real-life examples of how cats promote well-being and play a vital role in an individual’s care appear regularly in the excellent magazine, The Cat, which is a publication I do look at regularly and is published by Cats Protection. In recent months, there have been stories about how their cats helped an owner to cope with epileptic seizures, helped a seven year-old boy to deal with the debilitating problem of selective mutism, and comforted a 17 year-old girl confined to bed with the life-long incurable condition of Behçet’s syndrome. One particularly moving story related to how a visit from a cat to an elderly lady who was in a hospital ward and suffering from severe dementia got her to speak for the first time in three months.
There are many other examples. Indeed, I think of the experience of my own mother. In the last year of her life, she was widowed, immobile and more or less housebound. Her faithful cat, Toby, was her constant companion. She talked to him, laughed with him and moaned and shouted at him; he cared for her in return. Indeed, he lay on her bed as she died. That companionship is a priceless gift, which this legislation should protect. Let me explain briefly how these amendments might help, as I ask my noble friend the Minister to consider these three issues.
First, one of the many problems that those who are elderly with a pet can face is how to care for it when they go into a care home. There are some amazing care and retirement homes which welcome pets but others do not have a policy on them, which can cause anxiety and distress to those who need to enter one. For a person to have to give up what might be their sole companion is a tragedy for an owner and for the pet. It also adds to the growing burden on many animal charities, which are having to take increasing numbers of abandoned pets as economic problems have bitten hard in so many families.
Secondly, it would encourage those at the front line of care—GPs, in other words—to become aware of the role of a pet in an individual’s life. Many GP surgeries include in their information about the over-75s whether a companion animal forms part of the client’s household. The signal sent from amending the Bill would encourage many more GPs and clinical commissioning groups to ensure that this important information is routinely collected for all age groups, including the elderly.
Finally, the Bill needs to be drafted widely enough in its definitions of well-being and needs assessments to allow for money, whether budgets or direct payments, to be used where necessary to support an individual who perhaps wishes to retain a pet but is having problems due to health. Professional pet-sitting or feeding may be needed when an individual is hospitalised and where there are no friends or family to help. Knowing that a pet is being cared for can help encourage otherwise reluctant individuals to go into hospital for treatment and relieve anxiety. Equally, in cases where a care assessment shows that a companion animal would bring individual health benefits, money may be needed to help an individual obtain a companion animal. There are many examples of such budget programmes in other countries—most notably, I think, in Australia—where health and local authority budgets are pooled to provide companion animal support programmes. This principle should be embedded in regulation and statutory guidance for all relevant implementing bodies.
Most importantly of all, these amendments would ensure that the role of companion animals is given proper recognition and protection through an individual’s care journey. Some may be too vulnerable or frail to request that their beloved pet is taken into account when their care is planned. Others may need help or assistance in retaining their companion. Others still may not be aware of how a cat or a dog could improve their quality of life, ease their loneliness or help tackle a chronic disease. The amendments I have tabled would ensure that this happens as a matter of routine and is not left to chance in the way that, tragically, too often happens now.
My Lords, today is bowel awareness day. I have been chairing a reception for bowel care this afternoon. Two of the speakers had disabilities: one with multiple sclerosis and one a tetraplegic, paralysed from the neck down. Both needed bowel care and they both said that dignity and respect were so important. Amendment 78ZA should therefore be a must for the Bill. There are many important amendments in this group, including those on well-being and companion animals, which I support. Happiness is something we should all aim for.
My Lords, I add my support to Amendment 78ZA, to which my name is also attached. The noble Lord, Lord Bichard, has already spoken very eloquently of the reasons behind the amendment. Dignity and respect are absolutely fundamental pillars of well-being, which is why I would like to see these words spelt out in the Bill. Well-being is unattainable without dignity and respect as central components. In saying this, I am conscious that the public’s opinion on this matter is one of pessimism and distrust of the current social care system. In a recent survey, only 26% of the public felt confident that older people receiving social care are being treated with dignity. If the public do not trust their loved ones in the hands of the social care sector, what hope is there that well-being is being promoted?
We have recently seen and heard of shocking failures in the care of older people in both the health and social care sectors. These very harrowing examples serve to illustrate the importance of enshrining dignity and respect as a critical part of well-being in order to try to change the culture among care workers in the health and care sectors, to ensure the transformation of services that this Bill is intended to bring about and to have the sort of compassionate care that we all like to see. Dignity will also be very important when it comes to secondary legislation and specifically to the eligibility criteria. It is vital that these criteria have regard to the well-being principle. I am happy to be corrected about this if I am mistaken, but the draft feels very health-and-safety-oriented and does not mention dignity at all.
I would have liked to add my name to Amendment 79 about including well-being as part of the Secretary of State’s duty, the reasons for which have already been set out very clearly. The very wide-ranging definition of well-being, set out in The Care Bill Explained, makes it absolutely clear that for the well-being principle to be made a reality it would need to be the joint responsibility of a wide range of partner agencies, nationally and locally. Government action on key issues such as welfare, transport and housing are likely to have a very distinct impact on well-being at an individual level.
We rightly hear a lot about the importance of joining up health, social care and wider services: horizontal integration, if you like. For any system to work as it is intended and to be fully aligned it must be, as I said at Second Reading, vertically integrated as well to make sure that everyone, from the Secretary of State downwards, has the same objectives and is pulling in the same direction.
My Lords, I support Amendment 78ZA. Six years of serving on the Equality and Human Rights Commission taught me that if we embedded dignity and respect into the training of staff we would avoid many of the tragedies we have read about. This applies, right across the board, to staff in health, social care and housing. It is essential that we take dignity and respect as very serious elements of the training of all staff who come into contact with frail and vulnerable people.
My Lords, the well-being principle in Clause 1 was devised on the basis of the Law Commission’s report on adult social care which this part implements. The report recommended that the new statute should set out a single, overarching principle that adult care and support must promote or contribute to the well-being of the individual. Not least in the light of our debate at Second Reading, I can therefore understand the noble Lords’ intention in tabling Amendments 78 and 79. It is to ensure that any functions that the Secretary of State exercises under this part take into consideration how such provisions will impact upon people’s well-being. I can give the Committee what I hope will be a welcome reassurance on that issue and, in the process, a rather better and fuller answer than I gave at Second Reading.
It is already the case that the Secretary of State must have regard to the general duty of local authorities to promote an individual’s well-being when making guidance or issuing regulations. This is because, when making regulations or issuing guidance, the Secretary of State must consider how local authorities can fulfil their statutory obligations. He cannot ignore those obligations and I believe this addresses the central concern of the noble Lord, Lord Hunt, and others who have spoken to the amendment. The question is whether the Bill should go further. The Government do not believe that it is appropriate to apply the well-being principle directly to the Secretary of State. The well-being principle is intended to apply at a very real, individual level. It has been designed to frame the relationship that exists between the local authority and the individual adult, in effect setting out how it is expected the local authority will behave when making a decision, or doing anything else, in relation to a person needing care and support or to a carer. The Secretary of State does not act at this individual level, and I am still reluctant to make any amendment which might be seen to detract from this important legal reform.
Having said that, I have listened with care to the strength of feeling in this debate, not least to the point made by the noble Baroness, Lady Pitkeathley, about the Secretary of State’s duty to have regard to the NHS constitution and whether there was something comparable that we could devise in this context. That is an interesting comparison and, while I am not yet convinced that it is fully comparable, I am happy to take the points that have been made away with me and give this matter further thought before the next stage of the Bill.
Amendment 78A seeks to bring in to the well-being principle the idea of spiritual well-being and I listened with care to my noble friend Lady Barker who spoke to this amendment. The Government believe that the clause, as it is already drafted, takes such a factor into consideration. Clause 1(2) sets out that well-being means an individual’s well-being in relation to emotional well-being. The Government believe that emotional well-being incorporates the concept of spiritual well-being.
I turn to Amendment 78B, which proposes that local authorities must take into consideration an individual’s beliefs, values and past practices. While we share my noble friend’s intention in this regard, we believe that the clause as it stands already incorporates the idea that people’s beliefs and values should be taken into account when a local authority has regard to an individual’s views, wishes and feelings.
The second part of the amendment would be to ensure that “past practices” were also taken in account. I reassure my noble friend that we will be setting out in guidance the importance of taking into consideration, when planning a person’s care, their views and feelings as well as considering any practices in the past that have been important to that individual.
The noble Lord, Lord Bichard, highlights the importance of dignity in care in his Amendment 78ZA, and he spoke about that concept very powerfully. I am pleased to say that the Government agree that this is important, which is why we amended the Bill to make an explicit reference to dignity into the well-being principle, following pre-legislative scrutiny. With respect to the noble Lord, I cannot agree with him that the word has somehow been lost; it is right there on the page.
I turn to Amendments 78E, 87K and 88J, tabled by my noble friend Lord Black of Brentwood. These amendments focus on the very important topic of pets. The Government have considered this issue carefully since the amendment was tabled, and we believe that the Care Bill already allows for the consideration of pets. First, Clause 1, the well-being clause, provides that local authorities, when exercising any function under Part 1 of the Bill, have a duty to promote the well-being of an individual. Well-being is composed of many aspects, including emotional well-being. A pet might be so important to an individual that their emotional well-being would depend in some way on their pet. If that is the case, a local authority will have to take it into consideration.
Furthermore, Clause 1(3)(b) sets out that in exercising any function under Part 1 of the Care Bill a local authority must have regard to an individual’s “views, wishes, and feelings”. This could include how an individual feels about a pet, and their wishes for the pet. Clause 9, which covers the assessment of needs for care and support, also allows scope for pets to be taken into consideration in the assessment process. As Clause 9(4)(a) sets out, a needs assessment must take into consideration a person’s well-being. This could certainly include an individual’s pet, from which they derive a lot of emotional well-being.
I turn to Amendments 78D and 88L. The Government believe that it is more important than ever that care and support services operate in tandem with health services. The Government have committed to breaking down barriers between health, care and support, as well as encouraging co-operation, integration and joined-up working between local partners. The Government believe that the Care Bill already allows for such co-operation to occur, and I shall explain how. First, Clause 1(2)(a) makes it clear that the well-being principle incorporates physical and mental health. Local authorities must therefore already consider a person’s health when exercising any functions under Part 1. Secondly, Clause 3 details how local authorities must exercise their functions under Part 1 with a view to ensuring the integration of care and support with health provision, where they consider that this would promote the well-being of an individual.
Regulations on assessments for care and support are also relevant. As Clause 12(1)(f) sets out, regulations may set out when a local authority must consult someone with expertise before undertaking an assessment. Regulations may also set out conditions around co-operation with the NHS, by specifying the circumstances in which the local authority must refer the adult concerned for an assessment of eligibility for NHS continuing healthcare.
The noble Lord, Lord Hunt, expressed the view that the eligibility regulations do not sufficiently promote integration. I note the point that he made and look forward to debating this in perhaps fuller measure when we come to discuss eligibility. However, I ought to point out that the draft regulations published last week are subject to consultation, and I am sure that the discussion will explore the points that he made.
My noble friend Lady Tyler said that the regulations do not mention dignity specifically. I think that they have to be read in context. The well-being principle, including the reference to dignity, applies to the assessment of the adult’s needs and to the local authority’s determination of whether those needs are eligible.
To return to my noble friend Lord Black’s amendment on companion animals, we are clear that there should not be any limitations on the uses of direct payments, which was an issue that he raised, as long as they are used to meet needs for which they are paid and not in a way that is unlawful. The key is that direct payments are used to improve people’s outcomes.
I understand the intentions of noble Lords in tabling these amendments but I hope that they feel reassured that they are not necessary, although I will take back the specific issue that I referred to earlier. In the light of that, I hope that the noble Lord, Lord Hunt of Kings Heath, will feel able to withdraw the amendment.
Before the Minister sits down, I would just like to ask him: does he not really want to get things right? When there were problems at Mid Staffordshire, people were desperately thirsty, drinking out of flower vases, and were lying in their own refuse in their beds. Surely dignity must be written in all over the Bill.
I agree that dignity is a very important concept, which is why we expressly amended the Bill to include that word right at the beginning. Clause 1, which defines the well-being principle, is the foundation for everything that follows. While one could pepper the Bill with references to the word “dignity”, I am not sure that that would add very much in practice.
My Lords, I am grateful to the Minister for that response. I hope that he will reflect a little on the amendment from the noble Lord, Lord Bichard, and the noble Baroness, Lady Tyler. I understand what he is saying about the words in the Bill; I think that noble Lords just wanted to find a way of giving that greater focus. That will be well worth giving further consideration to. With regard to the amendment from the noble Baroness, Lady Barker, I am grateful for the reassurance that the Minister has given.
On Amendments 78 and 79, the Minister has essentially said that he still sticks to the general principle that the well-being clause applies to local authorities and individuals. The point here, though, and the reason why I am glad he is taking it away, is a point raised by a number of noble Lords: this legislation, which is a wholesale recasting in the light of the Law Commission’s work, is likely to endure for many years to come. That is why it is so important that the link between the Secretary of State’s duties, and those of local authorities, and the Secretary of State’s powers regarding guidance and regulations are brought together. I hope that the Minister will find a way of getting this into the Bill.
The noble Baroness, Lady Campbell, was very eloquent when she talked about what happens if health and social care do not provide an integrated service. She gave an example of a very distressing case of someone who could be out of hospital and back into work. This was down to a failure of two public bodies to sort things out. I know that the Minister says that in fact the legislation is okay; the problem is that these public bodies will continue to fail people who fall between two stools. These bodies do not seem to have an understanding that it is imperative for them to look after the interests of those individuals. I hope that the noble Baroness might return to this at a later stage.
The noble Lord, Lord Black, made some wholly persuasive arguments. My noble friend Lady Wheeler reminded me that Canine Partnerships is another organisation that is very much involved in pet companions for people with stroke, epilepsy and other illnesses. I myself have come across organisations in Birmingham in connection with the health service that do a fantastic job. All I would say is that if the noble Lord put this to a vote, the Opposition would be right behind him, so let us see. I beg leave to withdraw the amendment.
Amendment 78 withdrawn.
Amendment 78ZA not moved.
Amendments 78A and 78B not moved.
House resumed. Committee to begin again not before 8.50 pm.