Committee (5th Day)
Relevant document: 1st Report from the Delegated Powers Committee.
Clause 2: Preventing needs for care and support
80: Clause 2, page 3, line 2, at end insert—
“( ) the importance of identifying housing options required to exercise that duty”
My Lords, we come now to a group of amendments, five of which are in my name and the names of my noble friends Lady Wilkins and Lady Tyler. These five amendments have the same underlying purpose—namely to give greater prominence to the crucial role that housing can play in preventing and reducing the need for health and social care services. The amendments have been prepared by the Care and Support Alliance, which is composed of more than 70 organisations that support and represent older and disabled people. I am particularly grateful to the National Housing Federation, which has helped bring these amendments together and given excellent briefings to interested Members of your Lordships’ House.
The Bill has been welcomed by those organisations, and they note with approval that the definition of “well-being” in Clause 1 covers “suitability of living accommodation”. Also, in relation to the duty on local authorities to meet needs for care and support, Clause 8 includes reference to such assistance being provided “at home”. However, these passing references to the place where many elderly and disabled people spend almost all their time do not do justice to the significance of housing to enabling people to live independently.
The Bill takes highly significant steps to integrating health and social care services, but downplaying the housing element—the third leg of the stool—will undermine the legislation’s good intentions. The Age UK report, Stop Falling: Start Saving Lives and Money, notes that falls cost the NHS around £4.6 million every day and that around half of the people over the age of 80 suffer a fall each year. It makes clear that it is accidents in the home, or on the icy step outside, that so often lead to hospitalisation. Cold and damp premises are equally likely to be the cause of a deterioration in health. Once in hospital, if the home to which the patient should return is totally unsatisfactory, their discharge will be delayed and/or there will be a swift readmission to hospital when the home fails them. Informal family carers cannot cope with someone’s care needs if they are battling with the inadequacies of a home that has unmanageable stairs or cannot accommodate a wheelchair.
The case has been made for the financial benefits of getting the housing service right. The National Housing Federation’s new report, Providing an Alternative Pathway, for example, shows that housing for someone with dementia in a self-contained flat in an extra-care scheme provided by a housing association can cut the cost of their care by up to 50%, allowing them to live more independently with care and support on-site, rather than in a costly residential care home. Currently, the UK is spending £9.43 billion on housing those with dementia in care homes, so housing alternatives can have a huge impact on health budgets.
Often the ideal housing solution for so many of us as we grow older is a move to a more manageable home with very low heating bills, no stairs or steps, but with high standards, space, light and ventilation. As a wonderful bonus, when an older person downsizes, a much needed family home, probably with a garden, comes on to the market for the next generation. I declare my interest as chair of Hanover Housing Association, which endeavours to build accommodation of this kind, which is in turn likely to be the best place for care and support services to be delivered. The housing provider can supply the back-up, not only through emergency call systems—now much enhanced by new technology—but in personal terms in acting as helper and ally in securing care services. Age-friendly housing developments for older people also protect against loneliness and isolation for the resident through ensuring a sociable, companionable environment.
However, the great majority of people will stay put in their family home. A joined-up care and housing service can make this possible. Sometimes very minor adaptations are all that are needed to extend people’s independence and autonomy. Handrails that are discreetly and strategically placed can prevent falls in the home. Long-armed “D” taps for people with arthritic hands can reduce the occupier’s need for costly help. Introduction to a “handy person” service can get these things fixed. Arrangements to pay for a defunct central heating boiler to be revived can end the misery of choosing between being freezing cold and spending a fortune on an electric bar heater which may well be unsafe. This investment in the home can keep people well.
Home improvement agencies, often called “care and repair” services, can organise access to disabled facilities grants for items like stair lifts or the installation of walk-in showers, making life so much easier for family carers as well as for the person themselves. It is good to note, in the spending review, the transfer of resources from the Department of Health to fund a planned 20% increase in the budgets of disabled facilities grants.
All these measures that prevent the need for more costly care services achieve very rapid payback as well as transforming people’s lives. If a patient cannot be discharged from hospital for a couple of weeks because their home cannot take them back, the NHS will incur costs of well over £5,000—money that could have been so much better spent fixing the home and preventing a series of unnecessary and unwanted hospital stays. Avoiding a move into residential care for a couple of years will save tens of thousands of pounds.
Each of these amendments covers a different clause in the Bill and inserts a housing dimension to the very welcome measures already therein. First, Amendment 80 addresses Clause 2, which focuses on preventing or delaying a person’s need for care. It seeks recognition that housing is a crucial part of a preventive care service.
Secondly, Amendment 81 is particularly significant. It adds housing to Clause 3, covering promotion of integration of care and support with health services. It is interesting to note, in this context, that in Scotland this holistic view of integration is now taken. The relevant Scottish guidance says:
“It will be important that, in bringing … health and social care closer together, partners ensure that housing services (including those provided by housing associations and the third sector, as well as by local authorities) are fully included in the integrated approach to service planning and provision, and that health and social care planning and local housing strategies are mutually supportive”.
So says the Scottish guidance. Sadly, our Health and Social Care Act 2012 does not explicitly reference housing, and a framework for engagement was neglected in that Act’s guidance. This has led to a very patchy involvement with housing by the new health and well-being boards. Some are examplars of engagement with housing providers in a three-way partnership, while others seem blind to the significance of this element in the equation.
Thirdly, Amendment 86 covers Clause 4 and relates to information and advice. Again, this is a very important amendment. The Joint Committee that looked at the Bill strongly recommended that local authorities provide information and advice on the housing options available in their area. However, although the Government have incorporated the need for independent financial advice, the recommendation from the committee to include housing has not been taken up. This amendment, by including housing options in the Bill, should ensure that local authorities provide the requisite information on specialist and adapted housing in their area, on ways for people to get their home adapted, and on the ways in which people can cover the costs of home improvements.
Fourthly, Amendment 87 seeks to improve Clause 5, which is concerned with the diversity and quality of local services. It extends the definition of care and support services to ensure that local authorities include specialist housing, accessible housing and housing-related support in their mix of services.
Finally, Amendment 88 addresses Clause 9, which relates to the assessment of an adult’s needs for care and support. It is intended to make sure that local authorities pick up on whether adaptations to a home are needed or whether a move to more specialist housing would be best. Assessing the housing requirements of the individual is a vital part of the process of seeing what is best for that person and how their lives can be improved. The amendment seeks to make sure that this ingredient in the process is covered as a matter of course.
I hope that the Minister will feel able to take on board the kind of changes to the Bill which these amendments advocate. The report last year from the All-Party Parliamentary Group on Housing and Care for Older People, Living Well at Home, spelt out the case for the three-way integration of health, social care and housing. The White Paper published prior to the Bill promoted the theme of including housing more centrally in the future of social care. The House of Lords Select Committee report, Ready for Ageing?, highlights the housing requirements of older people. The pre-legislative scrutiny committee, so ably chaired by Paul Burstow MP, took this forward with strong recommendations for a higher profile in this Bill for the housing dimension. The 70 organisations in the Care and Support Alliance, which have a real understanding of the needs of older and disabled people, believe passionately that these changes would greatly improve the Bill. I beg to move.
My Lords, I strongly support the amendments which have been so expertly described by the noble Lord, Lord Best, and to which I have added my name, as well as Amendment 87ZC in the name of my noble friend Lord Hunt of Kings Heath.
This is an important group of amendments. In combination, they will help to ensure that housing is at the forefront of decision-makers’ minds when providing for an individual’s care and support needs. The person will be supported in a way which makes them the least dependent on health and social services only if housing solutions are properly taken into account. However, that element is all too often ignored, and dependency is ensured.
I well remember a dispirited social worker who described the effects of a two-year delay in providing an arthritic lady with lever taps. In the mean time, she had to have considerable support to wash and cook and objected strongly when that support was taken away because she was now able to turn on the taps. However, it helped to convince the council to clear their backlog of occupational therapy cases.
It is so often the case that the housing element ensures that a person can maintain their greatest independence and be enabled to live their life to the fullest extent they can. Housing solutions have to focus on the individual—ensuring that the person is at the centre of the services and not the system. There are numerous examples of how, when housing, health and social service professionals work well together, people are able to regain a control over their lives which can all too easily be lost when social or health care are seen as the only options.
The National Housing Federation’s recent report Providing an Alternative Pathway gives many telling examples. One is of a man called Bruce which will resonate with anyone who has had experience of a spinal injury unit. He was left tetraplegic after a motorcycle accident which also killed his son. In an instant, his home had been made inaccessible to him and all he could do was move into residential care. He quickly went downhill and after three months attempted suicide. Fortunately for him, the residential care was part of Papworth Trust, which was able to move him, as his health improved, to a semi-independent living scheme, still offering him lots of support. In the mean time, a two-bedroom flat was specially adapted to his needs and he now lives there independently, with a weekly care package, and is back in employment. In the National Housing Federation's estimate just this case represents an annual saving of more than £50,000 a year in social care costs.
Mencap's excellent report, Housing for People with a Learning Disability, was the focus of a recent meeting of the All-Party Parliamentary Group on Learning Disability. One mother described what happens when housing does not form part of the three-legged stool of the noble Lord, Lord Best. Her son, Sam, has severe learning disabilities and no speech. Following school, he spent three years away from home learning independent-living skills at college, with social services promising that they were planning appropriate provision for him when he returned home. He returned home to find nothing—no provision. Residential care was deemed inappropriate; the only supported housing was for people with more moderate needs and Sam needed 24-hour support. The housing department was not even aware of its responsibilities to youngsters with learning disabilities as a group with supported-housing needs. It was only by chance that Sam's mother heard of an empty, run-down house in the borough—empty because it had been left in a legacy to be used for people with learning disabilities and the council could not find tenants to fill it. It was about to be sold. The rest of her story was all too familiar, with hurdles and obstacles placed in her way, but her son and three other youngsters with severe learning disabilities moved in on 10 March last year. They are now flourishing in the community with their health and well-being markedly improved.
These solutions require teamwork and for people to work across disciplines in an integrated way. Why does it not happen? Is it that co-ordinated effort can all too easily be forgotten if it is not a legal duty and people are working under pressure? So it requires a clear duty on all the participants involved.
I hope that the Minister will reconsider the recommendations made by the Joint Committee and that he will come back with his own amendments on Report or accept these to be included in the Bill. I urge noble Lords to support them.
My Lords, having heard the words about Mencap spoken by the noble Baroness, Lady Wilkins, I, as president, must of course support this amendment. I say “must”, but I am surprised that these amendments have to be tabled at all. I would have thought that any Bill dealing with care must deal absolutely explicitly with housing. After all, noble Lords will remember when the long-stay, sub-normality hospitals were closed in the late 1970s, the 1980s and the early 1990s, the very thing that was required was housing. Mencap did provide the housing in those days, as best it could, with the Mencap Homes Foundation. It has progressed now to Golden Lane Housing, which allows people with a learning disability actually to own their own housing with the appropriate support. These provisions are necessary, and I am amazed that these amendments were necessary in the first place.
My Lords, I support this suite of amendments—this flight of amendments—on housing. As noble Lords have eloquently said, housing is the third side of the care triangle. Those of us who sat on the scrutiny committee were absolutely clear on that. We thought that it had been extended to our report, but clearly it has not been reflected totally in the Bill. There was mention of it in Clause 1, the well- being clause, in Clause 6 on co-operation, and also in Clause 8 on how to meet needs. The noble Lord, Lord Best, has filled in the gaps, with Clause 2 on prevention, Clause 3 on integration, Clause 4 on the provision of information and advice, Clause 5 on market shaping and Clause 9 on the assessment of needs. In each of these elements of the Bill, housing is imperative. The anxiety that many of us share is that if housing is not in these clauses, it will not be dealt with when an individual is assessed, or when there are issues around integration.
In the Select Committee, the most compelling witnesses were from the housing sector. They understood the impact that appropriate housing, and any adaptations to houses, would have on the lives of the people living there—on the health and well-being of the individual. The amendments in this group put housing where it should be. It is core to assessment and core to integration of care. It is a preventive measure, and it is also core to the provision of information. There is no point in having a conversation as a result of your assessment and as part of the information process if you are not aware of what your housing needs are, because without housing, the conversation makes no sense.
Local authorities need clear direction from the Government. The noble Lord, Lord Best, articulated this clearly when he introduced his amendments. Some health and well-being boards have got it and some have not. Those that have not should have it spelled out, so the amendments in this group are absolutely appropriate. I hope that my noble friend, when he sums up, will reassure the House in this regard.
My Lords, I support the amendments of the noble Lord, Lord Best. I also support what my noble friend Lord Rix said about closing the large institutions and providing the necessary housing. The reason the necessary housing could be found, either through charities or local authorities, was that it was clearly spelled out in government policy. I therefore strongly support the need for this provision to be in the Bill. Without that background, I would have found the job of closing two large institutions extremely difficult, because there was resistance from local authorities and local communities to providing suitable accommodation. However, as it was government policy, we were able to persuade and influence the local authorities to do it. Therefore, I support the amendments in this group.
My Lords, I will speak primarily to Amendment 88, in the wider context of Clause 9, and put an idea to the Minister that dawned on me during conversations with local authorities that are faced with problems in this area. Clause 9 deals with the assessment of an adult’s needs for care and support. It states:
“Where it appears to a local authority that an adult may have needs for care and support, the authority must,”
carry out an assessment. The clause goes on to list what the assessment must include. Amendment 88 would add,
“housing options to contribute to the achievement of those outcomes”.
What struck me as an outsider looking into these matters is that, irrespective of the changes to which the noble Lord, Lord Rix, referred, problems still arise where elderly people—perhaps in their 80s, 90s or whatever—have to transfer out of their homes, which they may well own, or from hospital into some kind of care environment, perhaps a nursing home. I wonder whether it would be possible for that process to be made more seamless in circumstances where a local authority took on the responsibility of marketing—I shall come on to what I mean by “marketing”—the home for sale, clearing the home and making all the arrangements for the transfer of that resident, be it from their home or from hospital, into a care environment.
It may be that a local authority could offer a package. At the moment, that package, in part, is offered by some of the charities. I have spoken to charities, such as Age Concern, which carry out various components in this process of transfer but I wonder whether money could be raised by local authorities through taking a proportion of the commission on the sale of properties by estate agents. In other words, a local authority would advertise within its area and estate agents could tender for the right to handle the properties for which the local authority took responsibility in this process of seamlessly transferring people from their homes to a caring environment.
As estate agents would not necessarily know whether they would get that business if it was organised in the wider market, if they knew they were going to get all the business provided by the local authority—in other words, that they would be the estate agent responsible for carrying out the process of transfer in a particular district—they might be prepared to share their commissions with the local authority because they had access to business which they might not otherwise have had. It would provide a revenue stream.
As we introduce amendment after amendment to the Bill, I keep thinking, “Where is the money coming from?”. It has to come from somewhere. It is all right Parliament passing legislation placing all these new responsibilities on authorities but, at the end of the day, the local authority has to find a way of raising the revenue. If local authorities could somehow attach themselves to the revenue from the sale of houses, it might well provide an income stream—and what better way to do so than to provide a package for the seamless transfer of the elderly into a more caring environment? I put it simply as a proposition that the Minister might wish to consider over time.
My Lords, everyone supports these amendments. I do not wish to detain the House but I would like to add my voice to that support.
When I became a councillor in 1973, it was my duty to concern myself with the housing problems of constituents who lived in my ward. After seven years, when I became a Member of Parliament, I thought the housing problems would go to the councillor who took my place. That was not the case. Right up to my last week of being a Member of Parliament, I was still receiving housing complaints and problems. I recall in another life, when I was a member of the Labour Party, some of my friends saying, “Education, education, education”—that was the motto—but I said there should be something else: “Housing, housing, housing”.
If people do not live in decent homes, they will not be able to do anything. If dampness is coming down the walls, the brightest child will never be able to study properly and get the best out of his or her education. So I say to the Minister that sometimes it is the simple things that matter in housing, not the expensive things that the noble Lord, Lord Campbell-Savours, has referred to.
I have mentioned dampness. There used to be a great deal of dampness in some of the houses in my area of Glasgow. A scheme was introduced—all credit to the Government, as it was not just the local authority —to bring in central heating. What a difference it made to the health of the young and old who lived in those houses. They could get up in the morning to a warm house and go to bed in the evening in a warm house. It meant that bronchitis, emphysema and all the other problems were greatly reduced.
I do not wish to bring in a highly sensitive matter, but I have to say to the noble Earl, that it rolls off the tongue of some government Ministers, including the Prime Minister, to say, “There is a simple solution to housing underoccupation. We can get people out and give them another house, so we will have vacant properties for others”. What if the elderly person is occupying—or perhaps underoccupying—a four-apartment dwelling, and her daughter stays round the corner? If the person is moved, the daughter will not be able to give the support that is needed. The Government may say that it does not apply to pensioners, but what happens if the person is in their 50s and is not too well, or suffers from an illness, such as asbestosis, which we debated in this House? If the person is moved away from family support, the support has to come from elsewhere.
I do not know whether I should, but maybe I will declare an interest. I am a member of the Glasgow North Housing Association, although with no pecuniary interest. Community-based housing associations have done marvellous things throughout the United Kingdom, and I have witnessed it in Glasgow. I talk about the small things again, such as a warden being available in sheltered housing. A person may have suffered a stroke or have some other illness. The very fact that that warden can chap the door and find out that the elderly person or stroke victim is all right makes a marvellous difference to the families of those with relatives in sheltered housing. It gives a great sense of security to families who sometimes live many miles away.
I remember one of the first cases that I ever had as a councillor. I was only 27 at the time and did not fully understand depression and the other problems that anxiety can bring. I remember a young woman saying to me, “I’m getting tablets from my doctor because of the anti-social behaviour in the tenement I’m living in”. I went about the business of trying to get her moved, and the local authority was able to do it. Her husband said, “I now know that I can go to work without getting a phone call to say that my wife is in a terrible situation. I know that my wife can now go to pick up the children from school as she liked to do before that deep depression”. In other words, the change of house and the relaxation that came from not having anti-social people around her made all the difference. Housing is so important to each and every one of us.
I want to bring us back briefly to the amendments that we were discussing. Broadly, housing obviously has a tremendous impact on people’s lives, but we are talking about inserting the word “housing” in a number of clauses that will enable co-ordination between health, social care and housing.
Many local authorities and well-being boards, as the noble Baroness, Lady Jolly, mentioned, already have it—that is, if you achieve this co-ordination, you will make savings and produce better outcomes for the individuals being helped. Having it on the face of the Bill will ensure that the leadership of all these authorities has to pay attention to it, and I think that is important. At the moment we have a postcode lottery. If you are fortunate enough to live in an authority that has got it together, your adaptations will arrive; you will have all your other housing issues sorted out, along with your care package, and, if you are an old person in hospital, you will be out in a very short time. If you are a person with a disability, as that disability increases, or if you have a sudden disability, your adaptations will appear because there will be that co-ordination.
In many local authorities, however, the housing department can opt out and not play its part, which causes huge delays—I speak as someone who works in a number of charities and with people with disabilities. I want to support the amendment’s inclusion in the Bill so that the leaderships of authorities have to take it to heart and so that we do not have a postcode lottery and this is all part of strategic planning for the authority.
My Lords, the Joint Committee on the Bill acknowledged that it had been widely welcomed, but asserted that this did not mean that it could not be improved—there are gaps and risks and unintended consequences. The failure of the Bill adequately to underline the importance of housing not just to well-being but to integrated care, to prevention and to being included in the provision of advice and information on quality of care and assessment is what these amendments seek to address. The interplay between housing and well-being—the standard of someone’s living circumstances and their health condition, the appropriateness of their house or flat and the likelihood of their being able to remain in it and care for themselves—is long established. However, as noble Lords have shown, it is overlooked in key clauses of the Bill.
Our Amendment 87ZC takes forward the vision of specialist houses fully integrated into the health and social care system which was so comprehensively set out by stakeholders from across the housing sector in their evidence to the Select Committee. The quality of that evidence was commented on by the noble Baroness, Lady Jolly. There are numerous examples of inspiring best practice where housing is an integral part of care and support and service delivery. The Bill needs to provide the momentum for good practice to become embedded across all local authorities and health providers.
The evidence to the Select Committee from organisations across the housing sector cites inspiring examples of where housing, health and social care provision and support join up to provide integrated person-centred care. However, alongside this, there is huge frustration that progress across the country has been so slow and patchy. This is especially so when what stakeholders refer to as low-level interventions, which really make a difference, are often the services earliest to be cut back and dispensed with. The Anchor Trust, for example, described the determination to keep its service-level manager on site at one of its sheltered housing schemes because it made all the difference. The noble Lord, Lord Martin, made this point, too. Anchor said that, in its view, once the manager left, the next steps for elderly and frail people were usually into residential care. This was one of the many examples given of the consequences of not having housing-related support regarded as a key social determinant of health. I look forward to the Minister’s explanation as to why the Government have not ensured that this is fully reflected in the Bill.
Earlier, we heard the case from the noble Lord, Lord Best, and my noble friend Lady Wilkins for Amendment 81, supported forcefully by the noble Lord, Lord Rix, on the importance of including the promotion of housing provision in the duties of local authorities under Clause 3 to provide integrated services, and of ensuring that there are similar duties placed on the health service. Our amendment to Clause 6 complements this by reinforcing integrated joined-up working with registered housing providers, including housing associations and registered social landlords, and recognising these as key, relevant partners under the Bill.
The need to recognise housing as a preventive service cannot be overestimated or overemphasised. Schemes such as Midland Heart’s reablement service for the elderly or frail combine social care and housing association support to enable people to be discharged from hospital back to their homes quickly and help independence to be regained. They delay or prevent the need for more intensive care, reduce the likelihood of repeated hospital stays and can prevent avoidable accidents. Commissioners need to be encouraged to consider specialist housing, home-from-hospital services, housekeeping-related support and adaptations when designing preventive services. Housing is a crucial preventive service and Amendment 80 is important for ensuring that this is recognised in the Bill.
Amendment 88 is also important for ensuring that needs assessments include an assessment of housing options, as is Amendment 86, which underlines the importance of ensuring that local authorities provide information and advice for adults and carers on available housing options and the choice of providers available in the authority’s area. While in Amendment 87 we fully recognise the need for more specialist housing to be built to meet the needs of care and support, we would be cautious at the present time of putting this extra burden on local government when it does not have the resources or the means to deliver. It is the responsibility of national government to provide the £10 billion extra investment in infrastructure that the International Monetary Fund has called for to get the economy moving and make shovel-ready projects such as housing happen.
I am grateful to the National Housing Federation for its excellent briefing, and I refer to an example of integrated care and support it gives that was provided by one of its members, the housing association Look Ahead, for a psychiatric patient. It shows what can be achieved. Following a six-month stay in hospital, it had initially been intended that he should move to a residential care placement, but instead he was referred to Look Ahead’s rehabilitation service. The support that he received helped him with basic life skills, diet management and managing his condition. After 18 months, he had successfully moved to his own flat, had been able to reduce his psychiatric medication and had started a nursing diploma. This service, taking him from hospital to independence in his own flat in 18 months, was provided by successful joint working between the housing association, the local authority and the NHS trust, with an estimated saving of nearly £250,000 across the three services.
We heard, too, at our latest stakeholder group meeting yesterday about a successful jointly procured and delivered reablement centre in Liverpool that is funded by the local authority and the clinical commissioning group in respect of hospital discharge. The scheme provides two to three weeks of intensive occupational therapy and other key services, which doubled from 40% to 80% the percentage of patients who did not require a continuing care package after this initial support. However, we understand that in some parts of the country CCGs are expressing reluctance to enter into joint funding schemes with local authorities in case the health funding element is leaked into other council services, given their budget situations—literally, I suppose, into filling potholes or such like. Can the Minister tell us what steps are being taken to reassure CCGs about this potential barrier to providing integrated services?
As part of its oral evidence, Jake Eliot from the NHF said:
“Too often, the integration that occurs happens because service users, carers, providers and commissioners are working skilfully in spite of the system rather than because of it”.
This is something that the Bill can change effectively. I hope that the Minister takes these words to heart and accepts the amendment. It would ensure that the Bill recognises the importance of housing. It is important not just for well-being but for prevention, for the provision of advice and information in the assessment process and for ensuring that the overall quality of care is fully recognised.
My Lords, in tabling these amendments, the noble Lord, Lord Best, brings to the attention of the Committee the important role that housing plays in both care and support, and as a determinant of well-being. I have listened with care to the powerful contributions in support of them. Having done so, I begin with an observation that I hope is incontrovertible, which is that simply having a roof over your head will have a profound impact on your well-being. Having access to suitable housing for those with care and support needs plays a vital role in promoting not only their well-being, but their independence. The noble Lord, Lord Best, brought this point home very well. Properly taking into account the suitability of someone’s living accommodation could, for example, help to prevent a frail older person from falling and thus suffering the pain and trauma of broken bones and an unnecessary stay in hospital, the need for a greater level of care and support following discharge, and the costs of this to the public purse. It is vital that the system actively works to promote independence rather than waiting for people to reach a crisis point.
To reflect the importance of housing as a determinant of well-being, we have explicitly included the “suitability of living accommodation” in Clause 1(2), which sets out a list of things to which well-being relates and that the local authority is required to promote in performing its care and support functions. Furthermore,
“accommodation in a care home or in premises of some other type”,
is set out in the high-level list of examples of how to meet needs in Clause 8. Together, this means that the Bill ensures that housing is an integral part of care and support, where it is not general housing as excluded by Clause 23.
In doing this, we are clear that local authorities are required to do several things. They must identify housing options that could prevent, delay or reduce needs for care and support under Clause 2(2)(a). They must shape the market for suitable and specialised housing under Clause 5. They must consider the suitability of living accommodation in a needs assessment under Clauses 9 or 10, by virtue of it being included in the list of matters in Clause 1(2) that must be considered as part of the assessment process. They must also give information and advice on suitable and specialised housing options, as well as housing adaptations under Clause 4, and integrate this with other housing information that they or another authority provide in their area.
In addition to the information and advice that local authorities are required to give under this Bill, they have duties under other legislation to give information and advice about housing in their local area. We would expect local authorities to align these information services in line with their duties towards integration in this Bill.
Before I move on to that matter, I will address the very interesting idea put forward by the noble Lord, Lord Campbell-Savours, that local authorities should share in any revenue from the homes of those moved into care. I shall certainly think about that. Some local authorities fund organisations to smooth the difficult process of moving house for older people whose homes have become unsuitable. In going further, while the noble Lord’s suggestion appears to have some merit, the preliminary advice that I have had suggests that there may be legal difficulties in local authorities gaining financially from such a service. However, I shall investigate that point further.
Joining up housing with care and support offers the potential to make measurable improvements in patient experiences and outcomes. Clause 3 requires local authorities to promote integration between care and support, health and health-related provision. This reflects the integration duty placed on clinical commissioning groups under Section 14Z1 of the National Health Service Act 2006, as amended. “Health-related provision” includes any service that may have an effect on the health of individuals that is not provided as part of the health service or local authority social services. This clearly and intentionally includes housing, thus creating a clear duty on both local authorities and the NHS to promote integration between care and support, health and housing.
To be able to meet needs in a joined-up and integrated way, multiple agencies must co-operate to ensure that care and support is properly co-ordinated. Clause 6 requires local authorities to ensure the internal co-operation of relevant officers, including housing officers, in delivering services relevant to care and support. As recommended by the Law Commission, the Bill places a reciprocal duty to co-operate on the relevant partners listed, all of which are public bodies with relevant care and support and carer’s functions at a local level. It also imposes a clear duty on local authorities to co-operate, as appropriate, with anyone involved in functions or activities relevant to adult’s care and support or carer’s support. This could include all relevant housing providers with which local authorities work.
The noble Baroness, Lady Emerton, asked what happens if there is resistance from local authorities to provide appropriate housing support. Clause 7 creates a duty to co-operate in response to specific cases. Through this, a local authority in its care and support functions could request the co-operation of the local housing authority in the case of housing an adult with needs for care and support. The housing authority would be required to co-operate with this request unless doing so would be incompatible with its duties or have an adverse effect on its functions.
The noble Baroness, Lady Howarth, pointed out that the degree of co-operation with local housing services varies by area. Of course, we recognise that there is local variation, but when areas respond co-operatively, fully involving housing as part of the solution, there can be manifest benefits to health and social care; for example, in the north-west of England, an initiative at Whiston Hospital arranges for adaptations to be made to an older person’s home, ensuring a safe and timely discharge after a fall or injury. With that in mind, my department is undertaking work with NHS England and stakeholders to form a compact that will identify and break down barriers to the integration of health, care and support, and housing. This is also linking housing to outcomes in the health, social care and public health systems.
The noble Lord, Lord Best, rightly emphasised how vital it is for housing providers to co-operate with commissioners and relevant partners in their local area. I agree, but we need to consider how best to achieve this in a meaningful and practical way. It is not our intention to impose new regulations on private, voluntary and third sector providers. Rather, we would expect local authorities to ensure that those who provide services on their behalf are required to co-operate through contractual arrangements.
The Government have shown their commitment to supporting joined-up and co-ordinated working by making £3.8 billion available for joint spending between the NHS and local authorities in 2015-16, which I mention particularly in response to points made by the noble Baroness, Lady Wheeler. She is right that there is anxiety about funds leaking out into wider local authority budgets. We believe that the arrangement we have proposed, whereby local services will have to demonstrate that the money they are going to receive will directly benefit the patient or service user in terms of their health or social care needs, will ensure that there is no leakage in that sense. By including within that joined-up fund the disabled facilities grant, which helps to fund adaptations that can support people to live independently in their own homes for longer, there will be a real incentive to drive integration between care and support, housing and health.
I hope I have reassured the Committee not only that the Government recognise the importance of housing but that the Bill makes it clear that access to suitable housing—including, where necessary, the provision of accommodation—is an integral part of care and support; and that, further, it creates a legal basis for integration and co-operation between care and support and housing more generally. I hope that the noble Lord, Lord Best, is comforted by all that and that he is content for the moment to withdraw his amendment.
My Lords, I am deeply grateful to all those who have participated in this debate, particularly the noble Baroness, Lady Wilkins, for coming in so supportively and giving us those really practical examples. It is astonishing that, in the case she mentioned, £50,000 a year was being saved, giving a much better life to Bruce, the tetraplegic she talked about. Big money is being saved in improving people’s lives, absolutely underlining the essence of what we are trying to do here. I am grateful to the noble Lord, Lord Rix, for bringing in the Mencap dimension so fully and reminding us of those old mental institutions, which the noble Baroness, Lady Emerton, was so instrumental in closing, and how housing was seen as the link that really mattered.
I am grateful to the noble Baroness, Lady Jolly, for pointing out how important the Joint Committee thought this to be. I know that members of that committee have not been happy that housing has not appeared in the Bill in the way that they had hoped when they produced their report.
The noble Lord, Lord Campbell-Savours, recognised that we have to find the money from somewhere. Sharing estate agents’ fees is a clever idea. The more likely one, I guess, is the transfer of resources from the NHS, because it is there that the savings are found and the two tie together so well.
The noble Lord, Lord Martin, emphasised the role of housing. He touched on central heating making such a difference to people’s homes, preventing bronchitis and emphysema and so on. When I visited the Care & Repair scheme in Leeds recently, staff told me that one of the most frequent causes of people having to go into hospital and of their homes being found totally inadequate was the fact that a central heating system that was 15 or 20 years old had fallen apart, and they did not have the wherewithal or the knowledge to replace it with a new boiler because that would involve a few thousand pounds. That one adaptation to the home alone would have made a huge difference to their health and well-being.
I am grateful to the noble Baroness, Lady Howarth, for emphasising that putting things in the Bill attracts the attention of the leadership of local authorities to their priority and importance. I am grateful also to the noble Baroness, Lady Wheeler, who emphasised what the Joint Committee on the Bill had said and how, since the previous legislation had gone through, we had seen very patchy take-up, with health and well-being boards and the rest, in recognising across the piece that housing is so important.
The Minister hoped that I would be comforted by the very full exposition that he gave of how there is the implication in so many places in the Bill that housing should be taken on board. I am sure that it is the intent of government that housing should be there; it is just a shame that it is so well hidden from so many of us. Although using the spending review’s £3.8 billion as a ring-fenced sum will require people to be more joined-up, including in relation to disabled facilities grants, and although the legal basis is no doubt in the Bill, it would be helpful if that was more overt and the Bill could make it a little clearer. We may want to return to this matter when we have heard about the compact that the Department of Health is working on, which would be very important if it emphasised housing in a fundamental way. For the moment, I beg leave to withdraw the amendment.
Amendment 80 withdrawn.
Amendments 80A to 80C not moved.
Clause 2 agreed.
Clause 3 : Promoting integration of care and support with health services etc.
Amendment 81 not moved.
81B: Clause 3, page 3, line 41, at end insert—
“( ) In exercising its duties under this section, a local authority must have regard to the relevant joint strategic needs assessments and joint health and wellbeing strategies required under sections 116 and 116A of the Local Government and Public Involvement in Health Act 2007.”
My Lords, the amendment is supported by my noble friends Lord Hunt and Lord Beecham. I shall speak also to our Amendments 81C and 87ZZA, as well as to other amendments in the group.
As my noble friend Lady Pitkeathley showed last week, we on these Benches will never tire of banging the drum for the importance of integration of health and social care—and housing—from the point of view of patients, service users and their carers. Our amendments would include in Clauses 3 and 6 specific reference to the body that stands the best chance locally of making this happen: the health and well-being board. These clauses deal with integration and the duty of local authorities to co-operate with relevant partners. We also stress in respect of these clauses, and Clause 2 under our amendment in an earlier grouping, the importance of the Bill emphasising a joint responsibility for co-operation and collaboration between local authorities and relevant partners, such as NHS bodies in their area.
We support the view of both ADASS and the Local Government Association that the Bill should include a specific duty on NHS bodies, equivalent to the duty on local authorities, to integrate services, enshrining this shared involvement in legislation.
Joint strategic needs assessments and joint health and well-being strategies should provide a strategic overview of how the health and well-being of local communities can be improved and how health inequalities can be reduced. The noble Baroness, Lady Jolly, suggested earlier that some health and well-being boards have got it and others have not. Amendment 87ZZA would ensure that they all got it, giving health and well-being boards powers in keeping with the duties that the Health and Social Care Act places on them. Amendment 87ZZA also adds health and well-being boards to the list of bodies between which the local authority has to ensure co-operation.
During the passage of the Health and Social Care Bill we argued strongly for health and well-being boards to be the bodies that play the lead strategic role in integrating services. Their role is pivotal to achieving integration. If they had been given the role of signing off CCGs’ plans, as we and other noble Lords argued, they would have both the power and authority to be the drivers of integrated care and joint budgets across health and social care and public health in their areas.
Joint budgets and ensuring that legislation and regulations support and enable their use across services, including housing, leisure and transport, are the key tool for making integration happen. That is why our independent commission on whole-person care will look at ways of bringing health and social care budgets together. As the shadow Secretary of State for Health announced to the Local Government Association last week, we are working closely with six councils that have agreed to be whole-person care innovation councils. These are Plymouth, Derbyshire, North East Lincolnshire, Lancashire, Islington and Gateshead—a good range of county, unitary and metropolitan councils from different parts of the country. These innovation councils will help to develop and test out the commission’s proposals. We will certainly want to explore how health and well-being boards are developing and how they can be given teeth to do the job that we want them to do.
As my noble friend Lord Hunt stressed in our recent response to the CSR, we welcome the announcement that an additional £2 billion a year from the NHS budget will be joined up with local government health and social care services to help to deliver care. Pooled budgeting was a Labour idea in 2009 and the integration of health and social care is the narrative of our whole-care commission. However, how does it sit with the CSR’s cut of 10% to local authority budgets? Will the £2 billion transfer be ring-fenced? What are the Government doing to tackle the crisis in health and social care that is happening now?
I also support, as part of this group, the intention behind Amendment 87ZB in the name of the noble Lord, Lord Rix, in support of his later proposals on safeguarding adults at risk of abuse and neglect. Clause 6(6) specifies the relevant partners of local authorities, including county and district councils, each NHS body, the police, prison and probation authorities and others specified in regulations. Amendment 87ZB would ensure explicit reference in the Bill to the providers of services being the relevant partner—that is, those which have been commissioned by the authority to provide care and support or other services as part of the individual’s care plan. Subjecting such providers to the same duty to co-operate as other bodies and services specified in this clause will improve accountability and bolster safeguarding and have a major impact in cases where someone has experienced, or is at risk of experiencing, abuse or neglect. We know all too well that, in a number of prominent cases, providers have blocked or impeded safeguarding proceedings by failing to co-operate on request. The refusal of Winterbourne View providers to share information for the serious case review is a stark and serious example of failure to be held accountable for appalling levels of abuse and neglect of vulnerable adults.
Finally under this group, I support the amendments to Clause 6 and Schedule 3 in the name of the noble Baroness, Lady Greengross, which list the purposes for which local authorities undertake their duties. These include promoting well-being, improving the quality of care and support, safeguarding and, importantly, identifying lessons to be learnt where there is abuse or neglect and applying these lessons in the future.
The noble Baroness’s amendment is right to specify under these clauses the importance of ensuring the early and co-ordinated assessment of an adult with care and support needs following discharge from hospital or other acute settings. Of course, there are many examples of both good and bad practice in this regard, and we heard about them during the earlier debate on housing. With good practice, you will often find a very comprehensive discharge policy in place and the decision being followed or adhered to.
From the point of view of long-term health needs, if you talk to patients and their carers, as I do regularly as a trustee of our local carer support voluntary organisation, they will often cite the hospital discharge process as the next most traumatic experience after the patient initially becomes ill. Often, people with long-term health conditions and their carers are completely new to the social care system, and discharge takes place into an unknown world of agency and voluntary sector providers of services and equipment, and primary and community care involvement. The good practice examples, where patients and carers are involved in and understand the homecare plan, meet the people who are going to help to deliver it and have a full picture of how GP and other community services will support them, stand out. However, with the current staffing and budget pressures on both hospitals and local authorities, the discharge processes all too often become a “fingers crossed that everything comes into place” process.
It is very important that the assessment and care plan are in place before discharge from hospital. Discharge from hospital and other care settings is a period of extreme concern for large numbers of patients and carers. Ensuring that there is an early and co-ordinated assessment of the adult’s and carer’s needs in the community and that a care plan is in place before the discharge is fundamental to the subsequent delivery of good-quality care and support, and I hope that the Minister will recognise the importance of the amendment.
In conclusion, we come back to the importance of underlining integration at every opportunity, and I look forward to the debate.
My Lords, I rise to speak to my Amendments 87ZA and 104A. I thank the noble Baroness, Lady Wheeler, for what she said and I heartily agree with her.
We read far too often about frail older people blocking beds in hospital wards and, apparently unintentionally, making the health service very difficult to function properly. However, they are there due to inadequate planning. These two amendments are intended to try to ensure that the discharge process is started when somebody goes into hospital—that is, right at the beginning of their stay in hospital.
We all have experience of very poor practice. My personal experience is of a 94 year-old who was admitted to a London hospital as an emergency and therefore arrived in pyjamas and with bare feet. He was returned home in pyjamas and with bare feet in the late evening in winter. He had to cross a grassy patch, go into his block of flats and up a flight of stairs in that condition in order to reach his home. There was no planned process to look after him. That sort of thing is totally unacceptable. The aim of this Bill is to stop that sort of practice and to make sure that it does not happen in the future. I think that all your Lordships feel the same about this: we have to get it right. As I said, I feel that the discharge plan should be initiated when someone is admitted to hospital and it should be used as the template for the discharge, when it occurs.
I declare an interest as chairing the All-Party Parliamentary Group on Dementia. We know from one of the inquiries that we have carried out that most frail older people who go into hospital have comorbidity—that is, they have more than one condition. If they have gone into hospital for a fractured femur to be fixed or for some other physical condition to be dealt with, they will stay in hospital for much longer if they also have, for example, dementia. They stay in hospital longer partly for the same reason: that no plan has emerged to look after them when they come out. It is very bad for them to be in hospital and it is bad for all the other patients as well, for obvious reasons. We need to ensure that the local authority and relevant partners know about the special conditions of a patient to get the planning right. We need to ensure that special care and support needs are taken into account long before they leave hospital. That is the reason for those two amendments, which I very much hope that the noble Earl will accept as part of good practice.
My Lords, I wish to speak to Amendment 87ZB, so wholeheartedly supported by the noble Baroness, Lady Wheeler. It would add providers of relevant services to the list of relevant partners of the local authority. The amendment lays the foundation for a number of amendments which I have tabled in the safeguarding section of the Bill, which will be taken later. There has been widespread concern that the mechanisms and procedures in place to safeguard adults at risk of abuse or neglect are totally inadequate.
Time after time, we have witnessed how processes have failed or safeguarding has not been taken seriously, which has led to serious consequences for people with a learning disability. For example, there is the death of Francesca Hardwick and her mother Fiona Pilkington, the murder of Steven Hoskin, and more recently, the abuse scandal at Winterbourne View. There have been a number of prominent cases where the provider has failed to co-operate in providing information on adults at risk or where cases have occurred such as that reported in the aftermath of Winterbourne, where the provider declined to share information for the serious case review and there was no requirement on it to do so.
The amendment is therefore intended to add providers as relevant partners, so that they are in the frame for further amendments to the safeguarding part of the Bill in Clauses 41 to 46. When we talk about providers, I am referring to those who are providing a service which has been commissioned from a person's care plan, such as care and support or education services. Although I appreciate that regulations will set out other relevant partners, we feel that providers should be named explicitly in the Bill. This will emphasise the importance of the provider of services being subject to the duty to co-operate and will bolster the safeguarding process accordingly. I look forward to hearing the Minister’s thoughts on the matter.
My Lords, I give particular support to the amendment proposed by the noble Baroness, Lady Greengross, for two reasons. First, we all know from a passing acquaintance with hospitals either in our own or relatives’ cases that they are large and complex organisations. Unless a proper assessment is made early on after someone’s entry to hospital needing care, the entry will not be recorded. If it is not recorded, you can be sure that those responsible for the discharge of the individual will not have been present when the assessment was made.
The complexity of the system is such that that is how it is—would that it were better and, doubtless, it can be better, but the reality is that unless a proper assessment is made and recorded, those discharging someone from hospital will not be able to specify adequate provision. In education, we all talk about added value. That concept has a place in hospitals. What will be the added value that will allow a proper discharge and will, in that process of discharge, ensure that the patient in question will not return early to hospital? That is the second reason for supporting the amendment of the noble Baroness, Lady Greengross. The research that I have seen indicates that where inadequate care is provided—that includes care plans not made at the point of discharge—the individual is many times more likely to find themselves back in hospital within the month. It so happens that I have seen research related to intensive care units, where you might expect that to be even more prevalent, but it applies across the board. To be sure that the care is right is to be sure that the care plan is right. My argument in supporting these amendments is that that has to include an assessment at the beginning. It helps, too, when a patient is moved to another more specialised hospital. That happens quite often as the investigations take place, so there is a great need for this.
My Lords, I wish to speak to Amendment 82A, which is in my name in this group, and to support the amendments in the name of the noble Baroness, Lady Greengross. For well over a decade, we have had evidence that the recovery rates for people being discharged from hospital during the week, through to people being discharged on Friday, vary enormously. There has been evidence in abundance for the past decade that the failure to integrate care plans for people leaving hospital with community services leads to their readmission into hospital as an emergency—and in some cases, to their death. All the factors that contribute to that should not be news to anyone who has ever read about delayed discharge.
At the heart of our failure to really look after older people who go in and out of hospital is not just the failure to carry out assessments at the proper time but the failure to share that information with all the relevant people along a care pathway. It has been interesting, particularly over the past year, to begin seeing something of a change taking place both in health and social care. One of the driving factors behind that are the shared outcomes frameworks to which health, adult social care and mental health now have to work. The fact that we have the five overarching domains and that each of them is working to performance indicators below them is beginning to have a real influence, not just on high-level strategic planning but on front-line work.
We have always known that there have been excellent examples of integrated care. Where care works well, it works fantastically well and where it does not, it is just a disaster. The trouble is that we can never really pinpoint and identify where that will happen, other than that the systems that work well are always those which have the patients at their heart, involved in the planning process as well as being recipients of care.
My Amendment 82A is prompted, as I think noble Lords will know from last week, by the Christian Scientists—the people who, as part of their belief system, wish it to be known that their care should not involve medical treatment because that is incompatible with their beliefs. Beyond that small group of people, whose beliefs I do not share, it is important to register in all this that when we are building systems that assess the needs of older people there has to be within them a point at which older people can dissent, particularly if quite forceful medical decisions are being made about their care. Sometimes we get incredibly enthusiastic in our support of doctors and manage to let that take things over completely.
The noble Baroness, Lady Greengross, has highlighted the key points that we need to focus on because, at the end of the day, integration depends entirely on all the different care providers in the pathway working to common information. If we cannot start now to develop those systems, we will not achieve what has proved for so long to be that elusive solution to integrated care.
My Lords, I also support all these amendments, particularly in relation to the previous discussion of getting older people out of beds that they are blocking, as I think the noble Baroness, Lady Greengross, put it. That is perhaps an inappropriate word but, in reality, those are the facts. The care plan that everybody has talked about is important, and hugely effective when it works. I have to admit that in my own hospital—I declare my interest as chair of Barnet and Chase Farm Hospitals Trust—it does not always work. Very often, the breakdown with the local authority can come from the start of the agreement on a care plan—what will happen to the individual, how many X-rays they will have, where they will go at the end and so on.
One of the good things in the new system—there are several—is the CCGs. The relationship between clinical commissioning groups and local authorities is proving, in the very short time that it has been working in my area, effective. The more pressure on commissioners in terms of getting hospitals running better, the more interest they have in making sure that local authorities are doing their bit as well. That partnership, in my view and my experience of the past months, has been working much better, which, for us, is a very good thing.
My Lords, I will speak to Amendments 92ZZEA and 92ZZEB. Clause 22 is titled:
“Exception for provision of health services”.
Subsection (1) is crucial, as it sets out the legal test for when NHS continuing care or registered nursing care should be provided and when the means-tested social care system may lawfully provide for nursing care.
Recently, I have been listening to people give evidence to the APPG on Parkinson’s, which I chair and which has been conducting an inquiry into NHS continuing care. Listening to the witnesses, it has become very clear that there are often lots of problems with the health service and social care services arguing over funding. People are having difficulty accessing continuing care under the NHS and have to get over lots of barriers. It is quite heartbreaking to hear the problems that people are having.
The wording of Clause 22 still carries a potential risk for those who self-fund their care. There are various provisions in the clause that allow local authorities to arrange for health services that should be provided by the NHS. Once councils start delivering healthcare, when they traditionally used to deliver means-tested and chargeable social care, there is a risk that someone—somewhere in the system—will mistakenly conclude that the council can charge for those services. There is a need to ensure that self-funders are not exposed if they are found to be eligible for NHS continuing care, or registered nursing care, and the package of delivery is with the local authority. These matters were raised by the Joint Committee scrutinising this Bill but have not yet been addressed.
In legal terms, local authorities are prohibited from providing anything authorised or required to be provided under the NHS Acts. This means that social services cannot provide care home accommodation if a power or a duty to provide the accommodation exists under any of the NHS Acts. Clause 22 has narrowed this down to just “required”, for example by omitting the “power” or authorisation provision. That leaves local authorities able to provide accommodation that the NHS has a power to provide. I believe that disputes and confusion have occurred between councils and the NHS over continuing care, and this seems to be a recipe for more. The Bill should be amended to prohibit local authorities providing a service or facility that is authorised or required to be provided under the NHS Act 2006.
My amendment would mean that local authorities would be prohibited from providing health services that are authorised or required to be provided under NHS Acts. My aim is to make it clear who can deliver what, so as to avoid self-funders being at risk, however small that risk might be, of having to pay for care that they should be getting free.
Clause 22(4)(a) also states that a local authority may, despite the prohibitions, arrange for care home accommodation with nursing care if it has consent to do so from the clinical commissioning group. This may also put self-funders at risk of being charged for services that should be free.
These amendments would introduce an explicit clause that sets out that, where a local authority provides services on behalf of a clinical commissioning group, the authority may not recover the cost from the individual whose needs are being met. I trust I have set out clearly why these amendments are needed and I hope that the Minister will agree with me.
My Lords, it is vital that care and support, health and other services are joined up, as this offers the potential to make measurable improvements in individuals’ outcomes and experiences of care and support. Clause 3 places a duty on local authorities to carry out their care and support functions with the aim of integrating services with those provided by the NHS or other health-related services such as housing. Amendment 81C, tabled by the noble Baroness, Lady Wheeler, raises the issue of co-operation duties on the NHS; I have no issue with that sentiment. Clause 3 is intended to reflect the similar integration duties placed on NHS England by Section 13N, and on clinical commissioning groups by Section 14Z1 of the National Health Service Act 2006, in the context of this Bill.
Clause 6 imposes a general duty to co-operate between the local authority and other relevant authorities that have functions relevant to care and support. Clause 7 supplements this by creating a specific duty to co-operate in individual cases.
Clause 22 sets out the limits on what a local authority may provide by way of healthcare and so, in effect, sets the boundary between the responsibilities of local authorities for the provision of care and support, and those of the health service for the provision of healthcare. Our intention is to replicate the effect of the current prohibitions on what a local authority may provide by way of healthcare, which are imposed under Sections 21 and 29 of the National Assistance Act 1948 and Section 49 of the Health and Social Care Act 2001. This is a matter eloquently raised by the noble Baroness, Lady Gale, in tabling Amendments 92ZZEA and 92ZZEB.
The word “authorised” in Section 21 of the 1948 Act has resulted in much confusion and case law. The intention behind Clause 22 is therefore to simplify the language and to make the boundary clearer without moving it. Make no mistake: where nursing care is being funded by the health service, it will continue to be unlawful for a local authority to recover the cost of this from the individual. It is the relevant clinical commissioning group that would be responsible for this cost.
On Amendment 82A, I wholeheartedly agree with my noble friend Lady Barker that no one should be given medical treatment or be medically assessed against their wishes where they have capacity to make such a decision. I hope that my noble friend will be reassured that the existing legal position and clinical practice is clear on that point.
Amendments 87ZZA and 81B were, again, spoken to by the noble Baroness, Lady Wheeler. The prominence of health and wellbeing boards will be strengthened through their role in signing off the joint plans that are required as part of the £3.8 billion pooled fund between local authorities and the NHS to support joined-up and integrated working. The need for local commissioners to engage with their health and wellbeing boards is made clear through their composition, which includes the director of adult social services, the director of children’s services, the director of public health and a representative of each relevant clinical commissioning group. The duty to co-operate already applies to these health and wellbeing board members.
Section 116B of the Local Government and Public Involvement in Health Act 2007 requires local authorities and clinical commissioning groups to have regard to the relevant joint strategic needs assessment and joint health and well-being strategy in exercising any of their functions. This includes their duties to co-operate and promote integration.
On Amendment 87ZB, I agree with the noble Lord, Lord Rix, that it is important that providers co-operate with commissioners and relevant partners in their local area. However, public law cannot create an enforceable legal duty on private, independent or voluntary providers to require this. We expect local authorities to ensure the co-operation of providers through the contractual arrangements they make with them.
Discharge from an acute care setting is a key interface between health and care and support. At this critical time, care and support must be joined up to prevent unnecessary delays and readmissions that can be distressing to patients, their families and carers. This issue is raised by Amendments 87ZA and 104A, tabled by the noble Baroness, Lady Greengross. Clause 6(5) sets out the high-level aims of the general duty to co-operate, but it does not attempt to provide an exhaustive list of circumstances in which this power should be used. We expect authorities and their relevant partners to co-operate when an individual is discharged from acute care under this clause.
To ensure the safe discharge of a patient from an acute care setting an assessment for care and support should happen before the patient is discharged, not after. Schedule 3 to the Bill sets out clear steps to ensure this. Clause 12(1)(b) already allows for regulations to specify other matters to which the local authority must have regard in carrying out an assessment. Given that this involves setting out procedural detail and related matters, it is more appropriate to set out such detail in the regulations than in the Bill.
Government amendments 87A, 87B, 87C, 87D and 87E would ensure that Clause 7—the duty to co-operate in specific cases—applies in relation to children undergoing transition from children’s to adult services. It was always intended that this provision be used in these cases, as the Law Commission recommended, and as is clear from the Explanatory Notes. These amendments would make Clause 7 explicit on this point, because at present it refers only to adults. I hope that noble Lords will accept them.
The noble Baroness, Lady Wheeler, asked me how the pooled—budgeted—funding would sit with the 10% cuts to local government, and whether that pooled fund will be ring-fenced. To access any of the funding in the £3.8 billion local integration fund local areas will have to develop plans on how they will use the funding. These will be overseen by health and wellbeing boards, made up, of course, of NHS and local government representatives. Funding will be given only on the condition that services are commissioned jointly and seamlessly between local NHS and local councils. We will transfer £859 million from the NHS to care and support this year—in 2013-14—and £1.1 billion next year, to help the funding pressures in the immediate term.
I hope that I have reassured the Committee of the robustness of the provisions relating to integration, co-operation, and delayed discharges, and that in the light of what I have said the noble Baroness will feel able to withdraw her amendment.
My Lords, I thank the Minister for his comprehensive response. We need to reflect very carefully on the issue raised by my noble friend Lady Gale in respect of NHS continuing care and the social care boundary and its impact on self-funders. I will discuss with her whether we need to return to this issue on Report. She is right to mention the Joint Committee, which is particularly concerned. We need to be absolutely reassured that the Bill takes these issues forward.
I will study the Minister’s comments on health and well-being boards. He more or less agreed with me but did not want reference to them in the Bill. However, he accepted my Amendment 81C—which is a first for me—so I am grateful for that. With those comments I thank noble Lords for a very important debate, particularly on hospital discharge, and I beg leave to withdraw my amendment.
Amendment 81B withdrawn.
Amendment 81C not moved.
Amendment 82 had been withdrawn from the Marshalled List.
Amendment 82A not moved.
Clause 3 agreed.
Clause 4 : Providing information and advice
82B: Clause 4, page 4, line 9, leave out “and maintain” and insert “, maintain and facilitate access to”
My Lords, Amendment 82B has the effect of requiring local authorities not only to provide information about the system of care and support, how to access it and so forth, but also to take action to facilitate access to that information; that is, to try to make sure that people know it is available. My remarks also apply to Amendment 86C, to which I have added my name, which requires that the local authority must produce or arrange for the production of packs of information relevant to the needs of individuals with specific medical conditions and ensure that these packs are provided to individuals following the diagnosis of a specific condition—not waiting until much later on, when they probably need social care or other intervention.
First, I apologise to the Minister and to your Lordships that I was unable to be here for earlier sittings of the Committee. I have been out of the country a lot on other Lords’ business and just have not been able to participate. I also must thank the Alzheimer’s Society for its help with these amendments.
I join other noble Lords who have welcomed the Bill, which has an emphasis on the provision of care and support for people who need it. I was impressed by the quote at the top of the Department of Health Factsheet No. 1, which states:
“Information, information, information; without it, how can people be truly at the heart of decisions? Information should be available to all regardless of how their care is paid for. There are some things that should be universal; information is one”.
That is from a Department of Health document; perhaps other noble Lords have quoted it before me, in which case I apologise. The point is that if people are unaware that information and advice are available, they are unlikely to look for them. We can assume that if these amendments are not accepted by the Government, there will be considerable underuse of information services and, of course, that the people who will lose out will, as always, be the most vulnerable—those who most need that information.
The Alzheimer’s Society tells me that it frequently hears of the difficulties people face when struggling through the complexities of the health and social care system for the very first time. Too often, people with dementia and their carers report that they did not have access to the information and advice they needed because they simply did not know it was available. We all know that feeling: if only we had known that it was available, we would have looked for it, whatever it was. Sadly, people often come across services by chance and far too late.
If a person in the early stages of Alzheimer’s is aware of a memory clinic, for example, which can either provide help itself or refer the client on to organisations such as the Alzheimer’s Society well before they need social care, the client can make adjustments to help them continue living as normally as possible and for as long as possible in their own homes. These are simple things like putting a note on the front door that says, “Are your keys in your pocket?”, and suchlike. With guidance, carers can gradually increase the home adjustments as they notice the need for them and thus defer the need for the involvement of social services and ultimately residential care.
Noble Lords will know the point that I am coming to. We all know that resources are incredibly tight. The point is that timely information and making people aware that it exists is very cost-effective. If you manage to keep people in their homes much longer, and if you manage to help them avoid social services intervention, all this will save taxpayers’ money. We can expect that a small spend on a proactive approach to information provision will save the taxpayers a great deal of money over time. I beg to move.
My Lords, I support Amendment 82B in the name of the noble Baroness, Lady Meacher, to which my name is also listed. At the same time I speak to Amendments 83, 83A, 84, and 85. I think that Amendment 86C is in the next grouping; I hope that I am right.
On Amendment 82B, we know that many people, as well as their carers, say that they did not have access to the necessary information and advice—and that they did not even know that it was available. They have had to seek out the information themselves. We are talking about people who are vulnerable and often at crisis point. It is the worst time for either frail people or their carers to have to find out where to go and how to find the advice they need. I would add that, in my long time working in this field with older people, I once had a telephone call from a Minister in the department whose mother needed care and who was asking me to help because this Minister had no idea where to go to get the information and advice. It is not just people who do not know their way round the right office—it is all of us at certain times. We just do not have the knowledge of where to go.
If we require local authorities to adopt a proactive approach to information provision, perhaps it will ensure not only that people have the right information at the right time but that the information is in a format that is accessible. This will help people to get the right care and support in place and give them the confidence they need in very difficult situations.
On Amendments 83, 83A, 84 and 85, I was very pleased to see that, in Clause 4, the Government have incorporated a key element of the Joint Committee’s report into the Bill, namely that it is part of a local authority’s duty to establish and maintain the service for providing people in its area with information and advice. We must make sure that advice relating to care and support includes information about access to regulated independent financial advice.
The Bill will also oblige local authorities to offer deferred payment agreements which will involve local authorities in taking an interest-bearing charge on the property of an individual against the cost of care fees which, as we know, will be repaid after the individual’s death. As has been said, however, individuals offered these products may be highly vulnerable. They expect the same authority to assess fairly both their eligibility for care and their ability to fund it, as well as providing appropriate advice and information about a financial product which the local authority itself is offering to pay for that care.
In a way this is in competition to FCA-regulated financial products, so, obviously, there is a potential conflict of interest here. This conflict is exacerbated if the care for which the loan is made is directly provided by the local authority and if the level of charges and interest are also determined by the local authority. It is therefore very important that people are directed towards regulated financial advice as part of the decision-making process. This amendment seeks to do that through regulated, accredited financial advisers such as the people who are members of SOLLA, the Society of Later Life Advisers. Only in that way can the development of safe and secure financial products be facilitated.
As we know and Amendment 83A makes clear, when very small amounts are involved, people can often be better helped by going to a Citizens Advice or Age UK locally and getting the advice that they need. However, I am very worried about the local authority not always being independent and perhaps having an interest in putting people into a care home when it might be possible for them to stay in their home. I want to make sure that people are directed to the type of advice that they really ought to get in these situations where they are particularly vulnerable.
My Lords, I will speak to two amendments standing in my name in this grouping. The first is Amendment 86H, to which the noble Baroness, Lady Pitkeathley, has put her name. This deals specifically with proportionality and early identification in providing information and advice.
In its report on adult social care, the Law Commission argued that it was essential that the issue of proportionality be addressed in the regulations setting out the assessment process. The Law Commission stated that where a person has complex or multiple needs, a proportionate assessment would require an in-depth and comprehensive exploration of those needs—something which we have already heard about this afternoon. Defining complex needs can be difficult, with the full extent of needs not always immediately identifiable. For instance, older people in particular do not always present their needs accurately on first or subsequent contacts.
Deploying qualified social work staff across all areas of service provision, including the information and advice stage, would help—as this amendment seeks to do—to ensure that the potential for complexity is recognised early on and the individual receives signposting to non-statutory services and/or initial statutory sector support proportionate to their needs.
Looking round the Chamber, I see several people who I meet on a weekly basis as we are currently carrying out post-legislative scrutiny of the Mental Capacity Act. The assessments of capacity across a range of people—not just the elderly, who are very important, but even much younger people—are extremely important. It is extremely important that there are qualified social workers who are involved in this exercise.
To have the social worker available at the pre-assessment stage, as part of an information and advice team, would allow unqualified staff the benefit of accessible professional support. I am aware that the College of Social Work supports this measure and the duty on local authorities to ensure that in providing advice and information, qualified staff are deployed in sufficient numbers to ensure that all aspects of need are taken into account. This would ensure that people are put in touch with the most appropriate services for them from the earliest opportunity.
I am aware of the letter that my noble friend sent to the noble Lord, Lord Hunt, dated 27 June, in which he covered in the first paragraph the query by the noble Lord, Lord Warner, about ensuring that there are sufficient skilled workers. When he responds, would he cover this question of sufficient qualified social workers? His reply to the noble Lord dealt mainly with staff employed in the health service as opposed to social services. We have heard a lot in these debates about the need for multidisciplinary teams in decision-making, so I would be grateful if he would address the question of the number of skilled social workers who might be deployed, particularly at the initial information and advice stage when early assessments are carried out.
My second amendment in this group is also in the name of my noble friend Lady Barker. It addresses the question of independent advocacy and proposes a new clause. Of course, I am aware of the role of, and the statutory requirement for, IMCAs in the Mental Capacity Act. I will not pre-empt the findings of the post-legislative scrutiny committee on the Act, but I will explain why I felt it necessary to propose a new clause in the area of independent advocacy. I refer the Committee to my interest in the register, and in particular my ongoing interest in autism, mental illness and people with learning disabilities.
The right to advocacy is essential to enable the people who find it hardest to communicate to exercise their rights, represent their interests and obtain the services they need. Clearly, if somebody is deemed not to have capacity, there is already statutory provision for an IMCA to assist them with decision-making. However, it is also vital that those who experience substantial difficulty in understanding, retaining, using or weighing information relevant to an assessment, and then expressing and communicating their views, should also have access to an advocate. I referred just now to autism. People on the autistic spectrum might be deemed to have capacity but their disability might mean that they would have difficulty on their own, without the help of an advocate to explain and help them work through the decision-making process. That group is not adequately covered by the provisions of the Mental Capacity Act.
Advocacy is separate from information and advice. It provides support to some of those who are most vulnerable and most in need of services, including those with autism. There was a recent commission on autism and ageing chaired by the noble Baroness, Lady Greengross. Both she and I have had to forfeit the presentation of that report to be here in the Chamber. The report found that the families of people with autism frequently act as their advocates. Ninety-six per cent of parents with a son or daughter with autism recently told a National Autistic Society survey that they were concerned about what would happen when they passed away or were unable to support their children. This fear is common to parents of people with many different lifelong disabilities, not just autism. Families frequently say how worried they are about what will happen when they can no longer perform an advocacy role, and that independent advocates must therefore be available.
If the Bill is to help ensure people access the support they need—including people who are currently missing out—advocacy will play a vital role. I ask my noble friend to consider this large group of people who are not covered by existing statutory provision, for whom the new clause would provide a safety net to enable their services and package of care to go forward, thereby ensuring that they have equal opportunity to access the services that we are discussing in relation to the Bill.
My Lords, perhaps I may remind the Committee that I am the honorary president of the Society of Later Life Advisers. SOLLA accredits the gold-standard financial advisers who will be so important to the working of the Bill.
My six amendments in this group are Amendments 83B, 83C, 86B, 86D, 86F and 86G. Before I turn to them, I will say a few words more generally about advice and the Bill. If the Bill is to do the job we all hope and expect it will do, information and advice should be not just an add-on but a central requirement, without which the Government’s plans, however well meaning, will collapse, and old people and their families will end up frustrated and angry. This is for several reasons. First, there is a widespread reluctance among old people and their families to face up to the problems of care in old age: how to get it, whether to be cared for at home or in a home, and how to pay for it. It is marvellous that people are living ever longer, but that does not mean that the very last years of their life are easy. Not surprisingly, people do not like to contemplate the years before their demise until they feel they absolutely have to.
Secondly, there is an extraordinary ignorance among older people and their families about social care. More than one person in two still thinks that the state will pay in full for the care that they will require. Thirdly—it is early days, I know—there is even less understanding of Andrew Dilnot’s solution. For example, many people—I have even come across a few in this House—think that once you have spent £72,000 on care, you will be looked after for free. This is not so. You will have to fund hotel costs of £12,000 a year. More importantly, you will have to fund the excess care costs over what a local authority would pay to look after you. That could cost a further £25,000 a year. If my arithmetic still works, that means many people will have to pay £37,000 a year after the cap has been reached, so they should plan for that.
Different people in different situations need different advice. Somebody whose care costs are paid in full needs different advice from somebody on the means test. Whatever their circumstances, very few people are capable of navigating these waters without a trusted pilot or pilots. Local authorities are experienced in conducting assessments of people and in helping them. The noble Baroness, Lady Greengross, made this point well. They have interests that may be different from, or even conflict with, those of the people they are advising. For example, under the existing deferred payment scheme you do not have to sell your house but can take out an interest-free loan. It is evident from the figures that many local authorities try like mad to persuade people not to go down that road because it costs the authority a lot of money if they do. Even if it would be beneficial to the individual, they steer them away. It is human nature. That is why it is vital that when advice is needed on this kind of subject, it should be independent of the local authority.
I agree with what the noble Lord said. Something that is rarely mentioned but is often a solution for many elderly people when they go into care is not that their house is sold but that it is rented out. That can be a very viable, practical and suitable solution. Local authorities never mention that, and nor do they have the means to provide such a service.
I quite agree with the noble Baroness. That is exactly why independent financial advisers can be so helpful. Often, the rent on the house will pay for the whole of care, and still leave the home to be handed on to the children if that is what the old person wishes.
All this underlines the fact that it is crucial that the advice comes from people who are qualified to give it—not necessarily local authority social workers, CAB advisers, regulated independent financial advisers and so on. Nor is it any good the local authority just handing out a list of people and saying, “You can go and see them and ask their advice”. For one thing, frequently there are issues of mental capacity, and the stress on an old person at this time is likely to be severe, particularly if they are thinking of going into a care home. For another, there is the general reluctance problem, and people are also often frightened by the cost of the independent financial advice that they may be seeking.
Some local authorities in these circumstances are performing heroically. I recently opened a centre in West Sussex which combines the resources of voluntary organisations, the local authority and independent financial advisers to offer a comprehensive service. It has recently relaunched its service and a local radio station, Spirit FM 96.6, has featured it in its drive time programme every weekday, which is tremendous. Incidentally, in doing this, the local authority is not acting wholly selflessly. Many people in West Sussex who have moved out of London to retire have quite a bit of resources but do not have infinite resources. If they are not well advised on how to use their resources they will run out of money and fall back on the council and its means-tested benefits to pay for their care. However, if they are properly supported, learn to use their money well and are advised of the products that are available to help them, they will not fall back on the local authority. So this, again, is a case where appropriate advice, properly structured, can save public money, not cost it.
Other authorities are less on the ball. There is an intrinsic patchiness among social workers, who are much more likely to be au fait with what would be a nice home to send your mum to than with the detail of how to pay for it. It is their training. My wife is one. I would love her advice on the former but she would probably defer to me on the financial aspects.
Another grave problem is that the qualifications required of an independent financial adviser to advise older people are so-so, which is putting it rather highly. For example, they can sell point-of-use insurance, which is the best insurance product for many older people, with little knowledge behind them. Those who have the SOLLA qualification—I call it the gold standard, but then I would because I am proud of it—are much better equipped but there are only 1,000 of them out of the total number of IFAs in the country, which is certainly 25 or more times that.
The new Financial Conduct Authority, the successor to the Financial Services Authority, has, as far as I can tell, recently been left out of the planning for the Bill. It has not done much planning itself and, therefore, we are about to set loose on many older people who are seeking advice for the first time advisers who, to put it bluntly, hardly know what they are talking about. This situation must be gripped if it is not to end in chaos and disarray.
The points I am making and the amendments I am tabling could be dealt with in four ways: in the Bill, in regulation, in statutory guidance or in non-statutory guidance. As we are discussing the Bill now, obviously I have made proposals to change the Bill in some regards and to introduce regulation in others, but I do not have a dogmatic view as to which is appropriate. If the Minister were to say, “Yes, we accept all your amendments, which we will give in advice”, I would be delighted. It would avoid any problem that the noble Earl might have in replying.
As to my specific amendments, Amendment 83B, which is linked to Amendment 86B, I owe to the Association of British Insurers. They also have the support of the Equity Release Council, on whose advisory board I sit. The amendments seek to ensure that people receive regulated financial advice about their options, particularly self-funders. This is advice provided by properly regulated professionals and needs to take account of welfare benefits, pensions and all other sources of financial support available to the individual. The amendments also insist on local authorities not only providing the list—this deals with a point I made earlier—but on pointing people towards the adviser and making sure that they take the advice on board. Nevertheless it is, at the end of the day—there is no other way of it being—up to the individual whether they take up the offer of advice.
Those two amendments are buttressed by two further amendments. Amendment 83C, which is similar to the amendment moved by the noble Baroness, Lady Greengross, mandates that financial advice must be regulated advice and not merely independent advice. As I have said, the regulations are inadequate and need to be strengthened—but better some regulation than none whatever, which is possible under the independent advice formulation in the Bill. People will be asking their uncle what they should do about paying their care, and uncle may not be an expert.
Amendment 86G distinguishes the circumstances in which an authority may say, “Go and see an independent regulated financial adviser”, and it lays down a time limit in which it must do it. So it cannot hang about and leave it to be done when it can.
Amendment 86D provides that local authorities should meet the costs of a first consultation with an independent financial adviser. In fact, most advisers, certainly SOLLA advisers, offer a free first consultation. However, there is still a risk that fear of the costs will prevent people from taking financial advice. Moreover, it is slightly odd that this, which is virtually a public function, should be provided by financial advisers free of charge. Many of them do not sell any products or obtain anything that they can charge for as a result of the contact. As we need a great many more properly accredited financial advisers operating in this field, it would seem sensible to increase the financial incentives for them to do so.
My other two amendments, Amendments 86B and 86F, I owe to the charity Independent Age, which leads for the Care and Support Alliance on advice and information. The amendments give legal force to an important government study. The Cabinet Office’s study, Barriers to Choice Review, reported this year that official information available from the local authority is often limited to statutory services and misses out vital support which is available from the voluntary sector. It recommended:
“Giving local authorities a duty to signpost social care users to where they can access independent advice and support”,
which is the thrust of the amendments.
This goes wider than financial advice. For example, people may need to challenge or complain about a decision made by the local authority. I suspect there will be a great deal more of that in the future now that these decisions are crucial to when you reach your cap. A local authority may recommend a care home which is cheap but which an old person or their family does not regard as adequate for their needs. They need independent advice to help them fight their corner. The amendment does not go as far as to use the “advocacy” word—that might be a bridge too far in today’s climate—but it tiptoes in that direction. Quite apart from the benefits it brings to older people, it is an essential element in providing the right kind of support that they need.
I conclude where I started. We cannot exaggerate the importance of this process. It involves a great many different parties—the Financial Conduct Authority, the independent financial advisers, the organisations that accredit them, the voluntary sector and local authorities—all playing their part and working together in the holistic way that is so essential to care. If we do not crack this one—and I know the Minister and his officials are willing to listen on this because they have said so repeatedly—and nail down a system which can provide that holistic advice, this marvellously designed post-Dilnot edifice will not stand in the winds of the real world and the complexities of the situations which many old people face. I hope that, not only today but in the months going forward, we shall have constructive dialogue with all those involved until we have designed a system of information and advice that is up to the hefty task that is being placed on it.
My Lords, I support the amendments in this group in the name of the noble Baroness, Lady Greengross, and I shall speak to my Amendment 86E. The noble Baroness has already spoken eloquently to her amendments and I simply wish to say that not only are they compelling but it is critically important that they become part of this Bill.
The decisions that most people make under the terms of the Bill will be some of the most important that they will ever make and it is obviously critical that people are able to make them on the basis of proper and impartial information. Many of these decisions will involve taking a view about the merits of various financial products. Many people—perhaps the overwhelming majority—will have had no experience of doing this.
There will inevitably be a high degree of uncertainty about how to choose and about the detailed implications of those choices. People will need guidance in deciding which, probably complicated, financial product to buy. This is no less true for these products than for any complex financial product, with the added emphasis that a wrong or inappropriate choice could have pretty unattractive consequences. That is why I strongly support the proposal to introduce regulated financial advice into the process, as the amendments of the noble Baroness, Lady Greengross, seek to do. Only with this kind of advice can people have some comfort that they are making the correct choices in a complex and difficult area.
My amendment in this group, Amendment 86E, also deals with the information and advice that a local authority must provide. As the Bill stands, Clause 4(3) simply says:
“In providing information and advice under this section, a local authority must in particular seek to ensure that what it provides is sufficient to enable adults”,
and so on. There are two problems here. The first is the phrase “seek to ensure” and the second is the unqualified notion of “sufficient”.
I raised the issue of sufficiency at Second Reading, when I said that there appeared to be no test for it. There is no provision in the Bill for local authorities to have a mechanism for measuring and reporting the success of their efforts in providing information or on the success of that information in achieving its objectives. My amendment is intended to address those concerns. In particular, it would remove the phrase “seek to”, so that instead of local authorities having to seek to ensure that the information they provide is sufficient, they simply must ensure that it is sufficient. The phrase “seek to” seems to me to weaken the obligation placed on local authorities quite unnecessarily. It is quite possible that any local authority could demonstrate that it was seeking to do something without actually doing very much at all. Arguably, for example, the slow and gradual implementation of a plan to provide information would fulfil the local authority’s obligation.
I am sure that that is not what the Government had in mind or what local authorities would really want to do. In that case, I see no merit in having local authorities’ obligations significantly weakened by the use of the phrase “seek to”. My amendment would remove this phrase and give the local authorities a clear, simple, plain-English duty to ensure that the specified information is sufficient for the purposes set out in the Bill. If it is possible to have a measure of sufficiency, as I believe it is, it is surely possible to ensure sufficiency rather than just seeking to ensure it. Again, in plain English—or in fairly plain English—the situation is this: we want local authorities to make the information that they must provide by virtue of subsections (1) and (2) of Clause 4 sufficient for the purposes set out in Clause 4(3)(a) and (b). We want them actually to do this, not just seek to do it.
That brings me to the notion of what “sufficient” may mean and what tests might apply. My amendment would qualify “sufficient” by inserting the word “demonstrably” before it. I can probably guess what my noble friend the Minister will say about the use of the word “demonstrably”. He will probably ask, “Demonstrable to whom?” and, “Demonstrable according to what criteria?”. The phrase “demonstrably sufficient” has a clear meaning in the context of Clause 4(3)(a) and (b). It means simply that local authorities will have to be able to show evidence that the information they provide actually does enable adults to identify matters that are or might be relevant to their personal financial position that could be affected by the system provided for in Part 1. It also means that local authorities will have to be able to show that the information they provide does enable adults to make plans for meeting needs for care and support that might arise.
Commercial organisations routinely apply this kind of test to the information they put out. It is not difficult, time-consuming or expensive to do. Doing it would have the merit of providing a real test of the meaning of sufficiency and a mechanism for reporting success in delivering it. I believe that this is what the Government and local authorities want. Using the phrase “demonstrably sufficient” provides for that.
My Lords, I support almost all the amendments in this group because I acknowledge their importance, particularly from the point of view of the Joint Committee, which similarly placed a great deal of store on the provision of information and advice. Indeed, it suggested that there should at the very least be a national campaign to promote the new arrangements to those who might use them.
I rise to speak briefly to Amendment 86H, to which I have put my name, along with the noble Baroness, Lady Browning. Social workers on the whole do not get a good press. They are heard of only when things go wrong. Most of the time the vast amounts of quiet, patient work that is carried out by social workers in local authorities, the NHS and the voluntary sector is ignored. We should give their skills and the vital contribution that they make to help people find their way around complex systems more recognition. The noble Baroness made it clear that she is suggesting that a social worker needs to be involved not in all cases, but just when present and foreseeable needs are classed as complex. In those cases we must take into account that people’s ability to take in information is tremendously variable, depending on their situation and state of mind at the time. I have lost count of the number of conversations I have had with service users and carers who are totally bemused by the information they are given or the access that they have even when they manage to get hold of some information.
I will never forget the carer who gave me a wonderful illustration some years ago. She said, “I feel as though somewhere out there is a great mushroom of information. If I could just find my way up the stem, I’d find out where all this information is, and it would help me. But I don’t even know where the stem begins, and nobody seems to be able to help me”. Information in its raw state is often very difficult to interpret. It is the skill of the social worker in assessing what information is needed, when and in what form it is needed in complex cases, and signposting the information and advice that is required in every case. Those particularly complex cases need social worker involvement. Such cases are not being met and will be even less well met in the future with the new system and range of information that will be available.
My Lords, I rise to speak to Amendments 83ZA and 86A, tabled in my name. For individuals entering the world of care and support for the first time, it can be a confusing, complex and protracted process. The introduction of information and advice services for those individuals will be very welcome.
I mentioned earlier that I chair the APPG on Parkinson’s and that we are currently conducting an inquiry into NHS continuing care. Continuing care is a package of care that is arranged and funded by the NHS and is free of charge to the person receiving it. The decision for eligibility rests not on a person’s condition but on whether the need for care is primarily due to health needs. While there are just over 57,000 people in receipt of NHS continuing care in England, it is unknown how many people may actually be eligible in law and have not even applied for it, or who have failed in their attempts to be assessed properly for it. As part of the inquiry into NHS continuing care, I have been hearing from people about their real problems in accessing NHS continuing care. We found during our inquiry that people with Parkinson’s and other long-term conditions are not given information about NHS continuing care. The impression that I have been given is that, because it will cost the NHS considerably, people are not encouraged to apply for it. This leaves people with no option but to go to the means-tested social care system to have their health needs met. That situation is entirely unacceptable.
As Clause 4 introduces a duty on local authorities to establish and maintain an information and advice service, it is important that all the appropriate information and advice are provided. With the further integration of health and social care, it is essential that individuals are in full possession of the facts about all aspects of the support to which they are entitled. While the list currently provides some crucial aspects for people receiving care and support, I believe that NHS continuing care is a glaring omission. We hear of the two services arguing the differences between what is a health need, which is free at the point of use, and what is a social need, which is currently charged to the individual. This can often lead to the individual either being forced unnecessarily to pay for their own care while the debate goes on or being left trapped in their hospital bed. Although NHS continuing care is part of the health system, it must be included in the list provided by the local authorities as set out in Clause 4. People who may be eligible for NHS continuing care are also likely to have such needs that they could be in receipt of support provided by their local authority. If their needs change so as to render them eligible for NHS continuing care, there should be a seamless transition to that system that does not affect the standard of support they receive.
A strong information and advice service must include information about an assessment for health provision, so that individuals can go to this service confident that they will find out everything they need about care and support. The Care Bill offers an unprecedented opportunity to address these defects within the NHS continuing care system. Including it in the list of matters about which people should be given information and advice would promote awareness of its existence and prompt councils to refer people for assessment where they appear to be eligible for NHS continuing care. I trust that the Minister will take note of the points that I have made and that he will be able to accept these amendments.
My Lords, I declare an interest in that I work with a number of charities involved in the provision of information and advice about health and social care.
When I read this policy, it seemed to me that it reflected the practice of giving information and advice as it has been done for the past 20 years. I am not sure that that model of information and advice-giving is sustainable. It has depended largely on local bodies, many of which are in the voluntary sector and extremely professional in their services, but which provide a lot of generic, low-level advice. I do not think that that is sustainable—I was going to say in the longer term but, given the way that local authority budgets are going to have to decrease by a third by 2015, I do not think that this is sustainable in the short term either.
In future, there will increasingly be a move towards providing information digitally. New organisations and new social enterprises, such as IncomeMAX, are already heading down that path, and a number of local authorities are increasingly turning much of their provision over to that way of doing things. That is fine for people who are very well informed and who can access information in that format. What I cannot see is a sustainable funding model for the sort of high-level, complex financial advice that the noble Lord, Lord Lipsey, was talking about. This is necessary when people need to be enabled to go through the process of making decisions about, let us face it, the biggest asset that they have, which is their home. We are talking about something on an altogether different level.
We should also note that the system that we have had until now in terms of the provision of advice about social care was predicated on there being different eligibility criteria throughout the country. That is not going to be the case in future.
Like many noble Lords, over the past three or four years since Andrew Dilnot first appeared on our horizons, I have attended many seminars and lectures where people have tried to work their way around this problem. Two things strike me as being important. First, we cannot lay all the obligations on local authorities alone. At least in part, the NHS has to realise that it has to fund information and advice as part of the overall health and well-being package. I freely admit that I have yet to come across people in the NHS who truly understand the basic importance to health of information and advice. One of the first things that the department and the Government could do is to work on how we explain to commissioners in the health service why the outputs of information and advice services are important to them.
Secondly, we already know—the noble Baroness, Lady Greengross, and I know very well—that if you ask a group of older people who have assets what is the number one thing that they want, they say that they want independent financial advice. They do not believe that the people who sell them products are independent. They are right not to do so. That is a problem for the providers of those products. The only way of getting around this that might work is if, in future, some of those products have an element of money within them that is somehow passed into a pooled fund of money that comes from the private and statutory sectors and which can be put towards the provision of independent advice. That is not a worked-out idea, but it contains within it something of the ideas that the noble Baroness, Lady Greengross, mentioned, which are the key points in all of this. She is right that there is a need for regulated advice. I am not quite sure at which point a person needs that. Is that regulated advice something that they need before they come to a decision about which financial product to choose? The law that governs the regulations that exist at the moment usually comes into play when somebody decides to buy a particular product, so there is a real problem about when people have access to the right type of advice. The noble Baroness is on absolutely the right track. Somehow, in all of this, we need to arrive at a point at which resources are spent by people with the right knowledge and the right degree of independence to enable them to come to the right decisions.
My Lords, I rise to support Amendment 88G in the name of the noble Baronesses, Lady Browning and Lady Barker, and myself. It introduces a new clause which would ensure that there is a duty to provide independent advocacy.
The right to advocacy is essential to enable people who find it hardest to communicate to exercise their rights; who find it difficult sometimes to represent their interests, and therefore obtain the services that they need. I spent just over 15 years serving in the other place and, throughout that time, I remember many people coming to my surgery who wanted advice and help. In many instances, they also wanted an advocate—someone who would put their case strongly and make sure that their voice was heard.
Reference has already been made to the Autism and Ageing Commission whose report was published today. It was chaired by the noble Baroness, Lady Greengross. I sat on that commission and it brought home to me again the importance of advocacy. I recall a lady called Clare Beswick, whose brother is autistic and has learning difficulties. She said:
“A best interest decision was made that Paul should live closer to me in the south east … I had to go to extraordinary lengths to enable Paul’s needs to be met … without my support, advocacy and intervention, I believe Paul would never have had the opportunity to be moved to be near us”.
That is the importance of an advocate.
I declare an interest as a vice-president of the National Autistic Society. The society’s survey in 2012 found that 66% of respondents over the age of 50 had not had their needs assessed since they were 18. Independent advocacy could make a real difference to these people by helping them to access an assessment and ensure that it is fair and accurate in relation to their needs. Of course, from the point of view of autism, advocates must have training in the condition so that they can interpret questions effectively and help individuals who have difficulties communicating.
People with autism do not self-present. Autism is about a lack of the communication skills that we in this Chamber take for granted. If the Government were to take on board this new clause, I can simply say to the noble Earl that it would represent a major leap forward for people who need strong advocate support.
My Lords, I want to speak briefly in support of Amendment 82B, tabled my noble friend Lady Meacher, which emphasises the need to facilitate access to information and advice services relating to care and support. This is particularly the case for vulnerable adults such as people with learning disabilities. They may benefit from specialist facilitation to access such information. I should say that I chair a social enterprise which makes information on health and social care issues easier to understand for people who find written information too difficult. I am also the carer for an adult who currently receives care funded by the local authority, and who himself needs easy information.
I hope that the Minister will agree that my noble friend’s emphasis on facilitation will add necessary strength to Clause 4(4), which states that information,
“must be accessible to, and proportionate to the needs of, those for whom it is being provided”.
Without appropriate facilitation, the information may not achieve its objectives for those for whom it is provided unless it is done in the right way and in a timely fashion. Certainly, my own experience as a carer is that at the moment far too much information of the wrong kind is often provided, which is confusing. Facilitation is also about helping to choose the right information at the right time so that people can make good use of it.
My Lords, as we are approaching Statement time, I will be brief. I want to support the noble Baroness, Lady Browning, in her Amendment 88G, which advocates the need for advocacy. In the world of learning disability, advocacy is often totally essential. Information and advice which is not proportionate, frankly, can be quite useless. Advocacy may well come from parents and carers, but sometimes it can be the wrong advocacy. An independent advocate is essential to many people with a learning disability, so I wholly support this amendment.
My Lords, I have spent most of my life as an advocate, so I have to say how important advocacy is. I want to say a few words in relation to the point made by the noble Baroness, Lady Gale, about continuing NHS care. The point is important in that Clause 22, as the boundary between health and social care, is vital.
I would have thought—I may be wrong and obviously the noble Baroness will correct me—that it ought to be the general practitioner who advises a patient as to whether they need continuing NHS care. During our deliberations in the Joint Committee there was quite a lot of discussion about the question of continuing NHS care, and it is obvious that there is some conflict of interest. The local authority providing the care may wish to have it provided by the NHS since that would be free and not its responsibility, so the boundary between the NHS and local authorities is particularly relevant in this connection.
At the moment, I do not see how it can be for the patient to claim continuing NHS care. The GP should be able to say to the patient that they need it and that should be sufficient for it to be provided. The likelihood is that a patient would have great difficulty in assessing for himself or herself whether continuing healthcare was needed, so it must be a matter for professional advice. I think that the advice that we are talking about in this context is advice about local authority services, not about the services that the NHS can provide. However, as I say, the boundary between the two is vitally important. I hope that the point made so eloquently by the noble Baroness, Lady Gale, arising from her own inquiry, will be looked at with a considerable degree of care.
My Lords, I hope that noble Lords will forgive me, but I forgot to speak to one of the amendments that is relevant to this group; that is, Amendment 86C. It is about people with dementia who have had a diagnosis. I know that the noble Earl will share the Prime Minister’s view and those of all of us who have looked at the number of people who receive a diagnosis of dementia. We now want to ensure that many more are diagnosed, and diagnosed early.
However, there are many reports that people diagnosed with dementia and their carers feel terribly abandoned after they have had the diagnosis. The Bill’s emphasis on access to prevention services and information and advice for people, particularly if their needs have not yet reached the threshold of eligibility for social care, is welcome. But there are no specific prompts to ensure that people receive the information they need at the time when it is most useful. The risk is that, although local authorities have set up information and advice services, the information does not reach people at the right time. A post-diagnosis information pack tailored to specific long-term conditions should be given to every individual who is diagnosed with one of those conditions. It would provide access to tailored information about the support that is available to them, and it would enable them to cope with the challenges of living with a long-term condition. The pack would provide information on the likely impacts of dementia and contain core information on national and local services. I think that this would be an important aspect of providing the right information and advice at the right time.
My Lords, this Bill has the potential to do for social care what Beveridge did for the welfare state and Bevan did for the health service. It is potentially the most significant development in, for example, residential care since the workhouses were replaced by a more civilised form of residential accommodation.
The noble Baroness, Lady Barker, anticipated precisely the point I was going to make, which is that this is not just a matter for local authorities. My principal reservation about these amendments, if I have one, is that it looks as though the entire burden of information and advice is to be placed on local authorities whereas of course, as the noble Baroness rightly said, there are other potential partners who clearly need to be involved. I scribbled on the grid that is helpfully provided by those who support the Front Bench on this side the words “in collaboration with”, and then I thought of a number of potential partners. Of course the health service is one of them, but in addition I would suggest that the Court of Protection needs to be involved. It has a supervisory and supportive responsibility for a particular group of people and, with the development of lasting powers of attorney and so on, their deputies as well. I have to say—I have said it before and I will say it again—that I am not convinced that the Court of Protection is doing a terrific job in this area, but that is another reason why it should be looked at as a potential partner.
There may be other partners. For example, in the case of younger people perhaps with a learning or other disability, there are roles for those involved in further education, the Department for Work and Pensions and the Department for Business, Innovation and Skills. Those bodies might look at their role in terms of what is available by way of education, training and so on. It seems to me that a range of organisations should be involved, certainly as a whole, but more particularly in the provision of information and advice.
On these Benches we support most of the amendments that have been moved and spoken to this afternoon, with the qualification that, where relevant and necessary, a reference to collaboration should be included. For example, in Amendment 82B, the first amendment moved by the noble Baroness, Lady Greengross, one would want to see “in collaboration with” appropriate partners.
We support the amendments, notably moved by my noble friend Lord Lipsey, around the provision of independent financial advice. That seems very important. I have a slight reservation about Amendment 86D, which is about payment of,
“the reasonable costs of a first consultation with an independent financial adviser”,
to be paid for “by the local authority”. If I am ever in need of this kind of advice, I would be able to afford that relatively easily. Given the pressure on budgets, is a universal application of that principle necessary or desirable? That, however, is a detail, that might be looked at later. Given the scale of the potential involvement and the potential conflict of interest referred to by several noble Lords, the independence and proper status of such financial advice are important considerations.
With regard to the amendment in the name of the noble Lord, Lord Sharkey, I will perhaps anticipate the Minister by quibbling over the word “demonstrably”. Frankly, I am not sure that that takes us very far. As the noble Lord admitted, what is demonstrable to some is not necessarily demonstrable to others. I do not think that that part of his amendment is particularly cogent, although I agree with the rest of it.
I have more serious doubt about the amendment of the noble Baroness, Lady Browning. Amendment 86H requires that the information and advice be provided by “social work-qualified staff”. It could be, but I am not sure that it should be a requirement that it should be, given the pressure on the service in dealing with casework as it is. I do not think that the skills of social workers are always consistent with the role of giving information and advice in the sense that is intended by the amendment.
It is important that qualified social workers are present for the initial assessment. One of the things that might come out of our scrutiny of the existing Mental Capacity Act is the fact that the assessment of capacity requires professionals. Social workers clearly have a part to play in that. Whether the person has capacity, partial capacity or no capacity at all, at that point some advice is given and direction is needed. It seems to me that that is not the role of an amateur.
That is absolutely true. Neither is the provision of information and advice. However, it is not necessarily the role of a professionally qualified social worker or a professionally qualified health visitor or other person. I agree—it is a point that the noble Baroness, Lady Barker, and I both made—that both sides, health and social work, must collaborate on this. It is perhaps the wording of the amendment, rather than the intention, that might be looked at.
There is a question about how best to proceed with the publicity that should follow the enactment of this legislation. The Joint Committee advised that the Government should work with all interested providers to launch a campaign to raise awareness of and support for the change. I hope that the noble Earl will confirm that that is the Government’s intention and bring us up to date on where the Government stands.
In the context of such a radical change, it might be desirable for there to be some pilots on the ground about this issue of information and advice, working in collaboration with the Local Government Association, the NHS Confederation and other major national partners, to look at how these matters can best be explained. There could also be, at a fairly early stage, some examination of good practice. I am not suggesting that the whole scheme be piloted but that in a few areas, after a relatively short period, there might be a process of peer review and an examination of how it is working on the ground. Given that local authorities retain their scrutiny role for health and social care, it would be worth while developing with the Centre for Public Scrutiny, the LGA and relevant health service bodies, a way for the new system to be subjected to useful scrutiny at local level, and for lessons learnt to be disseminated across the country.
There are questions about the advocacy role. There is clearly a case for advocacy being included. One notes that there is a glancing reference in Clause 8, which is the reason for the stand part debate. It looks a little odd situated between Clause 4 and Clauses 18 and 20, as it does not seem to relate specifically to either. It has been mischievously suggested that there might have been references to advocacy in other parts of the Bill at an earlier stage that were removed and this was left behind. Can the noble Earl indicate the Government’s intention in referring to advocacy in that particular clause? We are not intending to move that the clause should not remain in the Bill; this is purely a probe.
We see most of these amendments as contributing to a refinement of the Bill’s proposals and we welcome that. However, it is necessary to reiterate the need for caution about the role of local authorities, particularly in the context of the financial situation that they are facing, which will get worse under a very tight regime. The Government are making provision for this, but we must be careful that the sum is not divvied up across a range of things without seeing the whole picture. If we are to give priority to this issue of information and advice, it would be helpful if the relevant departments, together with the Local Government Association, could look at the real cost of this and ensure that it is identified and included within the total package. It is easy to add desirable things against a budget. We do not know the extent to which these matters have been costed, for example, in the sum that the Government have allocated. We know that the demand is constantly rising, partly as a result of demographic change, and that the costs are also inexorably rising. This will be a cost. It is a justifiable cost, but it needs to be identified, provided for and kept under review.
Having said that, we are very much in sympathy with the thrust of these amendments and we look forward to the Minister’s reply and to working with others of your Lordships’ House in ensuring that the Bill is capable of delivering what it sets out to deliver and that all relevant players are engaged and financed adequately, so that we can afford the best possible level of care to those—of any age and with any condition —who need it.
My Lords, I am very grateful to noble Lords for tabling these amendments, which highlight the importance of access to good information and advice, including independent financial advice and independent advocacy, for those who have care and support needs or are planning how to meet future care and support needs.
First, I will address Amendment 82B, in the name of the noble Baroness, Lady Meacher, Amendment 86E, in the name of my noble friend Lord Sharkey, and Amendment 86F, in the name of the noble Lord, Lord Lipsey. Clause 4 introduces a general duty to make a universal information and advice service available to everyone in the local community. I say to my noble friend Lord Sharkey in particular that we are clear that the information and advice service must be accessible to all, whether they fund their own care or get some care and support paid for by the local authority, and in order to fulfil its duty the local authority will need to facilitate access. The noble Baroness, Lady Meacher, raised the issue of early information and advice about Alzheimer’s in particular; this will be one of the vital areas that the services should cover.
The clause deals broadly with what the information and advice service must cover. Subsection (2) sets out the essential requirements for the service but— intentionally—this is not a definitive list. With regard to Amendments 86B and 86H, subject to specific qualifications, it will be for local authorities to determine the precise scope and manner of the information and advice that they offer. We expect many authorities to offer access to independent sources of information and advice, working together locally with the voluntary, not-for-profit and private sectors. We set out our expectations and additional funding for local authorities, which rises to £50 million a year by 2017-18, in the Caring for Our Future White Paper.
I would say to my noble friend Lady Browning that some authorities have also used qualified social care staff as the first point of contact and have found that this can be effective, efficient and timely, helping people to the care and support that will help them most. Others have provided a first point of access to information through more general services, which connect information and advice on a wider range of local authority responsibilities as well as local NHS provision.
I emphasise that statutory guidance will cover how information and advice can be provided in an accessible way and be proportionate to the needs of those for whom it is provided. My noble friend Lord Sharkey expressed doubts about the phrase “seek to” and suggested that it was rather too weak. Statutory guidance will set out the clear expectations of what the local authority’s service should cover or what it should seek to do in order to ensure that the information and advice is sufficient.
My noble friend Lady Browning asked about the number of social workers. More than 1.6 million people are employed in the social care sector, including 200,000 social workers. We do not set out any national targets but we recognise the need to improve skills, capacity and retention. We are working with stakeholders, including the National Skills Academy for Social Care and Skills for Care, to produce new national minimum training standards, which will further raise standards and encourage new people to enter the sector. My noble friend referred to my letter of 27 June. I confirm that this referred to Health Education England. Health Education England’s remit does not extend to social care; it covers health and public health.
Amendments 83ZA and 86A, in the name of the noble Baroness, Lady Gale, cover information and advice on health-related areas and information to people with specific medical conditions. As for many services, there will be a need for the local authorities to work with NHS organisations and more widely to provide focused information and advice to those who would benefit from it. There are already good examples of how information and advice services from a range of organisations can work together with the health and well-being of the individual at heart. Many use the national information provided by NHS Choices as a base. A lot of local authorities are providing information and advice directly to those who may have an entitlement to NHS continuing care. In addition, regulations under the Bill will specify the circumstances in which the local authority must refer the adult for an assessment for NHS continuing care. We will of course work with interested organisations to include such examples in statutory guidance.
Turning to the amendments addressing access to regulated financial advice, the noble Baroness, Lady Greengross, and the noble Lord, Lord Lipsey, make some excellent points about the importance of appropriate financial advice for those who have or are planning for care and support needs. This kind of advice may be particularly relevant to people who are funding their own care and may include a financial adviser who is regulated by the Financial Conduct Authority, but there is no need for the Bill to set this out specifically. There are other kinds of advice that may be relevant to such people and, as I have mentioned, we think it is important to maintain the general terms of Clause 4.
I take on board the concern about the use of the term “independent financial advice”—that this may cause some confusion with the term’s general meaning within the financial industry and the Financial Services and Markets Act 2000. We are happy to consider this aspect in more detail to ensure that no confusion exists. However, we do not believe that taking independent regulated advice should be compulsory. Whether a person takes advantage of independent advice is a matter of personal choice. This is particularly important because some financial advice may be subject to a charge.
There will be individual circumstances in which it will be appropriate to recommend independent advice from a regulated financial adviser, such as when people are planning to meet future care needs or when people go into residential care and are weighing up financial options such as selling the home. The fact that an organisation or individual is regulated is in itself no guarantee that the person has knowledge or experience of wider care and support issues; for example, housing or other care-related options. All this makes the adult’s choice of an adviser a vital aspect. The local authority should advise about the importance of independent regulated advice and signpost the adult to offer a choice of where they can obtain the best and most relevant advice. Again, we intend to cover such issues in statutory guidance.
We will also shortly be consulting on the design and technical implementation of the funding reforms, including deferred payments. This will include how the new duties to signpost independent financial advice will work. The noble Lord, Lord Beecham, asked about an awareness campaign about the funding reforms themselves. We are scheduled to discuss amendments on that very issue in a later group and I hope that the noble Lord will be content for me to cover the issue at that point.
I turn to Clause 8. Noble Lords have noted that advocacy is referred to explicitly in Clause 8 but not in Clause 4. That is not to say that advocacy should not be considered within the scope of information and advice in Clause 4—we are clear that it should be, and it is provided for by reference to types of advice that are “proportionate to the needs” of the individual.
However, Clause 4 sets out a general duty to make available an information and advice service. Clause 8 relates to circumstances in which an individual’s needs are being met. In our view, it is important to clarify that, in such cases, advocacy should be considered as one type of support to meet ongoing needs.
Clause 8 is located in the Bill specifically to set out examples of how to meet needs, before provisions that begin the adult’s “journey” through the care and support system. This is intended to aid understanding and to make it clear that, before undertaking assessments, local authorities should be aware of, and consider, the breadth of types of support that they can provide to meet needs.
Amendment 88G, in the name of my noble friend Lady Browning, focuses on access to an independent advocate. The Bill is clear that, through the various stages of what might be termed the “care process”—the needs assessment, care and support plan and any subsequent review—local authorities must involve the adult, any carer and any person whom the adult asks to be involved.
I draw the Committee’s attention particularly to the fact that the Bill sets out specific requirements actively to involve people in these processes, not just to “consult” them. Some people may require help and support to be as actively involved as we would want them to be. That might be through the actions and professionalism of the social worker; it may be through the support of family or a friend, or through the assistance of an independent peer or support worker. For some, an independent advocate may be required to make this a reality. I want to reassure noble Lords that we want to get this right. I say to my noble friend Lady Browning that we have discussed this issue with a number of voluntary organisations, including the Care and Support Alliance and the National Autistic Society—to name two—and we have committed to further joint work to assess which groups of people might benefit from advocacy. That discussion will continue. We will also undertake further joint work to assess the financial implications for local authorities, taking account of an appropriate balance between national prescription and a local authority’s organisational and operational responsibilities.
I hope that the Committee will be reassured by what I have said on this very important subject. It has been a productive debate. I hope that the noble Baroness, Lady Meacher, will feel able to withdraw her amendment.
I welcome the Minister’s assurance that Alzheimer’s patients will be a priority when it comes to the provision of information and advice— I shall have to clarify what that means in due course. I thank the Minister for his usual courteous and sensitive response to the many amendments that have been debated this evening. I am sure that many noble Lords will want to come back to those issues on Report—in particular, I hope that the noble Baroness, Lady Browning, will come back to her point about social workers being a suitable vehicle for providing information in their care planning work. It could save a lot of resource and waste of time. I beg leave to withdraw the amendment.
Amendment 82B withdrawn.
Amendments 83 to 86H not moved.
Clause 4 agreed.
House resumed. Committee to begin again not before 8.05 pm.