Committee (2nd Day)(Continued)
17: Schedule 1, page 11, line 9, after second “a” insert “written”
My Lords, I move Amendment 17 and will speak also to Amendments 19, 54 and 57, which are in my name. Like other noble Lords, I thank the Minister for statements he made earlier about having listened to concerns over the duty to consult with the person and over the inclusion of 16 and 17 year-olds. He will appreciate that a number of amendments tabled by noble Lords stemmed from that deep concern about the lack of a statement on the Bill that the person being cared for should be seen by the person arranging for their assessment.
On a matter of form and detail, I do not like the term “cared-for person”. I prefer the scheme used under the Mental Capacity Act, where the person is referred to as P. They are considered as a person in their own right; they are subject to the legislation as a whole person. It is a stylistic matter. We got there with “unsound mind”; perhaps if we keep going, we might be on a roll—you never know—so I throw that in.
These amendments dig at some of the same concerns as those at which the noble Baroness, Lady Finlay, was getting on a previous set of amendments. As noble Lords will know, under the DoLS legislation there is a duty to ensure that not only does the cared-for person know what their rights are and have access to justice, but the people who care for them also know that what is proposed is the least restrictive option. There is a real question under the liberty protection scheme, as laid out, as to how somebody who lacks capacity or the people who look after them would know that. Furthermore, there have been concerns—assuming the care home manager was responsible for much of the assessment—over how they too would know that what was proposed was a least restrictive option. These amendments are about seeking to establish a duty to ensure that people are fully informed.
That takes us to another basic criticism of the Bill, which is about what I would say was an overreliance on the code of practice. Noble Lords have many years’ happy experience—some of it on the other side of the Dispatch Box—arguing about the importance of codes of practice as opposed to law. There has to be a statement in the Bill for anything in a code of practice to have force. As the Minister will know, practitioners need only have regard to the code of practice; effectively, they may not have regard to it. It matters more towards the back-end of the Bill, where much of the Mental Capacity Act is amended.
Put simply, nowhere in the Bill does there seem to be a duty to provide this information to the cared-for person or to the people who care for them. In the coming set of amendments the Minister will no doubt make much of the new requirements to consult, but that is something slightly different. We felt it was important to restate this and back up what is already the intention under the best interests of the Mental Capacity Act, but that we felt had been ignored in this Bill. I beg to move.
My Lords, I added my name to Amendment 17 because I think it is important that things be written down clearly, particularly for the cared-for person—which is the term we are using—if they have fluctuating capacity or need to absorb things very slowly but want to understand. Also, their families and those concerned about them will not necessarily be there when someone comes in to assess them or formulate a care plan, but they will certainly have concerns and they may have a very good idea about wishes and feelings that could have been overlooked—not maliciously, but because people did not know about them. A written record will provide evidence for everybody about what is happening.
The way the consultation is conducted should therefore, I agree, demonstrate that restrictions have been proportionate and necessary, and that alternatives have been considered—and the reason they have been discounted should be given. I would like us to give people much more access to all their clinical records; the caring family, in particular, should have access to the records. Often, information held by family members and others close to the person is effectively like gold dust when it comes to planning their care, and would benefit from being shared.
Where someone’s condition deteriorates, if this has all been written down clearly you have a baseline against which you can measure changes. If they improve, the baseline shows the reason that things were put in place as restrictions, which could then be lifted. Again, that gives a benchmark against which to measure, which would make care more personalised. I hope this concept will be well received. I am unsure as to whether it should go in the Bill or in the code—it is easy to put lots into the Bill—but the principle is important.
My Lords, I have some amendments in this group. I welcome the explanations given by the noble Baroness, Lady Barker, in her introductory comments. The Bill requires the responsible body to complete an authorisation record containing important information for the cared-for person. However, it does not require the responsible body to provide this information to so-called cared-for persons themselves. I rather like the term “cared-about person”; that is what families have in their minds, that they are caring about the person. While this is about official, statutory care, we still want that essence of caring about the person to be central to it.
The responsible body does not currently have to provide the information to the person themselves or to their family or an IMCA should they be involved in supporting that person. Amendments 51 and 52 seek to address this omission, by ensuring that the person themselves and any appropriate person or IMCA supporting and representing them are given copies of the authorisation record as soon as possible after authorisation is granted. Amendment 53 would require that the person is told of the options to appeal and notified of the outcome of reviews, variation or termination of an authorisation.
I support my noble friend Lady Finlay’s advice that information should be shared. I add that it should be shared in a timely, not reluctant, way. Perhaps the Minister can confirm that omission of the requirement to inform the person about options to appeal and about outcomes is just an oversight and that it can quite easily be added to the Bill.
Article 5 of the ECHR requires the person to be given information about the reasons for depriving them of their liberty. Case law says that this should be in a language accessible to the person and, if the person is not likely to understand it, it should be communicated to a representative on their behalf. If the person or those representing them do not know why they are being detained, they cannot challenge it and, if they cannot challenge it, that undermines the point of Article 5 safeguards, which are about limiting arbitrary power to a system of checks and balances.
My Amendment 53 also places explicit duties on an IMCA to ensure that the cared-for person, P, and the appropriate person understand the information and their rights to request an AMCP assessment, advocacy and review, and to challenge the authorisation in court. My fourth and fifth requirements in Amendment 53 draw from the Joint Committee on Human Rights report, which said that,
“the responsible body should be under a clear statutory duty to refer cases”,
“where others fail to do so.”
My Lords, I do not recall, in some 25 years in both Houses of Parliament, rising to speak in a debate feeling more despair about a piece of legislation than I feel about this Bill as it stands. Amendments 17, 19 and 36 are so necessary and so blindingly obviously needed that I cannot understand why the provisions they cover were not included in the Bill in the first place.
Amendment 17 would require a statement from a care home manager to be a written statement. Of course it should be a written statement. Amendment 19 would ensure that the cared-for person and those involved in their care were informed of the proposed arrangements and any possible alternatives. Of course they should be informed and of course they should be told that there are alternatives. Amendment 36 would put right an obvious injustice that the Bill in its present form would create.
I am not alone in having grave doubts about the Government’s whole approach to giving responsibility to care home managers to initiate the process and considerations, as we heard in earlier debates today—but if ever there was a case when, in a hole, it is time to stop digging, this aspect of the Bill is certainly part of that. The Bill places a duty on the responsible body or the care home manager to commence an authorisation record covering a range of information and detail, but the person most affected and that person’s family may not be given that crucial information. This is out of the script of “Yes Minister”. The noble Baroness, Lady Hollins, is absolutely right in her approach and her amendments. The cared-for person and his or her family must be given copies of the authorisation record. With regard to Amendments 54 and 57 in the name of the noble Baroness, Lady Barker, I know that she is not too happy with the term “cared-for”; nevertheless, it underpins a person’s rights.
Last week, I was at the Parliamentary Assembly of the Council of Europe in Strasbourg. It is an organisation that Britain helped to create after the horrors of the last war to protect and defend human rights. The combined all-party British delegation, so ably led by Sir Roger Gale, has an exemplary record of defending human rights. I hope that when we return to Strasbourg for the next session in January, it will not be with the stain of having seen our Parliament enact legislation that removes many basic human rights from most of our vulnerable fellow citizens. The Bill needs to be changed and the Government need to start listening.
Well, I shall see whether I can lift the gloom from the noble Lord. I think that there was a slight mischaracterisation, in that the Government are listening. Indeed, we have responded and made changes. I hope that in responding to these amendments I will be able to show further that we are taking a positive and constructive view on improving the Bill, making sure not that it removes rights but quite the opposite—that it provides access to liberty-protection safeguards for people who do not currently enjoy them.
I begin by thanking the noble Baroness, Lady Barker, for leading the debate and I also thank other noble Lords. I shall go directly to her Amendment 17. Of course she is right, as are other noble Lords, about the arrangements for the cared-for person—person P—being written. I am very happy to confirm to all noble Lords that that is our intention and that we will make sure that the Bill reflects it.
With regard to other amendments, the entire thrust of policy across government, whether in health and care or anything to do with data, is about providing more people with the information that the state holds about them. I can give the absolute commitment to noble Lords that that is what we intend to do in the Bill and in changes that we make to the Bill going forward. It is essential that cared-for persons, their families, appropriate persons, IMCAs and so on are given full information about their authorisation and their relevant rights, including their rights to review and appeal. I can tell noble Lords that that will be set out fully in the code of practice.
On the code of practice—I can see the noble Baroness, Lady Barker, grimace—I will say two things. First, it is a statutory code of practice involving a consultation arrangement and a laying before Parliament—noble Lords know how these things work. The noble Baroness asked about the force of the code of practice and it is true that the Bill says “have regard to”. But case law confirms—I am happy to write to noble Lords with this opinion—that the code of practice must be followed unless there are cogent reasons not to do so. That means that there will be some occasions when the code is not practised, but those not following it will have to justify, potentially in court, why they did so in the interests of a person’s care. So the code of practice is statutory and it has very great force. It is worth pointing that out, not least because on this group and future groups we will be talking about information or an instruction that will be within the code of practice. I will take the opportunity to make that clear at this point.
I thank the Minister for that. This is a very important part of our discussion. I have two questions which I am absolutely certain he will not be in a position to answer, but I hope that he will write to me. First, how many cases of a failure to follow the code of practice rather than a failure to follow the law have gone to the Court of Protection? Secondly, can the Minister confirm that the original Mental Capacity Act code of practice was never reviewed and that it is not possible to make individual amendments to a code of practice: it has to be changed in its entirety? I shall not put the Minister on the spot now but we need to return to those matters in a further discussion because they are really important.
The noble Baroness is quite right: I do not have the answers to those questions, but they are very good questions and I will make sure that we answer them for noble Lords in a communication following this debate.
On the point about access to information, I think that two other aspects are worth considering. One is that under the general data protection regulation, which came in on 25 May this year, the cared-for person or their family, IMCA or somebody holding a lasting power of attorney—that is, somebody acting on their behalf—will, and indeed does, have access to their authorisation record. I believe, although I will clarify, that that has to be done free of charge. I know that that is certainly the case with medical records and GPs. In terms of access to information, that is an important advance.
Again, I want to get further clarification on exactly what is involved, but the NHS and the LGA have created a programme of local health and care record exemplars. It happens in a few parts of the country and it is about creating a single health and care record that contains all the information about a person’s health and care. Obviously it spans both health and care settings. That will be available not only to inform the care carried out by a clinician or someone in a caring role but information to that person and those with responsibility for them.
That obviously has huge implications for improving joined-up care. It is an important programme by which we set a lot of store. What I will take away from this discussion is the need to ensure that what we are describing here, around access to information by the cared-for person or by those caring for them, ensures that they will have access to the local health and care record, which would contain the kind of information we are talking about. If it does, we have a vehicle; if it does not, we need to think about what the right vehicle is.
The amendments in this group also support the IMCA to help the cared-for person understand their rights under liberty protection safeguards. I can confirm that this will be a key role for the IMCA. It will be defined in their job description and, again, contained in the code of practice.
Once again, we have already made changes, and are committing to changes in the Bill, that will deal with the questions raised about access to information. I absolutely concur with the sentiment behind the questions. There is good reason to believe that expanding programmes and mechanisms in the system will give us the opportunity to do that, and in a much more thorough way than is done now. I want to continue to work with noble Lords to make sure that we get that right as we move towards Report, so that it is properly reflected in the Bill. I hope that, on the basis of my comments and reassurances, the noble Lord, Lord Touhig, will feel a little less despairing and the noble Baroness will be prepared to withdraw her amendment.
I thank the Minister for his comments. I hear what he says about GDPR, but if he could send Members a small briefing note, that would be extraordinarily helpful. Clearly, there has been a significant change. I and other noble Lords will remember times in the past when individuals were not able to access historic care records because they contained information about a third party. A whole series of cases had to go through the European courts to establish exactly what the rights of access to care records were.
I will study what the Minister said. However, we need to be absolutely certain that the spirit of these amendments is reflected. Perhaps we may come back to this at a later stage with a simple amendment introducing a requirement in the Bill to provide information. How that is done can be set out at considerable length in a code of practice, but the requirement to do it needs to be in the Bill. With that, I beg leave to withdraw the amendment.
Amendment 17 withdrawn.
Amendments 17A to 18 not moved.
18A: Schedule 1, page 11, leave out lines 12 and 13 and insert—
“(b) that the liberty protection arrangements impose physical restrictions on the cared-for person,”
My Lords, previously we struggled with the definition of restriction of liberty. From the original judgment from the noble and learned Baroness, Lady Hale, the term “a gilded cage is still a cage” has become common currency and is sometimes used as a benchmark. The difficulty we face with this legislation is how we define the restriction of liberty for an individual and the normal variations of everyday living that vary from family to family and culture to culture, and with which we would not wish to interfere.
My noble friend Lady Murphy tried to provide a definition when we last debated this. Following her lead, I have tried in my amendments to come up with a definition which respects the personal cultural background of an individual, the right to private and family life that existed before they entered care, and the need for an appropriate way of living to be respected as they require some restrictions on their liberty to keep them safe. I want to avoid the risk-averse approaches that are sometimes taken and which can result in disproportionate restrictions, such as restricting the friendships and relationships that may form, particularly when a risk-averse approach may be motivated by the convenience of those responsible for providing care rather than a true balance of weighing up of risks. My noble friend Lady Hollins illustrated that very clearly in a previous debate on restrictions.
To avoid processes being burdensome within the system, it is important to differentiate temporary types of restrictions that may be imposed in order for treatment or other intervention to be given that is aimed at achieving therapeutic improvement—for example, in an emergency situation—from restrictions imposed in the long-term planning of the care of a person to keep them safe and empower them to live as well as they can. In addition, we must differentiate between the restrictions imposed by those providing care and the restrictions that come about inevitably because of the underlying illness or disorder—for example, due to the nature of neurological damage. Additional restrictions are then imposed by those providing care, which should be designed to be the least restrictive option—hence the amendment to reinforce that part of the Bill—to optimise the person’s ability to live well.
The Mental Capacity Act states that, acting in a person’s best interests, the decision-maker should take the least restrictive option. Although this is stated up front in the Act, to which this Bill is an amendment, it is worth restating here that arrangements must protect the liberty of the cared-for person and must align as much as possible with their wishes and feelings. We must remember that other legislation comes into play where there is evidence that those responsible for providing care are not motivated by the cared-for person’s best interests. That comes into the realm of safeguarding, and there was a very sad case recently, where the Modern Slavery Act was brought into force.
The problem is the tension between a universally applicable definition of a “restriction” and a more subtle approach, whereby one person might feel they are restricted when another person might not. Let me give noble Lords a simple example. A man who had been a table tennis champion was in a care home and was very withdrawn. A charity offered to fund a specially adapted ping-pong table—it was a little like a mini squash court. This gentleman was encouraged to try to play ping-pong. Initially, he seemed to fail to understand, but then quite suddenly he started to hit the ball effectively and efficiently. This coincided with a remarkable cognitive improvement, and as his physical strength improved, because he was moving better, his risk of falls also decreased and he communicated better. Without the insight that he had been a champion and had skills that could be built on, he could well have been left to linger, and nobody would have realised how much recovery could be achieved.
When we think about people with a severe head injury, it is important to remember that, when the frontal lobe is damaged, assessment can be extremely difficult. At first sight, these people might appear to be cognitively intact, but, if they are not properly assessed, they can rapidly run into all kinds of major problems because they are unable to do the weighing-up part of the decision, with the implications that that has for themselves and others. Therefore, we have to have some kind of definition, but it will be difficult to have a single definition in the Bill.
In summary, these amendments seek to ensure that we personalise the definition; that we do not confuse restrictions through disease and disorder with restrictions imposed by people. All restrictions imposed by people must be fully recorded and justified to empower the person to live as well as possible. I am not sure that we will come up with a concise definition in the Bill—perhaps it may be better if we do not carry on trying—but we must address the concepts in a code of practice or even, possibly, in regulation, which could be changed more easily. Otherwise we risk another legal case of poor care and poor decision-making which then goes on to have unintended consequences. I fear that at the moment we are living with some of the unintended consequences of things that have happened historically. I beg to move.
My Lords, I congratulate the noble Baroness, Lady Finlay, on again introducing this discussion on a difficult topic. I do not share her pessimism that it is impossible to find a definition. It would be quite simple to have a definition in the Bill which would enable us to distinguish between those who are and are not being deprived of their liberty.
The fact that people are deprived of their liberty, in reality, by their condition is an irrelevance. We have to stick with what is happening to people; what we, the state or the carer are doing to the individual. We would not find it too difficult to decide what is or is not a restriction. You can compare the living accommodation of a person in a care situation to that of someone who is living in the same place without those restrictions. Care home managers would not have too much difficulty in saying who was and who was not restricted.
We should not give up trying to have some kind of definition that lists those conditions. People might be receiving sedative medication so that they cannot move around and others might be restricted physically—there are still people being restricted physically—in dreadful chairs and so on who cannot move about. We could define fairly well what the conditions are. I hope we will come back on Report with some clarification of what they are so that we can put something in the Bill. I worry that if they are in the code of practice it will be so flexible that it will result in a postcode lottery, with one area’s policy different from another’s. That would be a disaster.
We should be able to get something in the Bill. I hope that we will not give up at this stage.
Following on from the observation made by the noble Baroness, Lady Murphy, one of the most common restrictions of liberty is medication and medication reviews. We often think of it as being physical but it is not. New medicines often come online and create change. I take her point and hope we will be able to work towards a definition.
I will not add much more because the noble Baroness, Lady Finlay, has done us all a favour by putting forward great questions exploring the Cheshire West ruling. The Joint Committee on Human Rights agrees that a definition needs to be found, otherwise—the noble Baroness is right—we will be back in a situation where things have not gone right and we end up in court again. We all need to put our minds to this. We should be able to find a definition and I look forward to the Minister leading that particular discursive discussion across the Committee.
I shall do my best. I thank the noble Baroness, Lady Finlay, for continuing to make sure that we grapple with the most difficult questions, as the noble Baronesses, Lady Murphy, Lady Barker and Lady Thornton, have enjoined us to do. It must be right that we at least give it a go while recognising that this is a challenging topic.
The amendments of the noble Baroness, Lady Finlay, are about restricting liberty protection safeguards to certain circumstances where physical restrictions are imposed, and outline the liberty in which the feelings of the cared-for person should be protected. Her intent was not to provide that definition but to provide a platform for us to have a discussion about the definition. We have been strongly encouraged by the Joint Committee on Human Rights to do so and, as I said in our previous discussion on this topic, we are considering the Joint Committee’s findings very closely.
I sense, and have sensed throughout, that there is a desire among noble Lords to provide such a statutory definition within the Bill. Obviously there are huge benefits of doing so. It would provide clarity; the noble Baroness, Lady Murphy, mentioned avoiding a postcode lottery; and families, professionals and the people themselves would benefit. There are compelling arguments for it. At the same time, we are weighing it against the safeguards that cared-for people need and ensuring that we comply with our obligations under the ECHR.
We obviously have not got there yet—no one is suggesting that we have—but I want to use this spirit of determination and problem solving to see whether we can get to that point—hopefully by Report. It is a topic for a longer discussion, which does not need to be in this Chamber, but we have to recognise that there is not a consensus among stakeholders. That is a challenge. We need to consider whether we can bring the entire disparate community along with us, otherwise we will have a problem and not solve the challenges we are dealing with.
I will commit to all noble Lords to see whether we can get to that point. There is a hierarchy about the ways in which we can achieve it—in the Bill, through regulation or through a statutory code of practice—but at the very least we should make a determined endeavour to do it. So I am happy to give that commitment. As noble Lords would expect, the Government have been working hard on this. We would like to share our thinking with noble Lords and start to build that consensus in the House and beyond to see whether we can get to that point. I hope that will give noble Lords the reassurances they are looking for.
On the substance of the amendment of the noble Baroness, Lady Murphy, that depriving a person of their liberty in emergency and interim cases should benefit the person and that that deprivation, life-saving treatment or doing a vital act cannot be done without depriving a person of their liberty, the Bill already states that steps depriving a person of their liberty must be necessary in order to give life-sustaining treatment, and the Mental Capacity Act requires that such steps must be in a person’s best interests. So that reassurance is there.
I thought Amendment 81 was tabled in the name of the noble Baroness, Lady Murphy. Anyway, it does not matter in whose name it was, those reassurances are in the Bill. If there are any niggling concerns about that we can, of course, make that clear offline. On that basis I hope the noble Baroness will be prepared to withdraw her amendment and begin those discussions in earnest.
I thank the Minister for that reply. Fuelled by the optimism of my noble friend Lady Murphy, we are moving forwards, and as the Minister has said, we need to give it a go but we must also take all the stakeholders with us. We will need some careful round-table discussions about this. I take completely the point about medication, and not using that word in the amendments I have drafted is an omission that needs to be corrected.
When I was considering emergencies, I was concerned about situations that are not necessarily life-threatening but still constitute some kind of emergency. They arise quite commonly in social care out in the community and emergency primary care settings. I do not think that they can be ignored when we are looking at a definition. We have to be quite broad, otherwise we might suddenly find that a gap emerges again, which would not be helpful. I look forward to thinking with others and I hope that they are more successful than I have been today. I beg leave to withdraw the amendment.
Amendment 18A withdrawn.
Amendments 19 to 20 not moved.
21: Schedule 1, page 11, line 41, after first “person,” insert “based on evidence,”
My Lords, again I preface my remarks by saying that these amendments were drafted when the role of the care home manager was less clear than perhaps it is now. Nevertheless, they take us to the important point about determinations on mental capacity and the requirement to make sure that they are evidence based. In the Bill as it stands, a huge amount of discretion is given to care home managers and people involved in care to determine whether someone has capacity. We do not believe that that is right. Determining whether someone has capacity is difficult to do and something for which a great deal of training and experience is required. We keep coming back to what would be acceptable levels of training and qualifications to exercise that determination.
Amendment 21 seeks to provide that there should be an evidence base and that those making the capacity assessment should go through it and be ready to justify their decisions accordingly. I will go back to a point and reiterate it, although it must be rather boring: a DoLS assessment is different from a care assessment, and whoever makes and records such assessments should know that they are challengeable in court, which is a big responsibility.
Amendment 22 again endeavours to make sure that the person carrying out the assessment of capacity should be properly qualified, a point I have made before. I do not think that the Bill as it stands is sufficiently robust about the level of professional training needed and therefore this is a matter to which we should return.
Amendment 25 in a way follows on from our previous discussion. With this Bill we will move into a new position where the assessment of capacity is not as clearly specific to the situation as it is under the Mental Capacity Act. We are also moving towards a position in which assessments can be rolled over for longer periods. I am not saying that that should not happen and I take absolutely the point that a number of the assessments being required under DoLS are unnecessary. When someone has had a diagnosis of dementia, for example, their capacity to make decisions may not fluctuate or change, but we need to be altogether a lot more precise in the terminology being used in the Bill. It is not just a change in someone’s condition but may also be a change in their circumstances which has led to the deprivation of liberty. We are bringing in a new test to show that things are necessary and proportionate. I do not think that it is that clear or that it will clarify the decisions which are going to have to be made. This is an attempt on our part to move away from what we believe to be a position where the subjective judgment of care providers would have been given too much weight in the determination of capacity. The amendments on that issue are probing in nature and I beg to move.
My Lords, I rise to lend my support to Amendment 21 tabled in the name of my noble friend Lady Barker and to speak to Amendment 22, which is tabled in my name. Amendment 22 is essentially about who should be able to determine whether an individual is, as it currently states in the Bill, “of unsound mind”. That is the terminology being used, but I would prefer to see terms like a “disorder” or a “disability” of the mind. That is one of the three key authorisation conditions. Perhaps I may say again how very pleased I am that the Minister has indicated his willingness to look at some new language so that we do not use the term “unsound mind”, which in my view is stigmatising and has no place in today’s society.
I return to Amendment 22. Currently, the authorisation arrangements in this part of the Bill state that a medical assessment has to be made but do not state who has to make it. It is likely that most people would assume—indeed, it may well be that the Government are assuming it and no doubt the Minister can reassure us on the point in his response—that a medical assessment needs to be carried out by a registered medical practitioner. However, it would be helpful and reassuring to have that made clear in the Bill. The report published earlier this year by the Joint Committee on Human Rights is clear that, in order to comply with human rights law, any deprivation of liberty under Article 5 requires,
“objective medical evidence of a true mental disorder of a kind or degree warranting compulsory confinement, which persists throughout the period of detention”.
Given the requirement for “objective medical evidence”, my contention is that there needs to be a guarantee in the Bill that only a registered medical practitioner with appropriate training has the power to determine whether someone has an unsound mind or mental disorder, depending on which language is going to be used.
My Lords, I will speak to two amendments in my name in this group, although I may also come back on what has been said.
Amendment 23 concerns supported decision-making and is based on Clause 12 of the Law Commission’s draft Bill. The amendment would require a clear determination,
“made on an assessment that steps to establish supported decision making are not practicable”.
“Steps to establish supported decision making are practical if, in relation to decisions about their personal welfare or property and affairs (or both), a cared-for person— … is aged 16 or over, and … has capacity to appoint a person to assist them in making those decisions”.
Amendment 24 concerns the restriction of defence and is based on Clause 9 of the Law Commission’s draft Bill. It states:
“The assessment must include … a description of the steps which have been taken to establish whether the cared-for person lacks capacity”.
NICE recently released guidelines on what it thinks the Bill should say regarding supporting a cared-for person:
“Support people to communicate so that they can take part in decision-making. Use strategies to support the person's understanding and ability to express themselves in accordance with paragraphs 3.10 and 3.11 of the Mental Capacity Act”.
NICE also recommended:
“Practitioners should make a written record of the decision-making process, which is proportionate to the decision being made. Share the record with the person and, with their consent, other appropriate people. Include: … what the person is being asked to decide; … how the person wishes to be supported to make the decision … steps taken to help the person make the decision … other people involved in supporting the decision … information given to the person … whether on the balance of probabilities a person lacks capacity to make a decision … key considerations for the person in making the decision … the person’s expressed preference and the decision reached … needs identified as a result of the decision … any further actions arising from the decision … any actions not applied and the reasons why not”.
These basic and important matters were included in the Law Commission’s draft Bill but not adequately included in this Bill. I am pleased to be part of this group and able to raise these issues. I will let my noble friend Lord Hunt talk about Amendment 50ZA.
My Lords, I am very grateful to my noble friend for that invitation. Amendment 50ZA refers to circumstances in which the pre-authorisation review is not undertaken by an approved mental capacity professional. Paragraph 18(2) of Schedule 1 sets out the circumstances where that applies, stating that the AMCP will be brought into play where,
“the arrangements provide for the cared-for person to reside in a particular place, and it is reasonable to believe that the cared-for person does not wish to reside in that place, or … the arrangements provide for the cared-for person to receive care or treatment at a particular place, and it is reasonable to believe that the cared-for person does not wish to receive care or treatment at that place”.
Paragraph 20 of Schedule 1 sets out what the person carrying out the review needs to do,
“if the review is not by an Approved Mental Capacity Professional”,
but it does not say who should do it. I want to raise this issue with the Minister. Clearly, there is concern that it may not come to the attention of the responsible body that the cared-for person does not wish to be treated in a particular place or receive a particular form of care or treatment. We could go back to the architecture of the Bill. We think that it puts too much authority in the hands of the care home manager who, in many cases, has to unlock the door to allow these concerns to be raised. Given that some people should be assessed with their review undertaken by an AMCP, but this will not happen, it is important to know the circumstances under which the review would then take place.
Essentially, my amendment is a probing one. The pre-authorisation review referred to in paragraph 20 of Schedule 1 does not have to be done by an AMCP, but Amendment 50ZA says that the person who undertakes it should at the very least,
“be qualified as a medical practitioner, nurse, social worker, speech therapist, occupational therapist or other profession as may be specified in regulations”.
That covers the point made earlier by the noble Baroness, Lady Finlay, that those professions are regulated. It is important for us to be clear. Some people may fall through the net and not be seen to qualify under paragraph 18(2) of Schedule 1. Therefore, the people doing the reviews who are not AMCPs must have enough professional standing to identify problems that might arise. I hope that the Minister, who is in a concessionary mood today, will agree to look at that.
My Lords, three amendments in this very important group are in my name. I fully support the stress being placed on the need to see whether, with additional help and support, the cared-for person could make their own decision. It is always better if they can take their own decision over any aspects of their care that need to be in place. For example, providing support to young people with learning difficulties or people with an expressive disorder may require special skills, time and patience to support them to make their own decision. However, the Mental Capacity Act is clear that every effort must be made to support people.
It is also right that the way in which support is provided, as well as the evidence for why such support may have failed, should be recorded—as in Amendment 23, which I strongly support. Decisions should be based on evidence as much as possible, not on the personal opinion of the assessor, although there will always be a degree of interpretation of evidence. For people in community and supported living settings, this will be important to stress as they may agree with and consent to certain aspects of the care plan but not understand others—so it is not an all-or-nothing. However, even if the person does not appear to understand, everything must be explained as fully and clearly as possible. It will be important for any such evidence submitted to support the deprivation of liberty to come from the professional responsible for the care plan, whoever that is.
We have already debated the role of the care home manager. For consistency, I have removed the care home manager from this part of the Bill. I should apologise to care home managers for my use of “secretary” in relation to their role, which could be misinterpreted. I did not mean to cause offence; I just wanted to make sure that we recognise that the care manager and the care home manager are often different people.
In response to the amendment tabled by the noble Baroness, Lady Jolly, I would advise caution. In some situations, a specialist clinical psychologist may be better than a medical practitioner at undertaking the assessment. I would hate for us to end up with the view that the doctor would always be the best person to do the assessment because I do not think that they always would be; there may well be others.
I welcome the addition of speech and language therapists. They have a great deal to offer to people with expressive disorders and can often establish communication when other people think that the cared-for person lacks capacity but in fact they simply cannot express themselves.
Yesterday or on Friday—whenever it was—we received a very helpful briefing from the Royal College of Psychiatrists. I found what it had to say on Amendment 22 very useful:
“The Royal College of Psychiatrists believes that only a ‘Registered Medical Practitioner’ should be able to determine whether an individual has a ‘disorder or disability of the mind’ … Currently the authorisation arrangements in Part 2 of the Bill say that a capacity and medical assessment has to be made, but does not say who has to make it. It is likely that the Government is assuming that this would be carried out by a ‘Registered Medical Practitioner’ but it would be helpful to have it on the face of the Bill.
The JCHR report was clear that in order to comply with human rights law, any deprivation of liberty under Article 5(l)(e) requires ‘objective medical evidence of a true mental disorder of a kind or degree warranting compulsory confinement, which persists throughout the period of detention’.
Given this requirement for ‘objective medical evidence’, there needs to be a guarantee in the Bill that only a Registered Medical Practitioner with appropriate training has the power to determine whether someone has an ‘unsound mind’ or ‘mental disorder’”.
I am very grateful to all noble Lords for tabling amendments on this very important topic of making sure that when these decisions are made and the assessments of them carried out that they are done on the best possible evidence. That informs all the amendments in this group.
We have talked already about the role of the care home manager in arranging assessments and providing a statement to the local authority while the assessment is conducted by a suitably qualified professional. Clearly we will explore that further following the debate tonight. It is also clear that in many cases care home managers will be using assessments that have already been conducted, wherever possible, ensuring that we reduce duplication. There is clearly a balance between making sure that we have access to the best possible information and not creating extra burdens on the system to duplicate work where a previous assessment would be useful, up to date and valid.
I will deal with the amendments in turn and try to think about how we can get that balance. Amendment 21 in the names of the noble Baronesses, Lady Barker and Lady Jolly, would remove the ability of care home managers to rely on previous medical and capacity assessments. It would mean that assessments could be relied on only if responsible bodies judged it appropriate. Our belief is that where valid assessments are already in place and have been completed by a suitably qualified professional—such as those completed as part of a care plan—they should be used. We are concerned about the implications of the amendments in this group because of the duplication that could arise, particularly perhaps if there is a difference between assessments and each person who carried out the work is still of the view that their judgment was the correct one. We need to be concerned about that as we are trying to simplify the system.
We also do not believe it would be proportionate to expect care home managers to seek permission from a responsible body on every case where there is a previous or equivalent assessment, especially when it is clear for example that somebody has a lifelong diagnosis such as a learning disability and a previous assessment can be reasonably expected to provide valid and reliable evidence of this.
I understand the intention of the noble Baronesses in wanting to avoid care home managers relying on previous assessments when it is not appropriate to do so, which I think is what has informed these amendments. That is where the responsible body reviewing is incredibly important. Generally speaking it will be a senior social worker who will be able to examine the case and if there is an overreliance on past—particularly quite long-dated—assessments in that statement, it will be a flag for escalation to the AMCP.
I understand why there is concern about giving too much leeway to the care home manager, but I also think the amendment would deliver a disproportionate system. It would not provide the degree of flexibility we want and therefore we intend to outline the appropriate use of previous assessments in the code of practice. I think that that is the appropriate vehicle.
Amendment 22 in the name of the noble Baroness, Lady Tyler, seeks to ensure that medical assessments are completed by a registered medical practitioner. Clearly our intention is that that should be the case, and that the person who conducts the medical assessment must be suitably competent. I use that word rather than “qualified” and we will set out further detail in the code of practice. As was stated by the noble Baroness, Lady Thornton, and others, human rights case law already requires that a deprivation of liberty must be based on objective medical expertise. That can be done on a competence basis rather than on qualifications. Qualifications change whereas competencies, by and large, remain the same. That is why we will focus on a competence-based approach rather than listing professions in a code of practice. A code of practice gives us the ability to exemplify the kind of competencies we mean without being restricted, which would be the case if it were in the Bill, to only certain categories of worker, which might change over time.
Amendment 23 in the names of the noble Baroness, Lady Thornton, and the noble Lord, Lord Hunt, creates a duty under liberty protection safeguards to assess whether steps to establish supported decision-making are practical. As I am sure noble Lords know, supported decision-making is already part of the law, and indeed it is the second principle of the Mental Capacity Act. Perhaps one of the reasons that this amendment has come forward is that this is an amendment Bill and therefore there can be a dislocation sometimes between what we are considering and the wider context.
It is already the case that steps should be taken to support people to make their own decisions. We have not brought forward the Law Commission’s recommendation to set up a formal supported decision-making scheme because that legal entitlement already exists. Wherever possible, of course, people should make decisions for themselves and be supported to do so. However, as I say, the second principle of the Mental Capacity Act provides that legal force and in the code of practice we will set out the guidance about how that should work in principle.
The noble Baroness, Lady Thornton, introduced Amendment 24, which describes the process of how someone should be deprived of their liberty. It was helpful for her to refer to the NICE guidance on this. We have already talked tonight about a written record—I think that goes some way—and the basis on which it is shared, which is also important. I will provide more detail on that. The concern about the way that this has been framed is that it is too specific to be in the Bill and the process and the terms may change over time. Although I am sympathetic to the idea that there needs to be clarity about what the appropriate process is, that is best done in the code of practice rather than in the Bill.
The noble Baroness, Lady Finlay, introduced Amendments 24A, 24B and 24C. I need to reflect further on the implication of these amendments because the way she described them was perhaps not how we had previously interpreted them. My only concern is that one of the effects might be that only responsible bodies could decide to rely on previous assessments, because she has taken care home managers out.
Amendment 25 from the noble Baronesses, Lady Barker and Lady Jolly, would require the care home manager or responsible body to have regard to any change in a person’s circumstances when seeking to rely on a previous or equivalent capacity or medical assessment. I agree with the intention of the amendment, which is to ensure that before relying on a previous or equivalent medical or capacity assessment proper consideration is given to whether it is reasonable to rely on it. The Bill allows for this already. Such an assessment can be used only if it appears to be reasonable to rely on it. As we have said, responsible bodies when reviewing such statements are obviously legally liable for making sure that the reasonableness test is carried out. Again, we will provide more detail in the code of practice about where it is reasonable to rely on an assessment.
The noble Baroness talked about the difference between condition and circumstances, or the complementary nature of the two. If circumstances change and this affects a person’s capacity or diagnosis, it would also need to be considered before relying on previous or equivalent assessments. We are reflecting at the moment on whether the Bill as drafted achieves our aim here. So this is a topic for a further conversation to make sure that we can get the appropriate balance in this area without introducing too many additional terms that might in themselves provide greater unclarity—which of course is something we are trying to avoid.
Amendment 30 deals with less restrictive arrangements. This is a principle of the Mental Capacity Act and the Bill makes no change to it. Again, we will provide more detail in the code of practice as to how the new model will work in the wider health and care system, including the Mental Capacity Act and the Care Act.
That brings me, at last, to Amendment 50ZA, introduced by the noble Lord, Lord Hunt. I think that its aim is to ensure that the pre-authorisation review is completed by a qualified person, as set out in regulations. As I said, under the current DoLS system, applications will often be reviewed by a senior social worker. We absolutely expect this to remain the case where the local authority is the responsible body. Where a hospital trust, CCG or local heath board is the responsible body, we would expect this role to be conducted by a medical professional. Again, that will be clarified in the code of practice. That is the appropriate mechanism for it, for the reasons I gave: descriptions and qualifications change over time. However, as I also said, since the code of practice will be statutory that will give it force, as will case law.
I have one final point on Amendment 50ZA. I believe that it would also allow responsible bodies to determine in care home cases whether somebody has the necessary skills and experience to complete a necessary and proportionate assessment. I think that was the intention.
In which case I will not go any further.
On that basis, I hope that I have dealt as thoroughly as I can with the substance of all the amendments in the group. Clearly, we want to make sure that the evidence is as good as possible when making these very important and serious decisions. As I said, in this instance the code of practice is a good vehicle for much of this work. On that basis, I hope noble Lords will not press their amendments.
My Lords, I thank all noble Lords who took part in this debate. It has clarified some matters to a certain extent. I very much welcome the Minister’s suggestion that we should meet further. There is agreement on the part of everybody that we want to cut down the number of unnecessary repetitions of assessment, but to do that we need to be quite clear that the assessments are done correctly and by the correct person.
The Minister talked about qualifications changing and wishing to move towards a competency-based arrangement, but the parallel with Mental Health Act and approved mental health practitioners is a good one. All sorts of people from different disciplines and backgrounds are approved mental health practitioners. As the noble Baroness, Lady Finlay, illuminated, a whole number of people from different professional backgrounds could be AMCPs. The important thing is that they have demonstrable expertise in this legislation. I yet again make the point to him that he talks about using different assessments, but assessments under this legislation are not the same as care assessments. They are particular ones. We have not had the discussion about the implications for the changes to Care Act assessments if this Bill goes through, but we need to because we need consistency between the two.
Nevertheless, I am heartened by the Minister’s response. We are not quite there yet on this. We need to do a number of different things to make sure there is consistency and clarity across the range of professionals engaged in doing these assessments, and that the people who are being cared for and their families, and care home managers, can have a reasonable expectation that these crucial assessments—it is assessment of someone’s capacity; it is a really important one—are done consistently under the Act. It is when assessments are done badly that these things start to unravel. I very much thank the Minister for his response and at this stage I beg leave to withdraw the amendment.
Amendment 21 withdrawn.
Amendments 21A to 25 not moved.
26: Schedule 1, page 12, line 9, at end insert—
“(4) If the arrangements are care home arrangements, the assessment must be carried out by an individual who has attended and passed the accredited training authorised by the local authority under section (Training for care home managers).”
My Lords, this group is all about training the professionals referred to in the Bill for the new world. I completely support the amendments from my noble friend Lady Barker and those of the noble Baroness, Lady Hollins. They fit well together. As a group of amendments they cover many training bases. Under the Bill, care home managers will be required to undertake assessments currently conducted by the responsible body, such as the local authority, the NHS or the CCG. While some care home managers and staff will possess a significant knowledge of procedures, the fact that they will now be required to carry out an assessment of whether somebody’s liberty is being lawfully deprived and is in the person’s best interests will require a much deeper level of qualification and understanding.
At present there are no fewer than six assessments for a DoLS application: age assessments, no refusals assessments, mental capacity assessments, mental health assessments, eligibility assessment and best interests assessments. For care home managers to be able to conduct these assessments to replace the DoLS scheme, they will need the appropriate qualification. In considering what is requisite to become best interests assessors, social workers must complete specific and complex training in addition to their university education. We wish to avoid the inadvertent authorisation of care and treatment arrangements that do not comply with the Mental Capacity Act, so training must include in-depth consideration of that Act and be of a depth that reflects the existing training of best interests assessors.
Other professional training has its roots in secondary legislation in the same way as outlined in the amendment, so we believe it is totally appropriate that training for care home managers in this regard should follow the same pattern. However the Bill ends up, training will be required. I would welcome an indication from the Minister about current plans for training individuals referred to in the Bill. I beg to move.
My Lords, I support Amendment 91, to which I have added my name. There is concern out in the field that care home managers will not be in a position to identify who will undertake the assessments under the Bill. It is not clear what training will be required for assessors. In his earlier comments, the Minister alluded to best interests assessors becoming the assessors under the Bill, but can he confirm exactly who will be undertaking the assessments? Only then can we be clear about what training they need.
The Minister also seemed to give the House an assurance that care home managers would not undertake pre-authorisation reviews. Again, could he confirm that and explain exactly who will undertake the pre-authorisation reviews? Again, the training of these people will depend absolutely on what their role is.
The 2008 regulations define who can undertake assessments. An assessor must be a qualified social worker, psychologist, nurse or occupational therapist. Also specified is precisely what training and testing the deprivation of liberty assessors have to undergo. Even though they are professionals and are required to have two years of experience in their profession, the deprivation of liberty training is also very precise. We need to know the extent to which the professionalism of the present system will be replicated.
The aim of the Bill is to streamline the process for authorising the deprivation of liberty. Any streamlining has to be thoroughly welcomed. I mentioned one idea of the British Association of Social Workers for streamlining. It has another interesting idea: that some streamlining could be achieved if the existing practice frameworks for care assessments and the Mental Capacity Act assessments were combined. The result would be that a trained professional undertook the deprivation of liberty assessments in the course of their other assessment work rather than having separate people. It would require revision of the codes of practice for the Mental Capacity Act and the Care Act, but it could be a useful way forward. Can the Minister explain whether this option has been considered? If not, would he be willing be to meet the British Association of Social Workers, and possibly me, to explore whether it has merit?
At present, we are clear neither about the roles of different people—assessors and pre-authorisation reviewers—nor about what their training might and should be. I would be grateful if the Minister could clarify some of these things.
I am grateful to my noble friend for her support for my Amendment 91, which calls for a comprehensive training strategy to be published to accompany the Act. The amendment comes about in part because little has been said of the training that those in the care sector will receive and on whether they will be resourced to undertake it.
The impact assessment estimates that care home managers will need only half a day’s “familiarisation” regarding the new regime. Given my own difficulties in understanding the Government’s intention despite spending considerably more than half a day reading and researching it and attending many briefings—many of this during recess—I doubt that half a day would be enough.
One reason for the implementation of the Mental Capacity Act being slow is that health and care professionals probably did not receive enough training effectively to embed the Act in practice. This Bill extends liberty protection arrangements to a much larger group of people, including those living in the community. My concerns in this group of amendments, as in previous groups today, focus on the needs of people with learning disabilities and their families, who make up the second largest group of people who will be affected by these changes—in care homes, in hospitals and in the community. Many of them may have been in receipt of such care for a long time, so we are talking not about a sudden referral for care but something which has been long established and where their current deprivation of liberty may be coming to attention now.
Despite this, the impact assessment does not put a figure on the number of people with learning disabilities who will be affected and thus the number of people in a rather wider range of settings who may need training—I may be wrong about this, but I could not see that.
Any training strategy must also consider ongoing training needs and how they will be resourced. We know that the sector is stretched to breaking point, so any additional, unfunded responsibilities will undoubtedly be keenly felt. The training will also need to address the current power imbalance where people with learning disabilities and family voices are often ignored. The fear is that training will be unable to change this culture and that the power imbalance could become worse when care home and hospital managers are able to choose whom they consult. So there is a real concern about the culture.
For this reason and others, my amendment recommends that vulnerable individuals and their families be included in developing and delivering the training. Having co-delivered training for health professionals together with people with learning disabilities and families, I know what a difference this makes in bringing pertinent issues to life for those being trained. If the wishes and feelings of cared-for people are to be at the heart of the system, they must be consulted and involved in the training. I would be grateful for the Minister’s comments on this and for explanations to noble Lords about how those responsible in the sector will be trained and the resources made available.
My Lords, I have two amendments in this group, Amendments 60 and 62, to which I shall speak briefly. To reiterate, the responsibility for this law lies and remains with the responsible bodies, and not with the care providers. If things go wrong, it is they who will end up in court. Consequently, and rather like the bodies under the Mental Health Act, they retain responsibility for ensuring enough sufficiently trained people are available to ensure that the law is applied properly.
Part of the reason for all noble Lords having such an interest in this issue is that we know from the review of the Mental Capacity Act that availability of trained staff is one of the biggest reasons why the Act failed to be properly implemented. Furthermore, we have statistics on the patchy nature of implementation by local authorities and some in the health service. Some authorities absolutely get this and implement it properly, but a lot just do not. It is an almost random distribution, which has a knock-on effect.
The other reason for noble Lords wanting to talk about these issues is the impact assessment. We have not really talked about the impact assessment for this Bill. The noble Baroness, Lady Murphy, used some particularly strong words, but she let them off very lightly, because I do not see how that impact assessment stacks up. Perhaps I may ask the Minister about one of the many assumptions made in the impact assessment. My understanding is that it assumes that training under this Bill will be needed for 10% of doctors and 10% of social workers. Can the Minister explain—if not now, then perhaps at a different juncture—that assumption and how it has come to be? I would be really surprised if the figure for social workers was 10%. Ten per cent for doctors is possible, but a figure of 10% for social workers needing to be trained under this Bill seems very low. My amendments were designed to enable us to have this sort of probing debate.
I support the comments made by the noble Baroness, Lady Hollins, on some of the training issues. Like many people here, I suspect, I have spent a great number of years training junior doctors in how to use mental health legislation, as well as social workers and occupational therapists. One of the most difficult things is to convey the culture of what we are trying to achieve in legislation of this kind. We all refer to the European court and the agreements, but what we are trying to achieve for individuals and why is difficult for many people to grasp when they have grown up in a very didactic, academic environment, where these things are not necessarily considered.
A key aspect of that cultural shift which is so required is the problems that arise between relatives, carers and professionals over what should happen to an individual. All the way through this Bill, I have been scratching my head and thinking, “Will this solve the Bournewood problem?” All the cases from Bournewood onwards have arisen because of a cavalier approach or attitude by professionals to discussing with relatives and carers what the individual wanted, needed or was used to. If we do not get those things right, we will not solve the problem and there will be another case because it will all be up again for grabs where the professional training has not been accurate.
I note that there are some very specific proposals about care home managers. There are some very specific difficulties about what training care home managers currently have, and it is absolutely basic and rudimentary. It is largely about keeping the accounts right. We need to find a way to get the culture of what we are trying to achieve for individuals and families into this Bill. Exploring those training options is crucial if we are to avoid another Bournewood.
My Lords, the noble Baroness, Lady Murphy, has made a very telling comment. Part of the issue of training is cost. It seems to me that part of this Bill is about cost shift from local authorities, which have found managing this process very difficult, to care homes. We have not discussed this very much, but will the Minister tell us who he expects to pay the cost of this whole process? I suspect that the answer is that it is going to be in charges, mainly for self-funders, who not only will probably pay the cost of their own assessment, but will probably—as they do at the moment—have to subsidise the cost of local authority-funded people who come under the provisions of the Act. Clearly, the Government did the RIA on the basis of trying to show that the cost will be minimal in order to prevent being rumbled on essentially what they are seeking to do, which is clearly to cost shift the public sector in favour of self-funders.
The RIA is simply non-believable, and puts into question quite a lot of the architecture of the Bill. We know that care home managers, as the noble Baroness, Lady Murphy, said, have rudimentary qualifications. We also know that the turnover for care home managers is quite high. Therefore, major new responsibilities are being given to people who are in a sector where they are often pretty poorly paid; they do not have much training, and they do not have professional qualifications in many cases.
Training is very important indeed, and we need to have some answers as to how this is actually going to happen and who is going to pay for it. If the answer is that it will mainly be paid for by self-funded, vulnerable people, I do not think that is right.
My Lords, I want to reflect on training and the cost of training. What is really interesting is where it is put on the balance sheet. If training is seen as a cost to an organisation, people will complain and feel that it is not necessarily money well spent. If training is seen as an investment, however, and is treated as such—certainly for local authorities—it would be a really good investment if it avoided court cases leading to very high legal bills. If training could be seen as an investment rather than a cost, while the problems will not go away, people might learn to think about things differently.
My Lords, unless training becomes mandatory on some level, the problem is that we will always train those who are willing to be trained while not reaching those who perhaps need to be trained more. If we could make training a little bit like fire training or manual handling, with very short bursts of realistic training, it might be much more effective. Over the years I have seen very costly, ineffective training and very low-cost extremely effective training. Often the most effective training includes a realistic assessment because assessment drives learning. I strongly support the comments made by my noble friend Lady Hollins because case-based training involving the people themselves has a huge emotional impact and therefore embeds change in the behaviours and attitudes to the person on the receiving end. On a slightly optimistic note, I am rather hoping that within Wales, we might manage to get an agreement that all doctors at every grade need at least a minimum awareness of the Mental Capacity Act and that we might then be able to build on that. I keep my fingers crossed.
The other point that we have to be careful of when we talk about training is that this is not about broadcasting information that might sound quite legalistic and frightening. One of the most important skills is listening, and listening skills have often failed in these cases, such as the ones referred to already in which the relatives were not listened to early on. They were not believed early on, the cared-for people were not adequately listened to and things spiralled down. Some of that lack of listening is just a result of poor communication skills training. I am not sure that we have to be overspecialised, but we need to raise the skills of everybody across the board. It needs to be embedded in revalidation—you might train somebody now, but in five years’ time there will be drift. The training, therefore—particularly if people are being trained to take on specific responsibilities—needs to be refreshed over time to ensure that it remains authentic.
My Lords, this has been a very useful and essential discussion about training. The noble Baroness, Lady Hollins, is quite right that there needs to be a strategy. I am concerned that there does not seem to be a strategy, so can the Minister tell us what consultation there has been about how this training—even the minimal familiarisation—would be achieved? Even the Minister accepts that that is clearly not going to be acceptable.
In terms of the stakeholders, the MHA—a charity providing care, accommodation and support for older people throughout the UK—heard from a care home manager in Hereford, who said, “As home managers without a mental health nursing background, it would be impossible to expect a home manager to undertake these assessments, as with the continuing health assessments, which we are deemed unable to complete as we are not healthcare professionals”. Well, quite.
Age UK says that at present there are no fewer than six assessments for a DoLS application. In order for care home managers to be able to conduct these assessments—or indeed be party to them, if only to act as secretaries, as outlined by the noble Baroness, Lady Finlay—they are going to need the requisite training.
The LGA point out that the Government should recognise the problems caused by these additional responsibilities and the financial pressures—as mentioned by my noble friend Lord Hunt—put on care homes by the provisions in the Bill, especially when the sector is already facing significant challenges in terms of both resources and workforce recruitment and retention.
Voiceability expressed its concerns about the new requirements on care home managers. It is concerned that this transfer of responsibility sets up potential conflicts of interest, which we have already discussed. Mencap says that there has to be significant consultation with the care sector about the implications of the new requirements on care home managers.
I am just wondering how we have got to this point in the Bill without that consultation having already taken place. We need to play catch-up because this is such an important area: not only are there funding implications, but we should not be expecting people who do not have appropriate skills to be carrying these responsibilities.
My Lords, I thank all noble Lords who have laid these amendments and contributed to this debate. The issue of training has obviously had a high profile in our discussions, from Second Reading onwards. I think we are all agreed that we can move to the system we want only if the people involved in delivering it have, in the previous words of the noble Baroness, Lady Thornton, the capacity and capability to do so. Again, I would like to deal with these amendments in groups and with other issues mentioned in the debate as they arise.
Amendments 60, 61 and 61A, tabled by the noble Baronesses, Lady Barker and Lady Finlay, would require local authorities to appoint a named officer responsible for the training, conduct and performance of approved mental capacity professionals and would give the Government regulation-making powers to prescribe the period of time within which an individual must be reapproved to continue to practise as one. The Bill is already clear that local authorities have the responsibility of approving individuals to become approved mental capacity professionals; subsequent regulations will make provision for training and eligibility for approval. Of course, this will build on the existing best interests assessor system that has been referred to, and which I believe is generally held in high regard.
The regulations will allow for a prescribed body to specify their training; in England, this is expected to be undertaken by Social Work England—the noble Baroness, Lady Meacher, raised a question on that. However, the local authority will clearly need to monitor the post-education training, conduct and performance of approved mental capacity professionals in order for such a professional’s approval to be continued. It is correct that we have not set out in the Bill how this should operate. The reason for that is to allow local authorities to decide for themselves how to organise and manage it, assisted, where relevant, by the code of practice.
With regard to the reapproval of AMCPs and in regard to Amendment 62, tabled by the noble Baroness, Lady Barker, we do not think it is necessary for the Government to give themselves this regulatory power to prescribe timeframes. Instead, it can be set out in the code of practice, which again is suitable for something as specific as this.
Many noble Lords, led on their amendments by the noble Baronesses, Lady Hollins and Lady Jolly, highlighted that, as we know, a huge amount of work will be required in the health and social care sector to implement the new system. Amendment 91, tabled by the noble Baroness, Lady Hollins, would require the Government to publish a training strategy. This does not in my view need to be set out in the Bill, but I can give a commitment this evening that a training strategy will be published within six months of the Bill’s passing.
Amendment 90, tabled by the noble Baroness, Lady Jolly, would give the Government regulation-making powers to prescribe the body responsible for training care home staff. Clearly, we will need to have and are committed to providing the necessary training to care home managers for their new role. That will include developing a range of training materials, co-produced of course with the sector, and other support for a range of roles in the workforce. We will be providing our statutory code of practice and other guidance to do that. We are already working with the Association of Directors of Adult Social Services to help shape this work. We are also beginning to explore a comprehensive programme of work on supporting this model by working with Health Education England, Skills for Care, the Social Care Institute for Excellence, the royal colleges and others. It is clearly important that we work with all providers to ensure that we have the right training strategy and deliver it through training providers endorsed by Skills for Care, which is the Health Education England-like body for social care, as noble Lords know.
We of course recognise that there is a cost to the sector. The noble Lord, Lord Hunt, and the noble Baroness, Lady Hollins, asked about the half a day’s training. We clearly recognise that more training than that is required. The noble Baroness, Lady Barker, asked about some of our assumptions on the 10% and I will come to her with more detail on the reasoning for that. In a regulatory impact assessment, it is always the case that you produce a version of what you think might happen. The reality will no doubt be somewhat different, but we recognise that there will be a cost for the sector to prepare to implement this new system, once it comes into being.
We are therefore considering what is called a workforce development model to ensure that that training is of high quality. This would allow us to provide financial help to providers to assist with training and events. The fund is flexible and would enable employers to support their staff, not least in providing backfill for them while they undertake training. It could also be used to pay for an instructor to conduct the training. I know that there is a desire to understand more not just about training but about how we will fund it. I can reassure noble Lords that there will of course be a comprehensive and properly resourced training programme in place.
I do not believe that regulation-making powers or details are required in the Bill, but I also recognise that the proof of the pudding is in the eating. As we have discussed since Second Reading, noble Lords will want to see much more detail about our intentions in this regard. What I can say is that I will do everything I can to facilitate that development, so that there can be the right degree of confidence that the training programme and its funding will be forthcoming to support the implementation of the new system.
Noble Lords raised a few other issues in the discussion. The noble Baroness, Lady Meacher, said that we need greater clarity on the roles of various people. I think we covered that in our earlier discussion of care home managers. The noble Baroness, Lady Hollins, made an excellent point about making sure that training includes the skills to work with working-age adults with learning difficulties. Using those people and their families to co-produce training is also an absolutely excellent idea, which I would like to take up with her.
Perhaps I may deal with two other issues. First, the noble Baroness, Lady Murphy, talked about cultural change. Training can help but of course it does not deliver a cultural change. We have to think carefully as we go forward about the other levers that exist to any Government to provide that cultural change that go beyond the standard ways of doing things. I would be interested in pursuing that discussion with noble Lords outside the Chamber.
Secondly, the noble Lord, Lord Hunt, asked about cost shift. There will clearly be a redistribution of responsibility, but the intention of these changes is that they should deliver a system that not only delivers justice to people who are currently denied it but does so in an affordable way, moving funding away from duplication and complexity towards greater caring. The intention of the Bill is not to rob Peter to pay Paul, as it were, but to ensure that there is a properly resourced and deliverable system and that its different parts are trained and capable and have the capacity to deliver the responsibilities that we are asking them to fulfil.
On that basis, I again thank noble Lords for a very useful discussion. There is clearly more detail that we can and will want to provide as the Bill progresses. I hope that noble Lords will feel content not to press their amendments.
Amendment 26 withdrawn.
Amendments 27 to 30D not moved.
House resumed. Committee to begin again not before 8.25 pm.