Care Bill [Lords]
The Committee consisted of the following Members:
Fergus Reid, Committee Clerk
† attended the Committee
The Chair: Good morning, colleagues, ladies and gentlemen. I am delighted to have been selected as one of the two Chairs for this Committee. I am sure that we will have some very interesting debates in the days ahead.
Before we begin, I have a few preliminary announcements. I have already been asked by Members whether it is possible for them to remove their jackets. The answer to that question when I was asked privately was yes, so, if others wish to do so, they may. I have been asked about the temperature of the room, which we are trying to turn down a notch or two.
On behalf of the Panel of Chairs, I need to remind you that they have recently reinforced their rule about no refreshments other than the water provided being allowed in the Committee Room. I ask Members to observe that rule. It is embarrassing for all concerned to be called up for such a thing by the Chair.
Please ensure, at this and subsequent sittings of the Committee, that electronic devices are turned off or at least switched to silent mode. I remind Members that I and my fellow Chair, Andrew Rosindell, do not intend to call starred amendments that have not been tabled with adequate notice. The required notice period in Public Bill Committees is three working days, which means that amendments should be tabled by the rise of the House on Monday for consideration in the Thursday sittings of that week and by the rise of the House on Thursday for consideration on the following Tuesday.
I know that most—perhaps all—Members here are familiar with the procedure in Committee, but I remind you that we begin with the line-by-line consideration of the Bill after a few preliminaries: the sittings motion and so on, which we will come to in a moment. We debate amendments not in the order in which they are tabled, or, indeed, the order in which they appear on the amendment paper, but the order in which they seek to amend the Bill on a line-by-line basis. When we come to votes, we vote at the appropriate point, so occasionally when you have a lead amendment and some related subsidiary amendments, those subsidiary amendments can come later in the Bill. If any Member or Minister wants to press for a vote on such amendments, that vote may come in a slightly disjointed fashion later in the day.
There is some logic to the procedure. If anybody is lost at any stage, I would simply say: come and talk to me or the Clerk. We are very approachable, and we will try to run the proceedings in a way that enables every Member to make the political points of substance they wish to make on the matters in the Bill and the amendments.
The selection list for today’s sittings is available in the room. This shows how amendments have been selected for debate and how they have been grouped. We group amendments on similar topics or themes so that we debate once, but only once, each of the major themes or issues under consideration in the legislation. The Member—or a Member—who has their name on the leading amendment in the group will be called to speak first, to move that amendment. Then, if there are other amendments in the group in the names of other Members, I would normally go to those other Members to speak subsequently. Then, other Members on both sides are free to catch my eye.
A Member may, of course, speak more than once in a particular debate on a group of amendments. They will get called up for doing so only if they are repetitive. But if they wish to pursue further matters, they are at liberty to do so; for instance, they can respond to questions that other Members have raised in their speeches.
At the end of the debate on a group of amendments, I will call the Member who moved the leading amendment again and, before they sit down, they will need to indicate whether they wish to withdraw the amendment or press it to a vote. If a Member wishes to press any amendment other than the lead amendment in a group to a vote, they also need to notify the Chair. That is normally done in the course of one of their speeches to the Committee on that particular group, but they can do it in a note if they wish. I will make a note that when we come to the appropriate point, possibly later in the proceedings, I will call a Division on that particular issue.
It is at the discretion of the Chair to decide whether to have a stand part debate on a particular clause. I—and I am sure Andrew Rosindell will do the same—will assess whether we have exhausted all the possible reasonable issues for debate under a clause. For instance, if there has been a debate on a narrow amendment to a broader clause, it would be reasonable to permit a stand part debate. Normally, if there are no amendments to a clause, one would allow a stand part debate if a Member wishes to have one.
I hope that those explanations are helpful. As I have said, the purpose of the Chair is to be helpful to Members. If at any point you are confused or want to know how you go about raising an issue, you are of course free to seek guidance from the floor, but also to pop up here and speak informally to me or the Clerk.
(1) the Committee shall (in addition to its first meeting at 11.30 am on Thursday 9 January) meet—
(a) at 2.00 pm on Thursday 9 January;
(b) at 8.55 am and 2.00 pm on Tuesday 14 January;
(c) at 11.30 am and 2.00 pm on Thursday 16 January;
(d) at 8.55 am and 2.00 pm on Tuesday 21 January;
(e) at 11.30 am and 2.00 pm on Thursday 23 January;
(f) at 8.55 am and 2.00 pm on Tuesday 28 January;
(g) at 11.30 am and 2.00 pm on Thursday 30 January;
(h) at 8.55 am on Tuesday 4 February;
(2) the proceedings shall be taken in the following order: Clauses 1 to 39; Schedule 1; Clauses 40 to 43; Schedule 2; Clauses 44 to 73; Schedule 3; Clause 74; Schedule 4; Clauses 75 to 94; Schedule 5; Clauses 95 to 102; Schedule 6; Clauses 103 to 107; Schedule 7; Clauses 108 to 111; Schedule 8; Clauses 112 to 125; new Clauses; new Schedules; remaining proceedings on the Bill.
(3) the proceedings shall (so far as not previously concluded) be brought to a conclusion at 11.25 am on Tuesday 4 February. —( Norman Lamb. )
The Chair: Before I ask the Minister to move the motion to report written evidence, I should explain to Members that, because this is a Lords Bill, we are not starting with oral evidence sessions. We are expected to make use of the records of the oral evidence sessions that took place in the Lords. However, it is possible for public bodies to submit written evidence for consideration in the Commons’ proceedings—indeed some have done so. The purpose of this motion is for the Minister to get the Committee’s agreement that such evidence will be published.
‘and any health service body when exercising any function jointly with one or more local authorities’.
‘and any health service body when exercising any function jointly with one or more local authorities’.
‘(5) “Health service body” has the same meaning as in section 9(4) of the National Health Service Act 2006.’.
‘(3A) NHS bodies shall co-operate with local authorities to support their activities under subsections (1) and (2), in particular to—
(a) promote and safeguard the health and well-being of carers;
(b) establish effective procedures to identify patients who are or are about to become carers; and
(c) ensure that carers receive appropriate information and advice.
(3B) Reference to an NHS body in a local authority’s area is a reference to—
(a) the National Health Service Commissioning Board, so far as its functions are exercisable in relation to the authority’s area;
(b) a clinical commissioning group the whole or part of whose area is in the authority’s area; or
(c) an NHS trust or NHS foundation trust which provides services in the authority’s area.’.
‘(d) the importance of working with health bodies in carrying out the function in subsection (c).’.
‘(1A) NHS bodies must exercise their functions with a view to ensuring the integration of services for the purposes of enhancing the health and wellbeing of people, in keeping with the duty on Health and Wellbeing Boards enshrined in section 195 of the Health and Social Care Act 2012.’.
‘(1) In exercising their functions health bodies shall—
(a) promote and safeguard the health and well-being of carers;
(b) ensure that effective procedures exist to identify patients who are or are about to become carers;
(c) ensure that appropriate systems exist to ensure that carers receive appropriate information and advice; and
(d) ensure the systems are in place to ensure that the relevant general medical services are rendered to their patients who are carers.’.
Paul Burstow: It is a pleasure to serve under your chairmanship, Mr Bayley. I look forward to the Committee’s deliberations over the coming weeks. I will explain the thinking behind my amendments, ask the Minister some questions, and see where that gets us.
Personally, I have been on a rather curious journey with the Bill. I started as a Back-Bench Member of Parliament, raising this very set of issues for a number of years. In May 2010, I was invited to become the Minister, and then took a number of the decisions that led to the draft Bill, which was published in 2012.
After leaving the Department, I was invited to consider putting my name forward to chair the Joint Committee that considered the draft Bill that I played a part in framing. That may sound a rather curious situation—to have worn one hat and then placed another on my head—but I want to reassure members of the Committee. I hope that those who served with me on the Joint Committee felt that I took a clear view that, when chairing the scrutiny Committee, my task was a different one, and that I had the opportunity to look afresh at the issues. That was a refreshing thing to be able to do. This Committee is a similar opportunity to look at this landmark legislation afresh and ensure that it hits the mark of the improvements that all members of the Committee want to see, from the point of view of our constituents.
The amendments are to clause 1, which for the first time places the idea of a person’s well-being at the heart of the social care system in England. It is about their value as individuals, the meaning of their lives, the contribution they make to society and their ability to participate. It is about their right to have a normal life, not one defined by four walls within which people deliver services to them. The clause governs all the decisions in part 1 of the Bill. I am delighted that the Bill, after having been amended in the Lords, does not apply only to local authorities; as a result of the Joint Committee’s recommendation, the Secretary of State will have to have regard to the duty in clause 1 when examining the power.
My amendments are in two parts. The first part pertains to whether the well-being duty should apply to the NHS, and if so, in what circumstances—other amendments also explore that issue. The second part is more specific, and seeks to place on the NHS a duty equivalent to the one that the Bill will place on local authorities. Amendment 29 pertains to the identification of carers.
The College of Social Work identified clause 1 as the most radical innovation in the Bill. However, it is not the only radical innovation; the Bill will also ensure that for the first time there is parity of esteem for carers in legislation. That is an important, radical shift in the way in which the system works. If the Government’s ambition is to have a more joined-up health and care system—I commend what the Minister has been doing to bring forward the pioneers, establish the better care fund and so on—we need to be clear about what its purpose is. It must surely be to promote individuals’ well-being and to ensure that we do everything we can to prevent them losing their social function. We should postpone or delay the loss of their social function and do everything we can to maintain and restore their ability to lead a normal life. In other words, we should ensure that they maintain their independence. That is what the clause is all about. In making the NHS subject to the well-being duty, we would move the NHS’s focus—at least in terms of its relationship with social care—from an individual’s body parts to their well-being.
The second amendment seeks to ensure that the NHS works with local councils to identify carers. Quite simply, carers are the glue that binds the system together. They are the system integrators, but all too often they are put upon and not supported enough. They do not fit in a simple box—certainly not a care and support box—and they need support from the health service. They are critical partners in the recovery, care and treatment of the person for whom they are caring.
There is much good practice—hon. Member have seen the briefings on examples of good practice—but it is patchy. There is good guidance. The Royal College of General Practitioners has great guidance on its website. But the problem is that it is not consistently applied. I know of good examples, such as in Cambridgeshire, where GPs prescribe carers’ breaks. However, that is the exception, not the norm. That has been a long-running issue for Opposition and Government Members. I pay tribute to the hon. Member for Worsley and Eccles South (Barbara Keeley), who has been campaigning on this issue for a number of years.
Governments have lots of different measures to try to get the NHS to engage fully with the carers’ agenda and identification. The previous Government announced funding and put things in the operating framework for the NHS, but it did not get traction and it did not deliver the change that they and we want. We have done the same. I commend the Minister for the new conditions that have been placed on the better care fund to try to get carer identification and carers’ issues front and centre with health and wellbeing boards and across health and social care.
The Bill places on local authorities a matching duty on integration. There are already duties in the Health and Social Care Act 2012 on all the relevant health bodies and health and wellbeing boards. It therefore seems curious that when we place a duty on local authorities to identify carers, as we do in the Bill, we do not seek to provide a matching obligation on the NHS bodies that will be critical in many cases to achieving that end.
Macmillan Cancer has done a very good job of identifying for us the plight of cancer carers. There are more than 900,000 of them, of whom about a half do not receive support at the moment and many of whose lives could be changed—indeed they could stay in work, which is a key objective here—if they were given the right support at the right time.
In conclusion, I want to ask one more question, which is about how the NHS’s obligations under the well-being principle of the legislation will be understood. There is a reference in clause 1 to beliefs. I asked the Minister on Second Reading about that and he helpfully sent a letter to all participants in the debate confirming something that Earl Howe had said in the other place. The letter stated:
“As Earl Howe confirmed during the debate on this point in the House of Lords, having regard to someone's beliefs includes their spiritual beliefs, for example, ensuring access to an appropriate figure of religious authority during palliative care. Guidance will be absolutely clear on this point and I hope this clarifies things.”
The Minister of State, Department of Health (Norman Lamb): I am grateful to my right hon. Friend for giving way. It is a pleasure, incidentally, to serve under your chairmanship, Mr Bayley. I am happy to confirm that palliative care is given as an example, but the principle of course applies more broadly. I am happy to reassure my right hon. Friend on that point.
Mr Jamie Reed (Copeland) (Lab): In addition to addressing amendments 26, 27, 28 and 29, I wish to speak to amendments 67 and 70 tabled by my hon. Friend the Member for Leicester West and me. With your permission, Chair, I will also speak to new clause 9.
Before beginning, I want to remind all Members here today that the work we are tasked with in this Committee is fundamentally important. I have no doubt that each of us desires to make real and significant improvements to the care system in our country. Away from our respective party allegiances, we know that, for the benefit of everyone who urgently needs to experience an improved system, our deeds have to match our words. It is absolutely essential that the Committee takes the time to make sure that the Bill becomes more than just another exercise in parliamentary gamesmanship.
The scale of the social care challenge is so daunting that our intentions, as expressed in the Bill, must be unambiguous. Our words must be precise and, more than anything else, the Bill must achieve what the Government state they want it to achieve. I look forward
The Minister knows that I hold him in some regard—indeed both Ministers—and I will endeavour to be consensual wherever I can. Indeed, that is the general approach of all of us who represent Her Majesty’s loyal Opposition in this Committee. It is absolutely clear to us that the Bill has been improved to some degree during its passage through the Lords, but further significant improvements are needed if the Bill is to be truly able to meet the challenge of the social care crisis that we all see throughout our country.
In turning to amendments 26 to 29, I pay tribute to the right hon. Member for Sutton and Cheam for the work he has done on the Bill at various stages over a good deal of time from both the Front and Back Benches. I also pay tribute to the hon. Member for Totnes for her role in tabling one of the amendments.
Part 1 of the Bill builds on the work done by the Law Commission, which was commissioned by the Labour Government in 2008. It sets out the legal framework for the provision of adult social care in England. Clauses 1 to 7 seek to establish the general responsibilities of local authorities with regard to a broader care and support role in the communities that they serve, and the services provided within them, with an emphasis on reducing need.
Clause 1 on the promotion of individual well-being makes provision for a set of legal principles that will govern how local authorities should undertake their care and support functions for adults under the Bill. This is something we support in principle and accordingly we have a significant degree of sympathy with amendments 26 to 29. To some degree they replicate the intentions of our amendments.
Integration is more than a buzz word. In reality, it is a difficult practice to implement. None the less we know it is absolutely essential if we are to create anything like the social care system that we know we need to create in our country. Amendments 26 and 27 seek to extend the duty to promote individual well-being, dignity, protection from abuse and neglect, the ability to participate in work, education, recreation and more to NHS bodies when they are working jointly with local authorities. The Bill as it stands seeks to apply this duty only to local authorities.
Integration is a two-way street. It is by its very nature a reciprocal practice. Given that by virtue of their financial strength NHS bodies will generally tend to be the dominant entity in any partnership with local authorities or any other partners, it is absolutely necessary that the duty to promote individual well-being should be placed on any health service body when exercising any function jointly with one or more local authorities. I would go further and say that this is an essential element with regard to making the portability of individual care packages truly workable in the future, an issue we will no doubt discuss in detail at a later point. These are essentially clarifying amendments that help to tidy up the Bill, which we support.
I turn now to amendment 67. I am grateful to Macmillan for their assistance in the drafting of this amendment and for all the work they have done on the Bill to date. It
Amendment 67 seeks to establish that equal participation between local authorities, NHS bodies and others in identifying carers. Macmillan point out that carers of people with diseases like cancer come into contact mostly with health care professionals, not social care professionals, something most of us recognise to be true from our constituencies and the experiences of our constituents, friends or families. This means that the identification of carers and of carers’ needs is not properly identified or understood in a timely way. It is estimated that only 5% of all cancer carers receive a carer’s assessment. Let us be clear what this actually means: we are looking at a failure rate of 95% in the identification of cancer carers and amendment 67 seeks to address that.
Just as amendment 67 puts a duty on local authorities to co-operate with the NHS in their efforts to identify carers, new clause 9 would ensure that health professionals would recognise when a patient was a carer and take their needs as a carer into account when treating them. The Bill is a crucial opportunity to improve the lives of carers. The Opposition welcome the Government’s moves on rights for carers, continuing the work that we began. But if we do not know who the carers are, if we do not know where these carers are we will not be able to provide them with the help and support that they need. The previous Labour Government introduced financial incentives for GP surgeries through the quality and outcomes framework to identify carers and to refer them for support. But, as with much else, the unfortunate hiatus of the 2010 general election meant that we could not continue with this work.
We need explicit duties on health bodies to identify carers, so that this is built into everything they do, not least because, although there are 6.5 million carers in the UK, many of them do not think of themselves as carers; they think of themselves as husbands, wives, parents, children or simply neighbours. Therefore, in practice, these people do not know what their rights are, including their rights to assessment and support, so they are not aware of how to improve life, not just for the person they care for but for themselves.
This is not a remote possibility; in fact, examples of good practice already exist. For example, in Torbay, if an individual suffers a stroke and enters hospital with a
Macmillan has calculated that, of the 905,000 carers of people with cancer in England—almost 1 million people—95% do not receive a carer’s assessment. These people save health and care services—and through them, us, as taxpayers—nearly £12 billion a year, yet half of them receive no support whatever. Macmillan has also identified why carers of people with cancer are not receiving support. Often, as I have mentioned, they do not consider themselves to be carers, so they do not know what their rights are. Only one in three carers of people with cancer has heard of the carer’s assessment, and only one in 20 has actually had one. That figure is estimated to be lower than for all carers looking after people with all other conditions and disabilities.
Of the people who have had assessments, most will have been referred by their GPs, but health professionals identify only 11% of carers, and GPs identify only 7%. If we pause to consider the difficulties surrounding general practice right now for patient and practitioner, it is safe to assume that this unidentified and unmet demand is growing. Macmillan cites Chantal Simon of the Royal College of General Practitioners, who says that, although
“Clinical commissioning groups already work with local authorities through health and well-being boards to understand and plan for identifying and supporting carers. Many clinical commissioning groups already have, or are developing, joint carer strategies.”—[Official Report, House of Lords, 3 July 2013; Vol. 746, c. 1308.]
Bill Esterson (Sefton Central) (Lab): My hon. Friend is making a good case for identifying carers, and he has given some good practical examples. May I raise the issue of young carers, who are often reluctant to come forward and admit that they have caring responsibilities? Does my hon. Friend have any thoughts on how such young people might be identified and supported in the context of the amendments and the new clause?
Mr Reed: Our proposals seek to meet the need that my hon. Friend identifies. He is absolutely right that young carers are even more vulnerable when it comes to accessing the support and advice available to them, for a variety of reasons, including maturity in life, interfaces with social care services, other obligations, such as attending school, and issues that go along with adolescence. My hon. Friend makes an important point, and our proposals seek to address the issue that he raises, as well as the needs of older carers.
From our local experience, we know that strategies such as those outlined by Earl Howe simply are not reaching health bodies, which, again, underlines the need for an explicit duty. New clause 9 would help the Government to fulfil their stated ambitions with regard to the Bill. They have stated that they seek to create a system in which everyone who needs support gets it. To do that, they must remove ambiguities regarding the bodies that we expect to improve the care system, fill the obvious gaps in support and require local authorities to work with health bodies to identify carers. New clause 9 represents a simple but important change, and it could yield a significant improvement.
Amendment 70 would extend the duty to promote integration, consistent with amendments 26, 27 and 67 and new clause 9. In the Bill, only local authorities are given a duty to promote integration between health and care services. Amendment 69, which we will discuss under a later clause, would give similar duties to all housing providers, and amendment 70 would extend the duty to integrate services to NHS bodies. I hope that we can build consensus on the amendments.
Amendment 70 should be clearly understood. Any casual outside observer listening to Members on both sides of the House talking about the establishment of an integrated health and social care system over recent months, if not years, could be forgiven for assuming that we would take the necessary steps in legislation to achieve that integration. Clause 1 seeks to achieve integration up to a certain point, and we welcome that, but it is lacking with regard to bringing about the implementation, culture, standards and practices of integration among all the bodies involved in tending to an individual’s care needs. Amendment 70 seeks to address that.
The Association of Directors of Adult Social Services and the Local Government Association both consider it necessary for the Bill to include a specific duty on NHS bodies, equivalent to the duty placed on local authorities, to integrate services and for that shared involvement to be enshrined in the Bill. That relates both to the precise meaning and effective practice of integration that I explored earlier.
To repeat, integration is a reciprocal practice based on equal participation. If equal participation means anything, it means equal duties and equal responsibilities. 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 health inequalities reduced.
ADASS considers local health and wellbeing boards as the pivotal delivery model in that regard. The Bill must reflect that if it is to bring about the wholly integrated and accountable system capable of identifying and meeting local needs.
Given that one of the stated purposes of the Bill is to create a more streamlined, clearer care system, the removal of ambiguities and the insertion of explicit duties, responsibilities and accountabilities within the system should be welcomed. For that reason, amendment 70 seeks to go further than the clause otherwise would. There is a logical and obvious need within the Bill for a much clearer duty of co-operation on NHS bodies.
“This Bill places major responsibilities on local authorities. Without the full co-operation of the National Health Service they will be very hard pressed to discharge those responsibilities.”—[Official Report, House of Lords, 9 October 2013; Vol. 748, c. 100.]
That seems incontestable to me. If we truly want an integrated, more effective care system, better able to meet the needs of the people who both pay for and rely on it, the Bill must include a specific duty on NHS bodies equivalent to the duty placed on local authorities to integrate services.
Grahame M. Morris (Easington) (Lab): It is a pleasure to serve under your chairmanship, Mr Bayley, on a Bill Committee for the first time. I hope to rely on your guidance on these issues. I am grateful to have the opportunity to speak on the clause. I was reflecting on the work that has been done over a long period of years, both by the previous Government and in consultations through the Health Committee and the Joint Committee on the Draft Care and Support Bill. I was rather disappointed on Second Reading when much of the debate turned to acrimony, when there is so much agreement over part 1, at least in respect of the framework, the power of well-being and the need to improve the service.
I have often been at loggerheads with the right hon. Member for Sutton and Cheam, but I find myself agreeing with virtually everything that he said, at least in relation to these clauses. That is a pleasant change. There is certainly disagreement on the care cap and other contentious areas about whether the necessary funding will be in place, the eligibility criterion for the threshold and so on. However, at least with regard to the initial clauses in part 1—in particular, amendment 29 to clause 2—I am pleased to rise in their support.
I want to say a few words on specific issues regarding improving identification and signposting and support information for carers. I also want to make further reference to carers of people with cancer. There is clearly a need to go a bit further in the Bill to improve the identification and support for carers, by strengthening the responsibilities of health bodies to promote the well-being of carers and signpost them more effectively.
We have had numerous discussions, and I thank the Minister for being such an active participant. I served on the Joint Committee on the Draft Care and Support Bill. I would recommend that Members read that report, HC 822. I pay tribute to my noble Friends, Baroness Pitkeathley and Lord Warner, and to my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley), who has also done a great deal of work on carers in promoting her private Member’s Bill. They all served on that Committee.
One of the Joint Committee’s recommendations was for not only local authorities but NHS professionals and other organisations to be involved in identifying and signposting carers. This is important: GPs, nurses, hospital staff and district nurses all have a role to play in ensuring that carers are looking after their own health and well-being and in being informed about and involved in the care of the person that the carer is looking after. The hon. Member for Totnes—I almost said my hon. Friend, which is kind of true—with whom
There are a number of practical examples. GPs should ensure that their register of carers is up to date and use their contact with identified carers as an opportunity to signpost them to any additional support that is available, particularly in terms of assessments and support from organisations such as local voluntary groups. Members in all parts of the Committee should have a carers trust in their area; certainly in east Durham we have an active one, which provides tremendous support, information and advice to carers in my constituency.
I have a question to pose to the Minister. It was mentioned yesterday, as part of the follow-up from the Joint Committee. Is there any practical reason why a statutory duty could not be placed on GPs to take on such a responsibility? Perhaps he might respond in his closing remarks on the clause. If there is no practical reason why that could not be done, a stronger duty might help to improve co-ordination and integration. In all parts of the House—not only among Opposition Members in Committee or in the Health Committee, where we support integration and have actively promoted it—there is a move towards collaboration and better integration.
The Labour party believes that we should integrate health, social care and mental health services, not only because that would improve outcomes, putting the patient at the centre of this network of care, but because it is more cost-effective and helps to reduce health inequalities. I am not saying that purely on the basis of political dogma; there is evidence to back it up. I am grateful to a variety of organisations that have circulated the evidence to myself and other Committee members.
According to Carers UK, 2 million people start caring every year for relatives. That is a substantial and growing number. The organisation also found that a third of those caring for 35 hours or more each week receive no practical support with the caring, as my hon. Friend the Member for Copeland has indicated. Health services are not supporting carers at the moment. Evidence from Carers UK research also found that two thirds of carers said that, although their GPs knew that they had caring responsibilities, they were not offered any extra help as a result. Clearly, that is not acceptable. Indeed, Macmillan research suggests that there are almost 1 million —900,000—cancer carers in England, half of whom are not receiving any support, despite the caring having a substantial impact on their lives.
Placing a statutory duty on the NHS instead of leaving the onus on local authorities could substantially improve the take-up of services by carers. Research by Carers Trust into the support needed by the carers of people with dementia found that just over half had not received information about managing the medication for those they care for. That is really important. Carers UK found that less than half of carers believe that health professionals included or consulted with them about the person they care for.
Why is that important? Carers have poor health outcomes and we are concerned about health inequalities. They are twice as likely as the non-carer population to be in bad health. The research by Carers UK showed
We owe a huge debt of gratitude to carers, who provide unpaid care for relatives and friends. It is estimated that they contribute £119 billion to the UK economy, which is the cost of the care and support that they provide. A veritable army of carers—1.3 million—spend more than 50 hours a week caring for others. It is larger than the total NHS work force. Carers cannot continue to provide that care without financial and practical support, but that will continue without pressure and demand for health and social care.
Such an intervention would have a cost benefit. Part of the Bill’s thrust involves preventive measures. Baroness Pitkeathley was nervous about the word “preventive” and thought it inappropriate. Perhaps early intervention to provide support would mitigate the risk of people suffering more serious ill health and, in turn, placing a greater demand and greater expense on health and social care services.
GP practices provide gatekeeper services and are perhaps one of the few service providers with whom a carer has contact. Carers may come into contact with health and social care services because caring crosses the boundary between health and social care, but carers are often caught between different services and professionals, particularly at critical transition moments such as discharge from or admittance to hospital. They often do not want to access services because of the needs of the person they are caring for. Some may actively avoid social care because of stigma or some sort of negative experience. There are various reasons why carers may not want to access social care support, but one of them should not be that they do not know what is available or that they have not been given the opportunity to find out. The issue is important.
The right hon. Member for Sutton and Cheam identified some good examples, which I do not propose to go over, of pilots throughout the country—for example, in Cambridgeshire and in Kensington and Chelsea—of GPs’ work. They are to be commended, but there is a great deal of work to be done. There are also some good examples in Scotland and Wales. I know that the NHS in Wales is much maligned by Government Members, but it has done some excellent work in identifying carers. The Carers Strategies (Wales) Measure 2010 has been an important initiative for carers in Wales, acting as a valuable catalyst and initiating some constructive work across the Wales. I know that the NHS in Wales has a different structure, with local health boards, similar to those in Scotland, but it is worth looking at such examples and seeing what can be learned about best practice.
The Chair: I did not want to interrupt an hon. Member on the first lap on the first day, but I would remind all members of the Committee that, although we are discussing an amendment that seeks to place into clause 1 a duty on health bodies to take an interest in the needs of carers, we will have a substantive debate about support for carers under clause 10, and about carer support plans under clause 25. I would therefore ask Members to concentrate their remarks on why we should insert into clause 1 a duty on health bodies to take an interest in carers.
Sarah Newton (Truro and Falmouth) (Con): It is a great pleasure to serve under your chairmanship, Mr Bayley. Colleagues will be pleased to know that I want to speak briefly so that others have the opportunity to join the debate on these important amendments.
I support and have put my name to the amendments proposed by my right hon. Friend the Member for Sutton and Cheam. He made the case for them extremely well, and I do not want to duplicate his remarks in any away. I am grateful for the information provided to us by Carers UK, Macmillan Cancer Support and others, which has enabled us to have a better understanding of the extent of unmet care for carers, which continues despite huge amounts of effort by many Members of Parliament over many years to highlight the fantastic work that carers do and the contribution that they make to our society, and despite a series of measures designed to enable carers to be aware of and access the support that is available. We clearly have plenty more work to do.
In the light of all the very real concerns that have been highlighted by people who have given evidence on the Bill and by Members who have spoken today, what reassurance can the Minister give us that, under this Bill and in the other legislation the Government have introduced, most importantly the Health and Social Care Act 2012, the needs of carers will be better identified and met?
Meg Munn (Sheffield, Heeley) (Lab/Co-op): I wish to make two points in support of the amendments. My first is about integration. I fully support what the right hon. Member for Sutton and Cheam said about the importance of the health service looking at people in a different way. I am not saying that that does not happen now, but when we are discussing clause 1, which sets out the fundamentals of how we see the social care process in future, it is vital that we are clear that there should be an holistic approach. In supporting people with their social care and health needs, integration works best if the duty to achieve the same processes is reflected in each area of care. Although there is a great deal of good will among many good practitioners on the ground, I know from my experience working in the sector, albeit many years ago, that without the backing of the duties in legislation, when the pressure is on, authorities revert to what they must do by law. That is why the issues raised by the amendments are important.
The second area I wish to talk about is new clause 9, which deals with health needs and the identification of support for carers being fundamental to the process. I absolutely understand why organisations such as Carers
On 1 April 1993, I was faced with managing the implementation of the National Health Service and Community Care Act 1990, and local authorities suddenly got a lot of money for their work, but we did not have the services to help people in the community. Over the first period, until we developed those services, we looked into every situation where we had ended up having to place an elderly person in an residential or nursing home—sometimes not because they wanted it, but because there was no alternative. Without exception, every situation arose due to “carer breakdown”—not a nice term, but it tells us what we need to know: for various reasons, the carer could no longer care. Most people want to stay at home and most people can stay at home, but they need to be supported at home. Identifying the needs of carers is vital.
My good and much lamented friend Malcolm Wicks introduced the private Member’s Bill that became the Carers (Recognition and Services) Act 1995, when I was still working in the sector—so it was a long time ago. That legislation was groundbreaking, but it has never been properly implemented, as my hon. Friend the Member for Copeland identified. One problem is that carers identification and support always comes at the end. When I have constituency a case where there is a problem and I ask the constituent—the carer—whether they have had a carer’s assessment, they say no. When I say to the local authority, “Why hasn’t this person been given a carer’s assessment, I am told, “Most people don’t want one.” The reason they do not want one is because they have probably sat for two hours doing a tick-box assessment about the person they are caring for and they have had enough by the time they are asked, “Would you like a carer’s assessment?” They say, “No, just give me some help and support.” That is what they want. The assessment is not being done properly. It needs to be done better, not just because it would save money or deliver better care, but because it is the right thing to do. We should all support putting it front and centre at the beginning, which is why I support the amendments.
Dr Sarah Wollaston (Totnes) (Con): It is a pleasure to serve under your chairmanship, Mr Bayley. I rise to speak to amendment 29 tabled in the name of my right hon. Friend the Member for Sutton and Cheam. I associate myself entirely with the comments of the hon. Member for Easington. I do not intend to repeat the comments made by the hon. Member for Sheffield, Heeley. I entirely agree with the points about the importance of doing carer’s assessments better and them not just being tick-box assessments.
I would like to speak from my experience about why identifying carers, for the reasons set out, is unlikely to happen unless we put a duty on the health service to be involved in doing it. That is because it is primary care teams that are the most likely people to be in contact with these groups, and unless we include them within the Bill and mandate this duty—perhaps the Minister intends to include it in the NHS mandate—progress will continue to be patchy.
As the hon. Member for Copeland pointed out, we have examples of extremely good practice in Torbay, but unfortunately we will continue to see piecemeal advances. In the areas where health professionals are perhaps most under pressure, and primary care teams are working under huge pressure at the moment, something that is not an obligation will, unfortunately, tend to shuffle to the back of the pack and might be missed. That would be a huge opportunity missed.
That is what it is about. Unless practitioners have “effective procedures” in place, something tends to be somebody else’s job, and people assume that somebody else has done it, whereas if procedures are clearly laid out, action is much more likely to be taken. I therefore see nothing to object to in amendment 29, as it aims to achieve the intended purpose of this extremely worthwhile piece of legislation, which is to identify carers, because that is right for them and for their own health, because it provides better care for those who they are caring for, and because it is the right thing to do.
I am reminded of the last time I was on a health Bill Committee. I think it was a nine-week marathon and there were, I believe, 102 Divisions. I remember that we started off with the Opposition dividing the Committee on a number of occasions; I was part of that. I hope that this time around there will not be as many Divisions, but of course the reason for a Bill Committee is to have an opportunity to discuss things, and as I said to the Minister, there will be things that we will agree on and things that we will not agree on. That is what a Committee is about.
I will outline some of the things that I think are important. I commend the right hon. Member for Sutton and Cheam for setting the scene very honestly for us all; other Members contributed to that process too. They are very well versed, with plenty of speaking notes from organisations that have contacted us, and bullet points as well. I am pleased to make some comment about that.
I will focus on amendment 29. What I believe it is designed to do—indeed, I believe that it is the thrust of the amendments that have been tabled—is to put a duty on the NHS bodies to support local authorities, to oblige them to identify and signpost carers so those carers can receive support. I believe that we must also put a requirement on local authorities to co-operate with a range of organisations in fulfilling their functions as set out in the Bill. The thrust of amendment 29 is
I am ever mindful of where we are going with health. We all know—within this Committee and outside it too—that the levels of cancer incidence are increasing greatly, and other Members have mentioned the number of people who will have cancer over the next couple of years, but along with the people who have cancer comes an increased number of carers. If, as has been indicated, the number of carers increases from some 2 million to 4 million by 2030—I think that those are the figures that have been used—I believe that we have an obligation to address that issue now in this clause, and the other things that will come through clause 10, I think you said, Mr Bayley. However, at this stage we have to identify the needs of those who have particular ailments and those who care for them, since we are looking at a problem that will increase greatly and affect a greater number of people, having a negative impact on the lives of carers.
Let us think for a second about the lives of carers. Caring affects their mental health, their well-being, their relationships and their working life, and 50% say that it affects their household finances. That figure applies specifically to cancer carers, but it could apply to many others as well. Cancer carers say that they can identify at least one type of support that they are not receiving, and again, that is an issue for a great many.
All of us elected representatives, as the hon. Member for Sheffield, Heeley said truly, know that carers are not all looking for money. Carers are just people who care, and the issue of money is not in their psyche. What is in their psyche? We as elected representatives know the issues because whenever they are in trouble, they come to us, and we identify what the issues are. Sometimes the help they need has not been delivered entirely, and we need to address that. I am keen to hear the Minister discuss the issue of the large number of carers needed to look after patients in the next period, and how the shop window of help that carers need can be identified much better by the two bodies working together. Those are some of my thoughts.
It will not surprise many here that only one in three carers for people with cancer has heard of the carer’s assessment, and only 5% have had one. Those figures are incredible and worrying. They identify the need for all of us here—the Government and the Opposition—to come up with wording for legislation that will help those people. If we can do so, we will have made a big step.
The hon. Member for Sefton Central mentioned young carers. We all know young carers who do a tremendous job. Never at any stage do they know that they need help. The only time they know is at the eleventh hour, when everybody closes in around them. They just do it—children look after their parents, grandparents and siblings. I respectfully ask the Government how we can
Bill Esterson: It is a pleasure to serve under your chairmanship, Mr Bayley. I am pleased to follow the hon. Member for Strangford, especially given his comments about young carers, with which I very much agree. It is incredibly difficult to identify young carers. They often do not want to be identified because of stigma or the fear that they may be taken into care themselves, and that the person for whom they care may suffer as a result. There are numerous reasons for the resistance. I do not have an answer; it is a difficult and challenging issue. I hope that the Minister will tell us his thoughts.
I rise to speak briefly on two points. One is identifying and supporting carers through the NHS. The hon. Member for Totnes mentioned the fact that primary care is the most likely to identify carers. That is incredibly important. In my experience of organisations over many years, what gets measured gets done. We might amend that to say that what gets mandated or legislated gets done. We have a tendency as human beings to do only what is requested or required of us. If there is a requirement to identify carers, we stand a much greater chance of seeing it happen and being able to provide the support needed.
The second point is the financial implications of supporting carers. Other Members have made the points well that carers need much greater support, that it is difficult for them to get support and that sometimes they are reluctant to do so. My hon. Friend the Member for Sheffield, Heeley made the point that carers do not want to fill in these questionnaires, which is quite right. We hear from Carers UK that 600,000 more people have taken on caring responsibilities since 2001, with 35% more being over-65. My dad is in his 80s and is caring for my mum, which is not an untypical situation. He is a proud man, a caring man and a loving man, and he does not seek support. He needs it. He is typical of many, particularly older, people in this country today. That is why it is so important—not just for my dad, but for the millions of other carers around the country—that we get this right.
Full-time carers are twice as likely to be in bad health as those without caring responsibilities. We have a duty as legislators to look after these people. If a carer’s health is allowed to deteriorate, they will have to be cared for later by the health service. If we get this right and identify problems earlier and are able to assist carers earlier, we will save money in the long term for the health service and for local authorities, which is another reason why it is imperative that we make the amendments.
Norman Lamb: May I start by echoing the comments of the shadow Minister when he said that he hoped that we could debate the issues in a sensible and reasonable way? These are matters on which there is widespread agreement and widespread determination to do better than we have done. I will certainly conduct myself in a way that avoids political slanging for the sake of it and will try to engage in proper discussion and debate.
I may be right, Mr Bayley, in remembering that you chaired the Committee on what became the Enterprise and Regulatory Reform Act 2013, which is the only
I pay tribute to my right hon. Friend the Member for Sutton and Cheam. I described earlier that he had, in a way, been the midwife of this Bill and now performs the role of health visitor, perhaps, in keeping an eye on it during its early stages. He has done an enormous amount, in his various roles as a Minister, then chairing the Joint Committee that scrutinised the draft Bill and now on this Committee, to achieve the best possible legislation. He has done brilliantly in that regard.
I am absolutely of the view that integration and co-operation between local authorities and NHS bodies are vital to the future of both. Indeed, I have argued for integrated care for many years. I have been frustrated by a horribly fragmented system that lets patients down and allows people to fall through the gaps between disparate services due to completely inadequate co-operation between different organisations. Organisations too often focus on their own existence rather than the needs of the patient. There needs to be a fundamental change. In a lot of what I have been trying to do since becoming a Health Minister—through the integrated care pioneers, the better care fund and in other ways—I have sought to make the argument for joining up these disparate parts of the system and, to coin the phrase of the shadow Secretary of State, focus on whole-person care. We do not need to fall out over political ideology here; it just makes sense from the individual patient’s point of view that the services are shaped around their needs, not those of the institution. The Bill can go a long way towards advancing that case.
Norman Lamb: My horrible fear is that too often it does not happen. We in this place may think that legislating and passing duties changes the world, but we can discover five years later that nothing has changed. So much of what we do is about how we embed different ways of doing things and change the culture of organisations. I fully accept that legislation plays a role in achieving that, but providing an appropriate statutory basis for better integration and co-operation is fundamental to the Bill. I therefore sympathise very much with my right hon. Friend’s intention in tabling amendments 26 to 28—indeed, I found myself agreeing with virtually everything said in this debate. None the less, the Bill as it stands provides a better basis for co-operation, for three reasons, which I will set out.
First, the NHS already has a number of duties related to promoting well-being; most notably, in the NHS constitution, about taking a patient-centred approach, promoting equality and understanding the priorities, needs and abilities of patients. The NHS constitution is
Secondly, because of the Bill, for any joint function, the local authority would need to ensure that the well-being duty applies to the entirety of the function. The related duties on the NHS would ensure that it must co-operate with that.
Norman Lamb: I am happy to try. The point is that where a local authority and the NHS seek to do things together, there is a duty through the Bill on the local authority to focus all of its attention on the well-being principle. For it to be satisfied that the outcome from that joint work met the well-being of the individual, it would have to ensure, in co-operation with the NHS body, that it had achieved that objective. I make the point—as I did in the paragraph to which the hon. Lady objected—that the NHS is already under such duties, through the NHS constitution, which similarly match the objective of well-being set out in the Bill. Where the two organisations work together on a particular purpose on behalf of a patient, both organisations will be under similar duties to achieve the same objective. Indeed, the Bill will reinforce that.
Debbie Abrahams (Oldham East and Saddleworth) (Lab): I reiterate the points already made about the spirit of co-operation—this is a really important step forward. However, may I press the Minister on what he just said? Surely adopting the amendment would reinforce the NHS’s principles as the important things that they are.
Thirdly, there is a distinction between general co-operation and integration, which is at the heart of the Bill, and specific legal duties that will be carried out jointly with the NHS. As the Bill imposes few, if any, functions jointly on health service bodies and local authorities, the practical effect of the amendments would be minor, as they would impose the duty of well-being only on joint functions and, in legal terms, the joint functions are limited. The danger is that the well-being principle ends up being applied to that tiny subset of functions that the NHS exercises jointly with local authorities, but to no other part of the NHS at all, which would lead to a rather confusing picture of duties within the NHS: duties of well-being on that tiny subset that would not apply to anything else done by the NHS, which seems to be a bizarre end point. It is better to focus on the fact that, through its constitution, the NHS is already under duties that broadly match the well-being duty that is imposed on local authorities under the Bill.
Grahame M. Morris: I am genuinely not trying to be difficult, but will the Minister give us some clarification? He is usually very persuasive, but I am afraid that I am not persuaded by his arguments. Is he saying that there is a difference between placing a duty and an obligation, and the statutory duty? Is there a fear that patients or carers would use legal redress through a breach of the NHS constitution? Will he answer my earlier question about whether there is any reason why this obligation could not be placed on GPs? Does he remember that there was some suggestion that that would require a renegotiation of the GP contract, and can he confirm whether that would be the case?
Norman Lamb: I am not sure whether the hon. Gentleman might be confusing two points. His question about application to the NHS might have been in relation to carers, but I might remember incorrectly. Amendment 26 would apply the well-being principle to
It would therefore apply the well-being principle only to that tiny subset of circumstances when the NHS exercises a function jointly with a local authority. It seems bizarre to apply a well-being principle just to that tiny subset of NHS functions carried out jointly with the local authority but not to apply it to anything else. The reason why we feel the amendment is unnecessary is because the whole of the NHS, through the existence of the NHS constitution, which the hon. Gentleman’s party introduced in government, is already subject to duties that are incredibly similar to the core of the well-being principle. I therefore think that we are there already without the need for this additional tweak to the application of the well-being principle.
Amendments 29, 67 and new clause 9 relate to co-operation between local authorities and NHS bodies in relation to identifying carers and promoting their well-being. Provisions in clause 6 already clearly require NHS bodies and local authorities to co-operate with each other when exercising their respective functions relevant to care and support, including those relating to carers. There are existing duties under the Health Act 2009 on promoting and safeguarding the health and well-being of patients, which would of course cover patients who are carers. These, together with the Bill’s co-operation provisions, already fulfil the intention of these amendments.
Paul Burstow: I anticipated that my hon. Friend might refer to the co-operation clause as the reason why we did not need a specific duty in the Bill. I understand that, but is he minded at least to consider giving us an assurance on Report that the guidance on the co-operation duty will make it explicit that the obligation around the identification of carers is an important example of how co-operation can deliver benefits to the health care system, the social care system and carers primarily?
Norman Lamb: My right hon. Friend pre-empts what I might come on to a little later. I totally agree about the importance of co-operation and collaboration. Indeed, my hon. Friend the Member for Totnes made the critical point that it is practitioners in primary care who first and most often come across carers. We know that practice is too variable in primary care. There are great
In the integrated care pioneer in Cornwall, there is a fantastic example of great practice—I think that the initiative is called Better Lives. GPs collaborate with informal carers, combating people’s loneliness and providing companionship and support, and in that way GPs discover that it relieves the burden on them. Carers can become an incredibly valuable partner in the care of the individual, but too often that is ignored.
Sarah Newton: The programme is called Changing Lives and it is a marvellous example of the integration that the pioneers will deliver. I welcome my hon. Friend’s support for that project as it is a real exemplar that does exactly what it says on the tin: changing lives for the better, both for the patient and the carer.
From 2014-15, GPs will be required to ensure that all people over 75 have a named, accountable GP with overall responsibility for their care. In addition, the 2014-15 GP contract will include a new enhanced service requiring GP practices to provide co-ordinated care to the most vulnerable people. GPs will be required to ensure that people who receive this tailored service have in place an effective care plan informed by the person’s needs and views, and, when appropriate, their carer’s views.
Over the coming months we will set out in more detail how we expect these changes to be implemented, including through the Government’s response to the engagement around our proposals for a vulnerable older people’s plan. We will make it clear that where a person is supported by family carers, we would expect the provision of high-quality care by GPs to include identifying carers. In that way, we can do something far more effective and practical than put in place a legal duty, which in itself may change nothing, and we can support them to carry out their caring role, including by signposting them to relevant information, advice and support.
I am also willing to consider whether the statutory guidance accompanying the Bill might usefully refer to the identification and support of carers as an example of co-operation, in addition to the specific duties that already exist in the Bill in this regard. In summary, the Bill’s provisions already fulfil the intention of the amendments.
I agree with the shadow Minister’s point—the hon. Member for Sheffield, Heeley said this, too—that people quite often do not regard themselves as carers. They are family members doing what they want to do: caring for a loved one. There is a danger of a tick-box culture, where people identify the carer and tick that box, but nothing actually changes. This is about changing the culture in primary care, and the vulnerable older people’s plan can do that, together with the right guidelines.
Dr Wollaston: I thank my hon. Friend for his reassurance about the guidance. However, if a local authority that was not getting such feedback about carers from some GP practices made a direct request, would those practices be obliged to respond?
Amendment 70 would require NHS bodies to promote integration. Reflecting the importance that the Government place on integrated, joined-up services, the Health and Social Care Act 2012 created a major focus on integration between local services, and that is supplemented by the provisions in the Bill. That will support the establishment of the £3.8 billion better care fund to promote joint working between the health service and local authorities in 2015-16, which will we discuss further in our coming sittings.
Clause 3 requires local authorities to promote integration between care and support, health and health-related provision. That reflects sections 13N and 14Z1 of the National Health Service Act 2006, which already—this is the important point—place clear duties to promote integration on NHS England and clinical commissioning groups respectively, particularly when that would promote the well-being of adults and carers in their area. That creates a clear duty on NHS bodies to promote integration when it would promote health and well-being.
Furthermore, section 195 of the 2012 Act places a duty on health and wellbeing boards to promote integrated working when that would promote health and well-being. Given that health and wellbeing boards must have a representative on the relevant clinical commissioning group, that places a clear duty on clinical commissioning groups to work as a constituent part of the health and wellbeing board towards integration of services, when that would promote health and well-being.
Clause 6 sets out a duty of co-operation between local authorities and relevant partners, including NHS bodies. Given that the integration duty in clause 3 and the co-operation duties apply to all care and support functions, there is already a requirement on local authorities and NHS bodies to work together to further integration and co-operation.
In conclusion, while we all share the aim of better integration between different organisations, I hope that right hon. and hon. Members will agree that the amendments and new clause are not the way to go about achieving it and that the existing framework of the Bill, together with existing duties on the NHS, achieve the objectives of those provisions.
Paul Burstow: I thank hon. Members who have taken part in the debate. There have been excellent speeches from Members on both sides of the Committee, and important points have been made. As Members have said, the tone has been about how we improve things and make sure we do the best by those who send us here.
I would pick up, in particular, on the point made by the hon. Member for Sheffield, Heeley about the shift of emphasis. At the moment, we have a system where the default is fundamentally about sustaining people’s dependency, rather than a system that is about celebrating, recognising and building on people’s strengths, which is what the Bill is trying to move towards. That is a big shift, but it is an essential shift.
The purpose of the debate was to probe the Government, and I think we have done that. We wanted to understand their intentions regarding the relationship of the NHS to well-being and, in particular, to the identification of carers. I wonder what book the Minister might get by the end of our debates—perhaps we can while away the hours over the next five weeks contemplating the answer, with great anticipation. However, I share his frustration about integration, and I admire his determination to make the necessary progress on it.
I take the Minister’s point about the way in which different duties already operate to place an obligation on the NHS to pursue well-being. I welcome what he said about statutory guidance, which is incredibly helpful when it comes to the identification of carers. I also welcome what he said about the vulnerable older people’s plan. It is essential that GPs see this as part and parcel of their job, not as a bolt-on extra that they may or may not do. The vulnerable older people’s plan and clear statutory guidance, for both the NHS and social care, are critical in that regard.
We have seen some progress. I hope that those organisations with which the Department is engaging on drawing up statutory guidance feel emboldened to press to make sure that they get exactly the right language in the guidance that will follow. I beg to ask leave to withdraw the amendment.