I am a retired nurse and a carer so I approach the Bill from an essentially practical perspective. I shall therefore start with the provision making Health Education England a non-departmental body. This change is vital if the body is fully to fulfil its responsibilities, as the noble Lord, Lord Willis, said. The Secretary of State will issue a mandate and this will be of great value to Health Education England, which must work in tandem—and within a defined budget—with a wide range of specialities and many different bodies. The Government’s addition of Clauses 87(5) and 93(3) from the draft Bill underlines the fact that planning for a period of longer than one year is essential when considering workforce requirements such as education and training which involve a long lead-in period. Clause 88 sets out the importance of having sufficient numbers of skilled workers to meet the health and social care requirements. LETBs will have responsibility for planning for the workforce and the skills requirements for a defined area but they must also take account of the wider geographical requirements if specialities and the time element are to be addressed, especially if this is to be cost-effective.

Healthcare assistants—support workers—have been a subject of concern regarding training and the review by Camilla Cavendish which the Prime Minister requested is due shortly for publication. Skills for Health has published a list of skills that should be part of the training for healthcare assistants. As we know, however, simply teaching a skill without providing the background knowledge is of no value in delivering quality care. Both Robert Francis QC and the noble Lord, Lord Willis, recommended mandatory training. I hope that the Government will seriously consider that after considering Camilla Cavendish’s recommendations. I ask the Minister seriously to consider mandatory training programmes which might link skills training to the NMC’s care standards, which are the core of the nurse

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training curriculum. That would provide a greater understanding for both the healthcare assistants and for the registered nurses who are responsible for supervising and delegating to the healthcare assistants. If high-quality care is to be delivered in the NHS, in local authorities and, importantly, in the independent sector of nursing homes and care homes, where standards are not always compatible with high-quality care, then the matter of training for healthcare assistants must be dealt with urgently.

Health Education England has an enormous task in improving the provision of workforce data on all disciplines and clarification is required about the part to be played by the Centre for Workforce Intelligence and how this slots into the Health Education England programme. Achieving the right numbers of appropriately qualified people who are in the right place at the right time is an enormous task but it is essential if safe, high-quality care is to be delivered to the satisfaction of patients and their families. There are already examples of shortfalls in all disciplines but in nursing there are great disparities between those who produce high-quality care and those who do not. These disparities usually reflect the ratios of registered nurses to healthcare assistants and the required level of supervision. The right numbers in the right ratios are the most cost-effective and care-effective way of delivering high-quality, safe patient care both in the NHS and in local authority health and social care services. I hope that the two vital issues of healthcare assistants’ training and the ratio of registered nurses to healthcare assistants can be sorted out as a matter of urgency.

Continuing professional development is crucial to the future of integrated care programmes. It is important that the values set in the NHS constitution and within healthcare trusts, primary care and local authorities are understood by all employees and employers. There is a need to encourage onward development of all employees by implementing a sound appraisal system which reflects the needs and aspirations of each employee and results in an individual CPD programme. If this is not rigorously followed through on, the issue of burnout and loss of commitment will become apparent. In such circumstances morale falls and healthcare provision can fail. Such a culture is not conducive to high-quality care and is similar to that experienced in Mid Staffordshire.

I turn to the Health Research Authority. Evidence-based practice and innovation depend on research findings. It is a great disappointment that the constitution provided in the Bill is stated in such general terms that it is impossible to determine whether there will be multiprofessional representation on the board or among the employees. All healthcare professionals now require a degree but the responsibility for research has until now remained with the medical profession and little attention has been paid to the other healthcare professionals when considering representation on boards, in committees and in terms of funding. How can innovations be developed without research backing? Promises were given verbally during the briefing for and passage of the Health and Social Care Act but there is no evidence that any notice has been taken.

One good example of the outcome of some research done by a Florence Nightingale Foundation scholar— I declare an interest as president of the foundation—was

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the introduction of care bundles. As a result of that scholarship the mortality rate in people suffering from three long-term conditions was reduced to below the average SMR. We need more projects and research like that to ensure that practice is based on evidence and sound research. I ask the Minister to ensure that there is more investment on the multiprofessional side of research as well as on the medical side.

Part 2 of the Bill refers to care standards. It is pleasing to see that the Government have taken steps to legislate on some of the Francis report on the Mid Staffordshire inquiries. The CQC’s role in identifying failing trusts on the basis of quality as well as financial concerns is welcomed by nursing staff who strive to maintain delivery of safe, high-quality care to the satisfaction of patients and relatives. Work by the CQC is ongoing and we will study it as an important step forward.

Part 1, on care and support, is a crucial part of the Bill that fundamentally sets out the responsibility of local authorities in the fields both of preventing the need for care and support and promoting well-being. However, the critical and most difficult part is promoting the integration of care and support within the health services. Fundamentally, integration is vital and the most important ingredient in successful health and social care, bringing together a huge band of people who will need educating, training and an understanding of the true meaning of holistic care that enables a patient pathway to be clear and understandable by those delivering the care, whether within the aegis of the local authority, the NHS or the independent sector.

In summary, the Bill is a welcome step forward in tackling the issues that so badly needed to be addressed. It will influence and persuade health and social care providers to provide the population they serve with quality and satisfaction.

5.40 pm

Baroness Browning: My Lords, it gives me great pleasure to follow the noble Baroness, Lady Emerton, in these matters. She has not only a lot of knowledge, but a great deal of personal experience. I always listen carefully to what she says. I refer the House to the register and to my interests particularly in certain charities which I shall mention. I, too, share the welcome that has been widely given across the House to this legislation. It has great potential to improve the lives of many people with a disability or who are elderly and frail. Simplifying legislation that affects local authorities’ care responsibilities is both timely and something that many of us hoped would happen for some time.

Like others, I share concern about the ability to fund such an ambitious piece of legislation. In the impact assessment available in the Printed Paper Office, I noticed that the monetarised benefits actually outweigh the public sector costs. If that is true, it is really to be welcomed, but I must tell my noble friend at the Dispatch Box that in Committee we will want to look carefully not just at the costs identified in the impact assessment, but at what are perhaps the glaringly obvious omissions, particularly future demographics. This Bill is very generous. To a degree, it seeks to underwrite the costs for people who currently do not

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receive state help with their care. The way in which the population demographics work out in this way is challengeable. I would say to my noble friend that what is really important is that we do not raise expectations through this legislation, only to find that they cannot be resolved.

I say this from personal experience. I remember some years ago when my son, who has Asperger’s syndrome, was in his late 20s and lived permanently at home with my husband and me. As the named carer, I received through the post forms to fill in, asking me what my carer’s needs were. Every time this form came, I am afraid that I wrote across it in large letters: “If my son’s needs were met, my needs would be minimal”. They probably caught me on a bad day. As any carer will know, the reality was that sometimes even the very basic needs of the person you are caring for are not met. In a way, this Bill promises that this will be addressed. After all, what does “well-being” mean if not the well-being of the whole person? The well-being of carers is very much dependant on the well-being of the person for whom they care.

This is particularly relevant among those people who cannot advocate for themselves. We heard in today’s debate discussion about people with dementia, mental health problems and learning disabilities—so ably expanded by my dear noble friend Lord Rix. I have had an association with various autism charities and can say that these people need somebody to make the case for them—usually the carer, though there is not always an immediate carer. It is really important that this legislation will fulfil its promises.

I am a little concerned about one particular area. Although it is extremely welcome that throughout this Bill there are requirements to assess—for example, the person needing care or the carer—if those assessments cannot be fulfilled, there will be a huge feeling of let-down. My own experience, not just as a carer, but having served for nearly 20 years in another place as a constituency MP, is that all too often there is huge push-back and resistance to an assessment, even when there is a statutory requirement to provide it. This is purely because the people who are asked to carry out the assessments know only too well that whatever their conclusions, they cannot do very much about them because the resources are not there to deliver what that person needs.

It must be pretty awful for the people who carry out those assessments to know that if they do their job fully and properly, at the end of the day there is not an awful lot they can do to make a difference to that person’s life. I think my noble friend described the resources attached to this legislation as being about the engine working better rather than putting more petrol in the car. I would say to him that the engine needs to work better and he needs to fill up a few more times, otherwise I do not think that the resources will meet the need.

Looking quickly at the autistic community, I mentioned earlier that there are some omissions. This applies both to autism and to people with dementia, perhaps more elderly people who go on to have Alzheimer’s. There are a huge number of people who are still undiagnosed. In the autistic community it is improving,

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particularly with younger children. However, there is still an adult community with needs that do not always come to attention. As with those with learning disabilities, if they have been living at home with elderly parents who themselves have a crisis, it is the crisis of the person they have been caring for that comes to the attention of the authorities. All too often, that means crisis management and huge sums of money with all the disruption that goes with it to try to put some form of stability package in place at short notice.

This is not helped by something which the Bill aims to address—I hope it is successful and has been touched on by many speakers already today. This is the relationship between health and social services. When I was a constituency MP, I used to say, tongue-in-cheek, “We are having an ‘Oklahoma!’ moment”. Often people would come to my surgery with the typical problems of those who do not receive the correct services, or are carers who are at breaking point and cannot get anybody to understand their needs. For those who can remember it, “Oklahoma!” has a song with the line, “The farmer and the cowman should be friends”—but they never seem to talk to each other. That is the “Oklahoma!” moment, and it is quite easily resolved by Members of Parliament. When in my surgery or on the phone I was presented with a problem that quite clearly needed a group of people to sit around a table and talk about it, I used to cut to the “Oklahoma!” moment as quickly as I could. All too often, good things happen when an MP says to health and social services, “I think you should get together”. Indeed, I sometimes used to say, “Don't worry, I'm very happy to come along to the meeting myself”, which usually galvanised a few people. Problems were not always totally resolved overnight, but we started to make progress. It used to occur to me, “Why do I have to have this ‘Oklahoma!’ moment when all these people could be doing all this for themselves?”.

I say to my noble friend that, as we go through the Committee stage of the Bill, I will want to pay particular attention to those parts that seek to improve things so that we do not have “Oklahoma!” moments. The structure must be such that automatically there is dialogue and not stand-offs about who pays for what, because the difference between who funds the social care and who funds the health care is addressed in the Bill. All of this bodes well for resolving many of these problems, but I still have concern that if the resources are not available, we shall not do so.

Finally, it is important that we have a new piece of legislation on the statute book; the Autism Act. It has not really bedded down yet and it is early days. But the new Care Bill must ensure that the duties in the Autism Act statutory guidance continue to apply to local authorities and local NHS bodies to ensure the ongoing implementation of that Act. I hope that the Minister will be able to reassure me on that when he makes his concluding remarks.

5.51 pm

Baroness Wilkins: My Lords, as so many noble Lords have said, making the points that I wanted to make, this is potentially a very important piece of legislation. I warmly welcome it. The well-being principle

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set out in Clause 1 is particularly welcome and the Government are to be congratulated on acting on so many of the Joint Committee's recommendations for strengthening the Bill. But unless this Bill is properly funded, its aspirational principle and welcome structure will just rub salt into the wound of the current crisis in social care. The Bill must be properly funded and other government departments must work in concert with this legislation if the social care crisis is to be alleviated.

The media debate around the Bill has largely focused on the care needs and the funding of that care for older people. I want to concentrate on the social care needs of working-age disabled people who comprise one-third of social care users. I will focus particularly on funding and housing.

Current government action on these two issues does not bode well. As we know, the fine aspiration set out in the well-being principle is cloaking a grim reality. This is particularly the case for the more than 20,000 most severely disabled people who, until it was closed to new applicants in 2010, were funded by the independent living fund to live ordinary lives in their own homes.

When I became disabled in the mid-60s, these were the people who, unless their families had sufficient money and suitable housing, were warehoused in residential care with no hope of living any sort of normal life. In the decades since, as we heard from my noble friend Lady Campbell, we have witnessed the liberation of this group to live fully integrated lives as part of the community. Some have been enabled to work and make considerable contributions to our society only because the ILF has provided top-up funding to the support available from local authorities.

But despite the fine words of Clause 1, these ILF users fear that current government action is threatening to return them to institutional care. ILF funding is ending and these people are being transferred to the local authority system in 2015. Their fears are not exaggerated and have been confirmed by the directors of social services, the Local Government Association and the Government's own impact assessment as well as the National Association of Financial Assessment Officers who have said that some councils will decide that residential care is a less expensive option than supporting people to live at home.

A few weeks ago, a group of ILF users took this decision to judicial review. It lost, but during the two-day hearing, it became clear that transition funding to protect current ILF users is available only for one year, 2015-16, and that neither the DWP nor the noble Earl’s own Department of Health want to take responsibility for making the case to the Treasury for further funding in the spending review.

What steps will the Department of Health and the DWP jointly take to ensure that funding is available after 2015? Will the Minister assure the House that ILF users will not be forced into residential care or confined within their own home with only ‘life and limb’ care following the transfer of funding responsibilities to local authorities? If this Care Bill is to fulfil its principle of well-being, what level of funding do the Government believe is necessary to ensure that we do

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not return to the days when disabled people with high support needs had no opportunity to live independently? If there is no time to answer at the end of the debate, would the Minister be so kind as to write to me?

The justified fears of ILF users serve only to highlight the current crisis in adult social care which is failing to support disabled people to do the basic things in life—basic needs such as washing, dressing and getting out of the house. I will not repeat the points that other noble Lords made so eloquently. However, as the Care and Support Alliance has emphasised, this Care Bill will fail to improve the social care system for disabled people if the welcome proposal of a national eligibility threshold is set too high. The White Paper's suggested threshold of “substantial” is too high. For the ambitions of Clause 1 of the Bill to be realised—that social care should enable participation in work, education and society—it is essential that the eligibility threshold should support that ambition, not demolish it.

It is vital that the national threshold is set at no more than “moderate” to ensure that prevention is at the heart of the social care system. Prevention must lie at the heart of this Bill. It will also depend on other government departments and other local authority services playing their full parts to ensure that social care expenditure does not escalate in an unintended way.

One of the most important factors in prevention is housing; both the provision of suitable housing and the aids and adaptation service. Countless stories of people being unable to return to their own homes after serious illness or accident because of inaccessibility are heartbreaking. They also result in costs occurring elsewhere in the system because of delayed discharge from hospital or expensive residential care. Simple adaptations to a person’s home can prevent the need for costly care, whether it is the provision of ramps and handrails, lever taps or a downstairs bathroom when stairs become insuperable.

This applies equally to the need for supported housing especially for people with learning disabilities. Frequently, local authorities do not even seem aware of their legal responsibility to house this group. I congratulate the Government on having listened to the Joint Committee on the draft Bill and including the suitability of a person’s home in the definition of well-being in Clause 1. During the passage of this legislation, I will seek to ensure that housing also appears on the face of the Bill in other relevant clauses so that it cannot be forgotten.

Finally, it seems like a forlorn hope that the Chancellor will recognise the urgent need to build the thousands of homes needed for social housing. They are particularly needed by disabled people who are more dependent on social housing than the rest of the population. Instead, the Chancellor spends our scarce resources on his help-to-buy scheme, which can only lead to yet another catastrophic housing bubble.

I wish the noble Earl the eloquence of angels in persuading his fellow government Ministers that they must all play their part if this Bill is going to result in more than just fine words and aspirations, particularly the Chancellor of the Exchequer.

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6 pm

Baroness Barker: My Lords, I declare an interest as one of the usual suspects referred to by the noble Baroness, Lady Pitkeathley. Like many of the speakers in today’s debate, I am a veteran of more care Bills than I care to remember. I wish to put on record my admiration not just for my colleagues Paul Burstow and Norman Lamb, who did a remarkable job getting this Bill to where it is now, but also to a number of people—not least of whom are the noble Lords, Lord Lipsey and Lord Sutherland of Houndwood—who over the whole of the last decade started the debate which has got this Bill to where it is today. An awful lot of work has gone on in the last decade that has shaped this legislation. It has to be clear, coherent and consistent; people and their carers need to know what they are entitled to receive from social care, what they will be expected to contribute and what their entitlements will be. That has been a long process, but it is a relief that we have finally got there.

A lot in this Bill is admirable and it starts for me at the third sub-heading in Part 1, which talks about the purpose of assessment. Assessment is key to all this Bill: the extent to which it is possible to assess a person’s needs, means and support networks and the extent to which social care, health and private insurance have a common assessment process are the keys to whether the aspirations that we all have for joint care can really and truly be achieved. At the heart of it all is housing. We have known for some considerable time that the care that an older person receives in later life depends upon whether they own a property and the extent to which they can use that to fund their care. This Bill goes a long, long way to ensuring that other people—those who do not have properties at their disposal—get the help that they need as well.

There is much detail in here about the assessment process and much of it is extremely welcome. However, there is one subsection—Clause 9(4), which looks at how one’s need for support is assessed—which talks about the need to look at what a person can do and the sources of support around them in their family before an assessment for eligible needs can be carried out. We need to be clear by the time this Bill finishes all its stages that people and their families are being assessed on what it is that they are able to provide by way of support and care, rather than what they are expected to provide to make up for some of the deficiencies of the care system at the moment. We do not wish to see people and their families pressurised into providing more than they possibly can.

I welcome Clause 11, which talks about the enduring responsibility of a local authority to care for an older person even if they refuse to have an assessment. All of us who have worked with older people know that horrible moment when a carer finds that their mum has gone for her assessment and sworn blind that she can do lots of things which on her very best day she might be able to do, but routinely she cannot. Here I also make the point that the noble Lord, Lord Hunt of Kings Heath, and I always raise on occasions such as this, in memory of Lord Weatherill. There are some people, particularly Christian Scientists, who do not lack capacity but who wish to refuse to have assessments and so on. Their views need to be upheld. I am

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extremely pleased that the need to assess somebody’s financial resources is in the Bill. It is quite clear that that assessment happens separately and after their needs have been assessed.

Clauses 15 and 16 talk about the cap on care costs and implement Andrew Dilnot’s report. Again, there is much in this that is extremely welcome. It is welcome that there are some things for which local authorities will not be able to charge. The whole process of how one gets from the point of an assessment of need to the point of eligibility is much more complicated than many people realise. There will be things such as care costs that people have already paid for in their own homes which are not taken into account. The same is true for payments for their daily living costs. We also know that the current system whereby local authorities will pay up to what they call the usual rate—which may be well below what an older person and their family believe they need—will continue to endure under this new system.

It is absolutely critical that this whole part of the Bill is scrutinised in great detail, because there is a danger that this could end up like the fares for a budget airline. You have an upfront figure, which by the time you finally get to the airport, turns out to have so many add-ons that it bears no resemblance to the original fare. If, at the end of our process of scrutiny, that is what we end up with, then the whole system will become discredited. We really need, above all else, to emerge from this legislation with everybody knowing in detail, with some certainty, what their costs are going to be.

One of the issues on which the Government’s response to the joint scrutiny committee was slightly disappointing was about drawing the boundaries between health and social care. Those of us who have been involved in working with older people for any length of time know that when resources are tight, the ability of the NHS and local authorities to withdraw and start pressuring people from pillar to post gets tempting. There was an attempt in the draft Bill to differentiate clearly between healthcare and social care. In the Bill that has emerged now, it is less clear than it was originally. That will not help anybody; it will simply set the basis for ongoing court cases about what constitutes continuing care. Again, one of our main duties in the passage of this Bill is to ensure that there is clarity on that point.

Turning to deferred payments for social care, we currently have a system of deferred payments and we have some case law already on the way in which that works. It is welcome that the Government wish to extend that and to make it more consistent across the country. However, I hope that in doing so, they have paid attention to the existing case law about when people’s properties can be taken into consideration when other members of their family are living in those houses. I have to ask the Minister what financial modelling has gone into this part of the Bill, because we are talking potentially about the deferment of a lot of money for a lot of care for a very long time. Given the state of the finances of local government at the moment, we could be talking about a policy of quantitative worsening of social care, rather than quantitative easing of it.

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I move on quickly to safeguarding. It is very welcome that we are finally getting a statutory power to investigate the potential abuse of older people. People such as the noble Baroness, Lady Greengross, have been working for 20 years towards a time when we put the abuse of older people on as serious a statutory footing as the abuse of children. However, the changes to Section 47 of the National Assistance Act—the power to remove older people from unsanitary conditions—without a power of entry when a third party is withholding access to somebody who may be being abused, may mean that we have a statutory power that is not going to protect people. I agree with the noble Lord, Lord Patel of Bradford, that Section 117 support for mental health is important, and we must make sure it is not weakened.

We have within our grasp a system that will deal with the biggest problems with which we have been grappling for more than 20 years: how to make our social care systems, our health systems and the rest of our public finances work together, so that individuals, their families, their communities and the National Health Service all know where they stand in relation to each other. We are not quite there, but with some concerted effort, and using our combined experience, we will get there by the end of this Bill.

6.09 pm

Lord Patel: My Lords, the Government have to be commended on bringing forward this Bill to reform the current system of social care and thus bringing in a fairer system. Many noble Lords have commented on the financial issues, saying that adequate finances will be required to make sure that the ambitions of the Bill are delivered. Noble Lords have also commented on another important issue, that of the eligibility criteria that are to be used. If these two things are not met appropriately, the duties being placed on local authorities in Clause 1—promoting well-being, preventing deterioration and reducing need—will be difficult to meet. It will also mean that more people end up in A&E, in primary care and as in-patients.

I am concerned about two other issues. As yet, the Government have not accepted the need to provide free care and support for cancer patients at the end of life. I remain encouraged by the comment made by the noble Earl when we considered this issue in the debate on the gracious Speech. He said that there was “much merit” in the idea. I hope that he will be able to convert the thought that the proposal has much merit into an amendment that the Government will bring forward.

A survey by Macmillan Cancer Support has shown that 91% of cancer patients at the end of life wish to die at home or in surroundings familiar to them. The barrier to this is the lack of care and support they need along with complicated, lengthy and stressful processes to access funding for care. Financial means testing when patients are dying does not seem to be compassionate or caring. The argument for providing free social care at the end of life is strong. It will deliver the Government’s vision of integration and choice. Research by the Nuffield Trust shows that a saving of some £52 million a year could be made through reduced hospital admissions. I hope sincerely that the Government will amend the legislation to do this, or accept an amendment that I will bring forward.

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There is also the issue of the support that the carers of cancer patients get or, rather, that they do not get. Almost 1 million cancer carers give their valuable time to this, saving services probably in the region of £12 billion a year, yet half of them receive no support at all and the other half very little. This is partly because most of them do not see themselves as carers and are unaware of their rights; fewer than 5% get any assessment at all. What would help is if a similar duty as the Bill puts on local authorities is placed on the NHS to work with local authorities to identify the support needs of carers who are themselves supporting cancer patients. Cancer carers will then receive the support they deserve.

The other areas of concern to me relate to Clauses 55 to 63, also referred to by the noble Lord, Lord Rix, and I associate myself with his comments. I want particularly to make a point about the support and care of children and young adults during the transition period. More than 40,000 children and young people aged between one and 19 in England have long-term conditions which, for the most part, will end their lives or for which they will require palliative care. They may have complex health conditions and severe disabilities, and for the most part they are looked after by parent carers. This is not end-of-life care, but care that brings some comfort, respite, the relief of suffering, and a little bit of quality of life. Evidence shows that while they are children and in their early teens, these young people receive support from children’s services. In their late teens they begin to receive services from adult services, but that support is often reduced, fragmented and disjointed. Parents describe this transition of care as “standing on a cliff, about to fall into a black hole”. It is not difficult to imagine the stress and anxiety it must cause to young people and their carers.

The proposals in the Bill are a step forward, but in my view they need to go further. A consortium of charities which has grouped together under the charity, Together for Short Lives, feels that this provision needs to be strengthened. The Bill should make it clear that when a young person reaches the age of 14, local authorities should initiate transition planning with the young person, their family and the relevant agencies, so that by the time they reach the age of 16 a five-year rolling programme for their support and care is in place. I hope that the Government will be sympathetic to this and that the Minister, if he is able to do so, would be willing to meet with representatives from Together for Short Lives and myself.

Part 2 of the Bill relates to performance rating. I support in principle the idea of introducing a system that assures quality of delivery of health and social care. Suffice it to say at this stage that whatever the final system that is introduced is like, it has to be credible and have the confidence of both patients and health professionals. If it is going to be based on three domains of quality—clinical effectiveness, patient experience and patient safety—the dataset needed to achieve this in an equitable and fair way is available for some areas, but not all of them. I hope that the Government will see the introduction of assessment as formative and embedded over a period of time, evolutionary in helping to develop appropriate datasets leading to improved services, rather than a one-off assessment that identifies only failures and shortcomings.

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I am very familiar with a system based on standards that encompass the three quality domains of clinical effectiveness, safety and patient experience, but using a different process that works. I know of no system within our national healthcare that is similar to the proposals, although of course there are large healthcare providers which are using a similar methodology. I look forward to the debate on this subject and hope to contribute to it.

Perhaps I may comment briefly on the other parts of the Bill, starting with Health Education England. In my view, the Government have brought in provisions that we agreed in principle in the Health and Social Care Bill. The Government have to be commended on doing this and I thank the noble Earl. I am also encouraged by the appointment of Professor Wendy Reid as the medical director. Health Education England will have someone with huge experience and skills in health education. My only comment relates to the local education and training boards. Why is there not a duty placed on them to promote research and research training, a point also mentioned by the noble Lord, Lord Willis of Knaresborough?

As for legislation related to the Health Research Authority, its current role is small and we will want to see how it evolves. I recognise the comments made by the noble Lord, Lord Willis, about too many regulators in the area of health research. I hope that the Government will look at this, while the inquiry into regenerative medicine may also give rise to some comments. I think that the Government are right not to put a duty on the Health Research Authority to require the publication of the results of research. It is much better that the authority should work with others to encourage the publication of research and that it develops over time an appropriate methodology. The mandatory publication of research by the authority would have been the wrong thing to do. It does not work; it has been tried in other countries, including the United States.

As for the Human Fertilisation and Embryology Authority, the original Government thinking was right, but now that they have changed their mind and have decided to keep the authority, I hope that it concentrates on its key role of improving services related to infertility.

In conclusion, on the whole I am supportive of this Bill and hope that the Government will be sympathetic to amending some of the areas I have alluded to in order to help improve the lives of those most in need of care and support.

6.19 pm

Lord Wigley: My Lords, I welcome this very important Bill. I do not want to repeat the points that have been made, but I will add my support to the comments made by the noble Baroness, Lady Campbell of Surbiton, on the need for real independence and dignity for disabled people and to the points made by the noble Baroness, Lady Wilkins, on the housing needs of disabled people of working age. I also share the concern expressed by her and by many speakers in this debate that this Bill will work only if adequate resources are available. I noted the comments made by the noble Lord,

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Lord Rix, that the system is now in crisis and that people with real needs are left without support, which is a worrying situation.

I want to highlight matters relating to the detailed working of this Bill and the complexity that arises in some areas by virtue of the fact that social care is devolved in Wales to the National Assembly, since some of the provisions in this Bill impinge on devolved responsibilities. First, can the Minister confirm that legislative consent Motions have been agreed with Ministers in Cardiff and that there are no outstanding issues that need to be resolved?

Secondly, on the issue of funding, the Secretary of State Mr Hunt said on 11 February:

“All the Barnett consequential issues are decided by the Treasury”.—[Official Report, Commons, 11/2/13; col. 601.]

I understand that additional spending in England of about £1 billion should generate about £60 million of consequential spending in Wales. Can the Minister confirm that a figure has been agreed, and can he tell the House what it is? There is the associated question of the Barnett formula being generally inadequate and particularly inadequate in this context, where the age and need profile in Wales differs from that in England. Wales has higher levels of disability for historical and industrial reasons, and thousands of people retire from England to the beautiful coastlines and countryside of Wales. They are very welcome to come, but there is a cost implication. Wales has the highest proportion of older people of any country or region in the United Kingdom. Nearly one in four are over 60 years of age, and that is expected to increase by a further 5% over the next 10 years. The noble Baroness, Lady Browning, rightly emphasised the need to be aware of the demographic changes that are taking place and the effects that they will have. Any funding system that is based merely on total population relativities will inevitably generate inequalities.

Thirdly, the Government of Wales are currently in the process of reorganising social care in Wales. The Social Services and Well-being (Wales) Bill is similar to this Bill in many aspects and will, inter alia, increase the number of services for which people can claim a direct payment from the local authority, introduce national eligibility criteria, and provide for portable assessments to avoid the cost and trouble of reassessment. These detailed provisions need not exercise your Lordships’ House. What is of concern, however, is that any provisions in this Care Bill with an England and Wales remit will impact on the changes taking place in Wales under the other legislation.

Equally, changes taking place in Wales will have an implication for cross-border placements and the portability of care packages. Can the Minister tell the House whether discussions have been concluded with Ministers and officials in Cardiff and whether all issues in this area have been resolved? In particular, has there been a resolution of the portability of social services assessment undertaken in Wales in the event of persons choosing to move to England, and likewise of the portability of care packages for persons choosing to move from England to Wales? I am not referring to cross-border placement, which is quite another matter. Will the UK government cap on social care costs follow an individual

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who moves to Wales from England and is already in receipt of a care package, and if the cap is different in Wales, which of the two would apply? There is a real danger of disputes arising. The Care & Support Alliance commented:

“The Care Bill could have gone further to set out a strong and clear dispute process”.

The difficulty to which cross-border issues give rise within England between local authority areas is covered by Clause 36. This provision deals with people choosing to move for genuine reasons, but it does not appear to deal with those moving between England and Wales for genuine reasons. Likewise, Schedule 1 deals with the cross-border placement question, and paragraph 1(2) deals with the placement from England to Wales, but it does not appear to specify who has the responsibility for paying. Perhaps the further provisions referred to in paragraph 1(5) are meant to cover this, but it is far from clear and we need some assurances on the matter. It is also less than clear that paragraph 6(2) of Schedule 1 is adequately rigorous to provide for full recompense or that it is relevant in all cases. I should say that the Social Services and Well-being (Wales) Bill also fails to clarify these cross-border issues. These are matters that we certainly will need to clarify and to follow up in Committee.

Finally, I refer to the proposed health research authority provided for by Clause 96. Clause 98 states that the HRA’s remit is to promote the co-ordination and standardisation of practice in the UK in the regulation of social care. The Bill places a duty on the HRA and the devolved Administrations to co-operate with one another, but how on earth is such a duty going to be enforced? And what happens if disagreement arises between conflicting expectations in Wales, Scotland and England? Does the Secretary of State in England have to act as a referee in such a dispute? I am not arguing against the need for such co-operation, of course, but legislating for these matters never guarantees the desired outcome. All these issues are points for further consideration in Committee. Meanwhile, I am very content to support the Second Reading of the Bill.

6.26 pm

Lord Lipsey: My Lords, I declare an interest as unpaid president of SOLLA, the Society of Later Life Advisers. I want in my remarks to concentrate on the Dilnot-related parts of the Bill—that is to say, the cap and the related changes to the means test. I should state straightaway that I welcome the cap. Indeed, I hope that the House will not think it unduly immodest of me if I claim to be, if not its father, perhaps its grandfather. In the minority report of the 1999 royal commission, which I signed with the noble Lord, Lord Joffe, there was a proposal that people should have their care costs covered if they were in care for more than five years. I was not even able to command the majority in the minority on that matter, because the noble Lord, Lord Joffe, did not agree with me on that, although we agreed on everything else. So right from the beginning I have been a strong supporter of people being protected against catastrophic costs of care. I emphasise the word “catastrophic”, because I am also extremely glad that the Government opted for the

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£75K cap, which I referred to in this House in my initial reaction to the Dilnot proposals, and not for the much lower figures put forward by the commission, which frankly I thought to be unaffordable.

I hope that my credentials as a broad supporter of what the Government are doing are established and that it will not seem impossibly contrarian if I point out two disadvantages of the proposed scheme that we need to bear in mind throughout proceedings. The first is that it is still pretty expensive—£1 billion by the end of the next Parliament, rising to £2 billion by 2030, according to calculations by the Health Economics Group at the University of East Anglia and the LSE’s PSSRU. In the times of austerity in which we are living, any increase in public spending needs to be very thoroughly justified, because of its implications for taxation if nothing else. There is a particular danger in spending money on helping people to pay for care. The real acute and immediate crisis that we face is not about people paying for care; it is about the amount of care that we are providing, on which spending has been cut by about £710 million in real terms since this Government came to power. There are loads of figures, but that is the one that hit me. People are doing without services. If you do not have substantial needs, you do not get services any more. When the priorities come to be weighed, that seems to me to be the pre-eminent one.

There is also the issue of where this money goes. The Dilnot proposals—for all their advantages, which I will come back to before noble Lords get convinced that they should not go forward—do little for the poor. They mostly benefit the better-off. That is because poor people get paid for in full under the present means-testing system. It is the better-off who have to pay. Of course they do not like that and it understandably creates a furore. Even the Government’s plan, which I will call “watered-down Dilnot”, benefits most the better-off. According to the same academic sources that I quoted, the plans in 2030 will be worth £52 a week to people over 85 in the top quintile by income—the top 20%—compared with just £20 a week to those in the lowest quintile. That is an inevitable consequence of replacing means-tested benefits with targeted universal benefits, which is why some of us are chary of the current fashion for scrapping means tests.

Dilnot argued that the cap will protect a bigger share of the assets of those with modest wealth than those with lots of wealth. That is true. It is, however, also true that those with modest wealth will have to contribute to the cost of their care a higher percentage of their wealth than will richer people. It was therefore as difficult a choice for me as it was for Joel, my noble friend Lord Joffe. I go back to the only dispute that we ever had.

Against those disadvantages had to be weighed two important advantages. One is that there is real injustice in the present system, because it is a total lottery as to whether you need care or none at all. It seems unfair that one set of people, however well off they may be, have their wealth wiped out because they happen to need a lot of care, while more people—about two-thirds—get away with the full loot to leave to their children because they do not happen to need care. That lottery is unjustifiable.

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I have been in politics for some time and, frankly, I thought that it would be a tremendous advantage if, at reasonable cost, we could get this issue of paying for care off the agenda and concentrate on the things that really matter—the money that has to go into care services, the way that those services are organised and the way that individuals get more control over those services. The issue of the old having to sell their homes to pay for care is a distraction from a more important debate, and the proposals, at modest cost, will take it off the agenda. It is right to proceed with them, but I am sorry that the cap changed from £75,000 to £72,000 and that it has been brought in a year earlier as a result of the Budget. That means increased Exchequer costs earlier, which is robbing money that should go on services.

Incidentally—this is a side issue, but important—the administrative burden on local authorities is quite alarming. Getting this done by 2016 is a major deal. Authorities will need to invest huge amounts in systems, staff, advice and all these things—perhaps £500 million just for the administrative costs. The Government must—I repeat, must—pay for that in full, but it will be nip and tuck as to whether it is done in an orderly fashion to the new timetable. If that had not been done, we would have had a little extra money. At quite modest cost, the government scheme could be tweaked to do more for those with relatively modest wealth and we would not have to worry as much that all the benefits were going to the better-off.

This now gets a bit geeky, but I will persist. The Government propose to raise to £123,000 the limit on how much wealth you can have before you stop getting means-tested support. That is good; it represents the value of a cheap house in some parts of the country. However, it is not very good. I do not know how many noble Lords are fully aware of this but, in fact, if you have £123,000 in assets and that modest house, all the money that the Government are trying to give you under the means test will be taken away from you. Why is that? It is because of a little-known thing called the tariff. Under the present system, for every £250 that you have in excess of about £14,000 in assets, you lose £1 a week in benefit. You would require a 20% return on your savings—£50 a year on £250—to benefit. The money is taken out of your pocket by this tariff in the means test as it is put in by the increase in the ceiling.

How could this be changed? It could be done easily. Suppose that the tariff was changed so that, instead of losing £1 for every £250 of your assets, you lost £1 for every £500. Therefore, those with assets of up to £123,000 would get decent benefits from the state towards the costs of care. Nor would the cost to the state be great. According to the academics whom I quoted, the cost would be around £150 million—less than a sixth of the cost of the Government’s proposals. A small slice would go to those with modest income and wealth and, if necessary, it would reduce the very large slice going to those with substantial income and wealth. In other words, if this proposal were to be combined with the cap proposals, we would have a much less regressive package. If it were necessary to fund it by raising the cap from £72,000 to, say, £80,000 or a little more, that would be a price well worth paying for a more socially just solution.

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My party has rightly criticised the Government, mildly, because their plan does not do enough for the less well-off. Here is a ready-made solution. The Minister was described at a meeting earlier this afternoon as a saint. I would not dissent from that. I do not mean to be offensive to the noble Earl, but he would not like the tag put on him that he cares only for the better-off. When the Bill goes to Committee, I am confident that the noble Earl, Lord Howe, will stand up and accept amendments to reduce the tariff to £1 for every £500, thereby making this Bill much more progressive and helpful to those hard-working people on modest incomes who want their fortunes to be protected.

6.36 pm

Lord Bichard: My Lords, I should declare an interest as chair of the Social Care Institute for Excellence—or SCIE, as it is known in non-media circles. The first chair of that organisation was the noble Baroness, Lady Campbell, so I am conscious that I have rather a lot to live up to, but I will do my best. I took on that role because I believe that social care is the most important social issue for the next decade or two. That means that this is one of the most important Bills to go through this House in this Session or, indeed, at any time. As others have said, the Bill has the potential to redefine the landscape of care and to offer a new deal to those in need of care, many of whom, let us not forget, are vulnerable and frail and face difficult and complex problems and decisions about their future. They have often contributed greatly to our society and their communities, and deserve to be properly supported and sustained when the need arises.

Again, there is much in the Bill to applaud and welcome: the greater emphasis on prevention, the cap on the cost of care, the responsibility to promote individual well-being, the emphasis placed upon integration and co-operation, and the new rights for carers. We can all applaud and welcome those provisions. However, in Committee we will naturally look at ways in which we can make the Bill even better. I want to suggest five measures that we may consider.

First of all, I should like to see an even stronger commitment to dignity at the beginning of the Bill. The recent events in mid-Staffordshire and in individual care homes must surely have taught us that whatever changes we make to organisational structures, technology, financial systems, buildings or even equipment, they count for little if personal dignity is not afforded absolute priority on the ground. It must be the bedrock upon which everything else rests. It can no longer be taken for granted or left unsaid. Clause 1(2) refers to dignity, but in passing. It does not feature strongly enough and is entirely lacking in other key provisions, such as in Clause 1(3). I should like the very first clause to state boldly that the general duty of all providers, not just local authorities, is not only to promote individual well-being but to ensure that individuals are treated with dignity at all times and in all settings.

In making my second point, I declare that I am a vice-president of the Local Government Association. There is a danger that Parliament—I use that term rather than “Government”, because we all have a responsibility in this—sees this Bill as an opportunity

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to make bold statements of good intent and then immediately to pass on the responsibility for achieving them to local government, with insufficient thought being given to the consequences.

Local government rightly has a key role to play in this, but we all know that it is bearing the brunt of budget cuts, and it would be irresponsible of us not to take account of the pressures facing local authorities as we debate the Bill. Others have already reminded this House of the reductions that local authorities are making: £2.68 billion in the last three years to social care funding, and another £800 million in 2013-14. Like many others, I can see no way in which the ambitions of the Bill can be achieved without some additional funding sooner rather than later. At the very least, in our discussions and in our debates we should carefully make explicit and take account of the practical implications of every clause and every proposal, so that we do not just make bold statements of intent.

My third point is that there is a danger that in making these proposals the Government do not examine closely enough how their own practice and their own behaviour can make it more difficult for all those on the front line to deliver the kind of integrated service we all want to see. It would be quite wrong for the Government merely to encourage others to go away and integrate without looking carefully at their own practice and their own behaviour. The King’s Fund—I am a member of its advisory board—says that in feedback from its work with local health and social care leaders, one reason for the lack of progress in developing integrated care is that some aspects of current policy, practice and regulation are acting as serious barriers to progress. The Government need to look at how Whitehall departments can be made to work together more effectively. They need to look at the impact that silo-based budgets, targets and regulation systems have on good practice on the ground, and they need to look at some of the big strategic issues, such as the interface between the NHS Commissioning Board and clinical commissioning groups. This needs to be addressed afresh.

At the moment, a great many good things are happening out there, but very often you are told, as we were recently in the Select Committee in this House, that they happen in spite of Whitehall and in spite of Westminster, not because of them. Maybe Clause 3 should refer again not just to local authorities exercising their functions with a view to ensuring integration but to Government. Let us not forget housing providers. Why do we feel comfortable imposing statutory responsibilities to co-operate on everyone except central government departments?

My fourth point relates to the importance of information and advice, and to the need for this to be properly independent from providers’ interest. Clause 4 refers to the need for financial advice to be independent, but we need to ensure that individuals are not vulnerable to other advice that might disadvantage them but benefit providers. Clearly, the Government have set their face, for the moment at least, against a legal right to advocacy, while acknowledging in the Explanatory Notes that advocacy might be necessary in some circumstances. I wonder whether this issue would benefit from one further look. Is it really not possible for us to

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come up with some affordable advocacy support for people who are, as I said earlier, facing such difficult decisions?

Finally, I would like to see us making greater efforts to make care and support provision more inclusive. At the moment, care homes, to take one example, sometimes stand apart from their communities, and too often communities seem content for that to happen. Such a situation would be completely unthinkable with schools. As a result, opportunities to improve residents’ quality of life are missed, and crucial opportunities to identify unacceptable practice are missed too. We cannot expect infrequent CQC inspections to be the only way to spot poor care, and I believe that David Behan, the chief executive of the CQC, agrees. More frequent visits from volunteers could make a big difference. It is quite clear that relatives of residents are often reluctant to complain, because justly or not they fear that this would be held against their loved ones. We need stronger external involvement, and we could help to achieve it by adding a duty in Clause 1(3) to take steps to ensure that care and support facilities are open, transparent and accessible to local communities. It is already good practice and we can see it happening in the best care and support facilities, but it needs to be uniform.

This Bill could be a defining moment in the history of care in this country. Care is an issue that should in large part rise above party politics. I look forward to this House doing what it does best: playing a key part in achieving the best possible legislative outcome, but ensuring most of all that those in need of care are treated fairly, and always with the greatest dignity and respect.

6.47 pm

Baroness Donaghy: My Lords, I welcome the introduction of the Care Bill. There are areas which I hope to see strengthened, but it represents a basic framework on which future generations should be able to build. My concern is how we make the words a reality. It is not the first time that this has been mentioned in debates. Will future funding restraints prevent any real improvements? How can we ensure the essential co-ordination between hospital care and home or residential care? My final concern is around the capacity and welfare of our workforce in health and social care and in local authorities. To make the words a reality the Care Bill must, in the words of Age UK,

“make a tangible difference to the lives of people with care and support needs who are currently effectively ignored by the system”.

The Bill contains measures to ensure a single national eligibility threshold for care services, but if, as the noble Lord, Lord Rix, has already mentioned, the regulations set the minimum level at “substantial” rather than “moderate”, it would affect 100,000 people and would render a national system meaningless. Age UK asks for the Bill to be strengthened in a number of ways, for instance by linking eligibility for social care to the achievement of outcomes based on the individual’s well-being, as defined in the Bill. The requirements on local authorities to plan to meet the diverse needs of their populations and to promote quality and choice could be strengthened by requiring service commissioners

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to monitor and take action where necessary. Clause 8, describing the kinds of support which local authorities must offer, should include issues such as transport.

Finally, on turning words into deeds, good quality information and advice is needed. The most stressful thing for any family caring for the frail elderly is finding their way through the maze, feeling unsupported and fearful that they are not accessing the best possible services for their loved one. Website information is welcome, but some people need more intensive help. The clause on advocacy has already been mentioned. It should be strengthened, perhaps by creating a positive duty on local authorities to ensure that someone has the help and advice they need.

Secondly, despite not being written in the scope of this Bill, future funding is critical for its success. As many of us have said in this and previous debates, there have been real-terms cuts to social care funding: 7.7% in 2011-12 and 6.8% in 2012-13. The rising levels of unmet need are such that 800,000 people who need care now are not receiving it. The Nuffield Trust calculates that,

“there would be a funding gap of between £7 and £9 billion by 2021/22 if funding were held constant in real terms”.

It adds:

“These funding pressures would rise to between five and six per cent a year if the recommendations of the Commission on Funding of Care and Support were implemented, resulting in a total funding gap of £10 to £12 billion by 2021/22”.

This gap will have to be faced by the next elected Government and will probably be met only by a combination of productivity savings, managing chronic conditions, holding down pay and taking a larger share of public funding. The social care funding gap is likely to be between 3% and 6% a year, depending on trends in chronic conditions, and Dilnot costs of course. The Nuffield Trust concludes that:

“The NHS in England may face continued austerity measures into the early 2020s”,

which is something of an understatement.

The Local Government Association supports the intentions behind the Bill but has pointed out that,

“the government’s austerity programme … does not fit well with the aspirations of the Bill”.

Policy decisions and financial decisions have become detached. The point about underfunding has also been made by the Care & Support Alliance and Age UK.

The need to co-ordinate health and social care is going to become even more desperate. In its response to the Francis public inquiry report, the Nuffield Trust states:

“The reality is that more and more trusts will be treating large numbers of sicker, older adults in an atmosphere of pay restraint and frozen budgets”,

and recommends that,

“the highest priority for initial development of fundamental standards be given to care of the frail older people on acute wards … and that this priority should shape any new requirements for data collection in NHS trusts set by the NHS Commissioning Board or the Care Quality Commission”.

The NHS is already creaking under the weight of our failure to solve the social care crisis. When I was a carer, I fought tooth and nail for my mother to be allowed to stay in hospital until her health improved

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rather than be sent back to the care home where she spent the last 18 months of her life—not that her care was good in hospital; it was a choice between bad and worse. I understand the dilemma of families who want to do the best for their elderly relatives. Perhaps we need more halfway house temporary accommodation, jointly funded by the NHS and local authorities or charities, to relieve the undoubted pressure on hospital beds. If care standards in residential homes were better, that would relieve pressure on hospital beds.

The changes proposed in the Bill will put enormous pressure on staff in the health service, social care and local authorities generally. The Joint Committee on the draft care and support Bill has already raised the issue of initial and ongoing training and support needed for local authority staff and social workers. Others have dealt with the certification of care workers. Long shifts and low pay are a real problem in residential homes and often determine the quality and commitment of staff. With all these new responsibilities being piled upon staff by this Bill, we should not forget our responsibility to meet their capacity and welfare needs. Also, the statutory requirement for candour may not sit easily with a more market-oriented approach to health and social care. This would also place a tremendous burden on some staff.

Finally, I have not referred to the “Dilnot-lite” elements of the Bill. Of course it is disappointing that the Dilnot figure was not accepted. The proposed figure will benefit very few people, particularly with the additional £12,000 a year overhead costs, but it is a start and having a framework is very important.

The timetable for the Mesothelioma Bill clashes with the Committee stage of this Bill, so I will not be able to be present for the early stages, but looking around I feel sure that all angles will be well covered by noble Lords on all sides of the House.

6.55 pm

Lord Sharkey: My Lords, it is a pleasure to follow the noble Baroness, Lady Donaghy. Like her, I very much welcome this Bill. It is a very good Bill and the Government are to be congratulated on bringing it forward, on responding constructively to the recommendations and observations in the Joint Committee’s excellent report on the draft Bill, and on incorporating the essence of the Dilnot report into the Bill. When it becomes law, the Bill will have the effect, among other things, of introducing certainty, stability and consistency into the provision of care. It will also create the conditions in which financial institutions can begin to write policies that will directly help in the pooling of risk, which is not the case at the moment.

The Bill deals with a very complicated subject and seeks to make fundamental changes to the current arrangements. Many of the critical components of this reform of the care system are to be left to secondary legislation and guidance. Although it is clear that many details will need to be and should be left to secondary legislation and guidance, I think that the Bill would benefit by addressing some of the key issues more directly in primary legislation.

The recent toing and froing over Section 75 of the NHS Act illustrates the point. There are some things to which the answer is not yes or no. There are things

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that the House may very well want to debate in a way that produces amendment. I suggest that the size of the various caps critical to this Bill are such things and would be better debated amendably than on a yes or no basis.

Dilnot noted in his report that setting the cap above £50,000,

“would not meet our criteria of fairness or sustainability”.

The proposed cap of £72,000 is greater than Dilnot’s £50,000, even allowing for inflation. I suspect that many Members will want a vigorous debate in Committee on where the trade-off between reach and affordability should lie. The same goes for the definition of eligibility in Clause 13, and for Clause 34(1), which will by regulation set out when an authority may agree to defer payment. All these things may be better discussed in the more flexible environment of primary legislation.

I will now comment on four more specific areas of the Bill. The first is communications, which is dealt with in Clause 4. The Dilnot report, which for me is a model of absolute clarity, has 10 recommendations. Two of these are about communications because Dilnot clearly views that issue as central to the success of the entire scheme. Recommendation 7 says:

“To encourage people to plan ahead for their later life we recommend that the Government invest in an awareness campaign”.

This is proactive and prospective information. Recommendation 8 says:

“The Government should develop a major new information and advice strategy to help when care needs arise”.

This is reactive and responsive information. The Bill addresses the second recommendation and not, I think, the first.

Clause 4 specifies in some detail what information must be provided by local authorities but it seems to be aimed, as Dilnot puts it, at situations “when care needs arise”. It does not seem to deal with Dilnot’s Recommendation 7, which asks for more general, wider and very much earlier awareness campaigns. Dilnot seems to be asking for a heavyweight, national publicity campaign aimed at the general population before need arises.

Furthermore, the Bill contains no provisions for defining the test for sufficiency in “sufficient” information as stipulated in Clause 4(3). It does not seem to include the requirement to provide information, for example, about how to appeal against a judgment of ineligibility. I assume that there is such a right of appeal, and a simple and quick mechanism for handling such appeals in the first instance, even though I could not spot it in the Bill.

There also appears to be no requirement in the Bill for local authorities to have a mechanism for measuring and reporting their success in providing information or the success of that information in achieving its objectives. I should be very interested in the Minister’s comments on general early-awareness campaigns; on the need to measure success in providing what the Bill calls sufficient information; and on the existence of an appeal mechanism at first instance.

The second area I wanted to speak about is eligibility. I have already said that I think that the criteria for eligibility should have been available before this debate.

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I also worry about a Section 75 problem in dealing with the criteria and secondary legislation. In particular, I wonder how local authorities are to be able to take a properly comprehensive view of who might be eligible. The Bill states in Clause 9:

“Where it appears to a local authority that an adult may have needs for care and support”,

and so on. That strikes me as a very passive and rather weak obligation. It does not specify any duty to be properly aware of such adults, merely to act if it appears to the authority that an adult may have such needs. We may need firmer language here. The Bill would surely benefit from obliging local authorities to take appropriate and proportionate steps to make sure that they are reasonably likely to know when an adult is in need of care and support.

The Bill is also silent on the time that a local authority may take between becoming aware that an adult may be in need, making an assessment, determining eligibility and providing the service. It is clear that we need national standards of service here. I assume that requirements will be written into guidance, but I would welcome the Minister’s assurance on that.

The third area that I want to address is the question of direct payments. The Joint Committee was quite right to propose that we should not be too restrictive about the use of direct payments, and I was glad that the Government agreed to that in their response and to see no unreasonable restrictions in the Bill. However, the problem is likely not to be abuse but accidental mismanagement and complications arising from it. It seems highly likely that some who ask for and are allowed direct payment may find the subsequent commissioning and managing of the services that they need stressful, complex and burdensome. It may be a very good idea if the local authorities have an obligation to provide friendly oversight of and help with the management of direct payment services, at least in the first months of their existence. It would be a great pity if the valuable ability of people to specify and obtain what they need was allowed to suffer from bureaucratic, management or legal difficulties due to inexperience, misunderstanding or contractual unsuitability.

The fourth and final area on which I should like to touch briefly is funding. As many other noble Lords have said, to make all that work, the funding needs to be sufficient. In particular, the Dilnot cap needs to be set at the optimum level to balance reach and affordability. We will want to examine the assertions made in the impact assessment carefully in Committee. I hope that the impact assessment’s calculations turn out to be accurate on examination and when we are in possession of all the details to be contained in secondary legislation.

I note, for example, that the Joint Committee states in Recommendation 5:

“The introduction of a capped cost scheme, which will result in many more people being assessed and entitled to a personal budget, is likely to lead to an increase in disputes and legal challenges. We are not confident that Ministers have yet fully thought through the implications for local authorities of these changes”.

Rather worryingly, there does not seem to be any financial provision for that in the impact assessment.

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I end by repeating what I said at the beginning. Notwithstanding my four areas of concern and my feeling that the balance here between primary and secondary legislation is not quite right, I believe that this is a very good Bill. I believe that, with proper funding, it will lead to a clear and genuine improvement in the provision of care, and I congratulate the Government on introducing it.

7.04 pm

Baroness Greengross: My Lords, I add my name to the list of noble Lords who have expressed the view that the Bill is very welcome indeed. I was privileged to serve on the scrutiny committee considering the Bill. Integrating—or at least having co-operation between—services that are so differently organised at the moment is extremely difficult to succeed in, but essential if we are to get it right. We are talking about an extremely vulnerable group in our society. In fact, there is more than one group. There is a huge number of frail, older people and a very large number of disabled people of all ages. It is not fair or worthy of our society to think that people can shop around for the services that they need. It is impossible, we know that. They must be integrated.

I have a very simplistic view on this. I know that it is difficult to bring a paid-for service and a service that is free at the point of delivery together, but if the money is ring-fenced and put in the hands of either the clinical commissioning group or the health and well-being board, where they are mandated to mix up the money and use it in a co-ordinated way, I cannot understand why that would not work. As I said, that is my simplistic way of looking at this.

Everyone has echoed the fact that we need more money to make this succeed. We do, but Andrew Dilnot and his colleagues demonstrated clearly that the amount of money needed to make this succeed is a minute proportion of what we spend in the National Health Service, primarily on acute services, and that if we integrate those services we can achieve a great deal. We do not always measure the savings that we will make on acute NHS services, as a proportion of NHS costs, by getting this right. Those are not, generally speaking, the right services to deal with the people involved. People often need to go into hospital for short periods but much of what they need can, and much more could, be provided in the community.

I have previously spoken with the noble Earl about the innovation that is necessary, including step-down facilities for people who do not need to be in acute hospitals, like the Scandinavian model of patient hotels. That would not be privatisation, as they would be NHS-funded contracted services which provide private accommodation and family care—opportunities for care rather than healthcare—with access to medical specialists as and when necessary. All sorts of such experimental schemes can be introduced if we mix the money. I think that that is the priority.

We need to get rid of the terrible situation at the moment where people are waiting in their own homes for the care that they need. I know about this because I was the lead commissioner for domiciliary care for older people not very long ago. If people who need

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services are at home, a care worker comes to you who cannot count the time that it takes to get there but then has to get you up, clean you up, clean up your room, dress you, make you a meal, talk to you and help you eat your meal within 15 minutes. That is, physically and mentally, totally impossible. It is an insult and an impossibility. We cannot go on doing that to vulnerable people, so we must somehow put our resources together and get this right. It is a disgrace at the moment and of course, when it does not work, we need advocacy services. I agree with the noble Lord—forgive me, but I think that it was the noble Lord, Lord Bichard—who was talking about the role of care homes. Another step-down facility can be the care home, if the care home of the future can be more of a local hub.

I would like to see that my mum gets to know the care home provider, goes there for French classes, local history lessons or art—and for the odd weekend if daughter is going away—and that, knowing it, she goes there for a holiday and then moves in. That is not dumping mum; it is mum going to a place that she already knows well. The care homes of the future must be a resource for the local community and linked to all the other services. They must be part of the step-down procedures, from acute hospitals to caring for the sort of vulnerable people who we are talking about.

In the Bill, there is the possibility of making this happen but we must get some things clarified. What are the duties of a local authority in promoting well-being, for example? It is not absolutely clear. We must be certain that there is enough care and support provision in every local area. In terms of well-being, we need to make sure that the Prime Minister’s challenge on dementia, which is due soon, will outline how much progress is being made on making the quality of care as important as the quality of treatment. When we talk about the growing challenge of dementia, it is not always about treatment but about care. The prevalence of dementia makes that essential. The other point that we might bring in is that much of dementia care should come under public health because it is about prevention, well-being, design and preventive care. If we can bring public health professionals, who are now very important at a local level, into this group of providers then we stand a chance of getting this right.

I also support the noble Lord, Lord Bichard, in making the point that end-of-life care is important and that we must make sure that people who are approaching their last days do not have to pay for the care that they need. These definitions of what health and social care are should disappear at that point. We are talking about services to dying people. After all the years that I have worked in the field of aging and with older people I know that the loss of dignity and respect, and going into an inappropriate hospital setting, are what people fear most as their life draws to a close.

I agree with everybody who said that moderate care must be part of the equation. If I was a director of adult social services, I would have to concentrate on those in the greatest need. We are so limited as regards the number of people who can obtain services at all. If we could only include moderate services, we might have a chance of preventive types of care being part of our envisaged service provision.

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We must also do something about self-funders subsidising the funders who get their total funding paid for by the local authority. In terms of inflating the cap and the personal care account, although annual wage inflation appears to be the chosen index some sort of acknowledgement must be made of the actual cost of care. I assume that the practice of self-funders paying more than local authority-funded people, often for the same accommodation in a residential or other type of care home—subsidising the latter, in other words—will be clarified or should cease. Otherwise, self-funders are going to reach the cap far in advance of other residents. This is not only unfair but might well be challenged as not being legal, being a form of taxation which is not publicly accountable.

When elderly people who are frail go into hospital, their discharge procedure must be verified and known about as part of the admission process. I think we made this clear in the scrutiny committee. We get these terrible stories now of very frail people being discharged from hospital with no proper plan. We know, because we have heard about this recently, about the horrible wait that people have to leave hospital. We must make sure that advice relating to care and support includes information about how to access relevant independent financial advice. This should bring in the members of SOLLA; the noble Lord who spoke about that was in an authoritative position to do so.

Some new schemes are coming forward from one or two think tanks, including one with which I am associated, which are looking at more affordable savings products that might appeal to people of modest means. I hope that for people not normally able to pay for an insurance scheme, these products would help encourage the insurance companies to come in and provide the sort of long-term schemes that are needed to make this care system work properly. Unfortunately, they really do not exist in this country at the moment, but with the catastrophic costs being taken on board by the state it should be possible before too long to interest the insurance industry in being part of paying for care for older people in the future.

This Bill has been awaited for a very long time. We need to make sure that other things that we have learnt, such as human rights protection, are not left out of the Bill as it proceeds through Parliament. We know that there are some serious problems in ensuring that human rights protection will follow people, however their care is provided. I hope that we can work on that in Committee to make sure that it is clarified and that it is simple to access human rights protection. Whoever the provider of care might be, frail and vulnerable people, who are usually very old, need that protection. We have seen too many instances of human rights being abused and quite dreadfully breached. This Bill is so important, as long as it guarantees that those sorts of abuses will not happen in the future.

7.17 pm

Lord Warner: My Lords, let me say at the outset how much I welcome this Bill and in doing so I pay tribute to the contributions made to its construction and arrival in this House by Paul Burstow and Norman Lamb. I should also declare my interests, as a member of the Dilnot commission and as a member of the

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Joint Select Committee on the draft Care and Support Bill. I emphasise that it produced a unanimous cross-party report with more than 100 recommendations for improvements, mainly in relation to Part 1 of the Bill. The evidence given to the Select Committee showed strong stakeholder support for the Bill, but there were important proposals for further improvements that we reflected in our recommendations.

At this stage I shall not comment on the Dilnot recommendations, other than to distance myself slightly from the remarks of my noble friend Lord Lipsey and to associate myself with the excellent remarks made by the noble Lord, Lord Sharkey. I will come in a moment to some of those Joint Committee recommendations that were not accepted by the Government. First, I would like to ask the Minister about the Bill’s silence on the key area of public health to which the noble Baroness, Lady Greengross, referred.

We know that the NHS’s core business is the management of 17 million people with long-term chronic conditions, many of which have been largely caused by—if I may put it this way—lifestyle decision-making. We know that nudging on its own does not really cut the mustard with issues around smoking, alcohol consumption and poor diet and that legislation may be needed. It was disappointing to many people outside this House—certainly, I have had a lot of approaches about this—that the Government did not use this Bill to bring forward the standardised packaging of cigarettes, the minimum pricing of alcohol and some kind of simplified system of food labelling. They have failed to do so. Will the Minister tell us a bit more about the Government’s plans for introducing legislation in these three areas? If it is not to be this Bill, when will we see legislation tackling these issues, on which there is a very large measure of public support for something to be done?

I now turn to some areas in Part 1 that require fuller scrutiny in Committee and probably amendment. The principle in Clause 1 of promoting well-being has been warmly and widely welcomed, as the noble and learned Lord, Lord Mackay, mentioned earlier. The Joint Select Committee considered that this principle should be applied to Ministers when exercising their responsibilities under the Bill. Ministers in oral evidence seemed slightly sympathetic to this idea, but when they got back to Richmond House they seem to have gone cold on it and rejected the Joint Select Committee’s recommendations. I will be interested if the Minister can produce more convincing arguments than I have heard so far on why the Joint Select Committee’s recommendation was rejected. If we are not convinced by the arguments of the Minister and his colleagues, I hope that some of my colleagues on the Joint Select Committee will join me in prodding the Government a little further with an amendment to see what they are made of.

I shall flag up briefly for the Minister some other areas in Part 1 where I am minded to put down amendments. On integration, I think the response to some of the Committee’s recommendations suggests that the Government are a bit happier talking the talk rather than walking the walk with practical ideas such as—dare I suggest it?— pooled budgets, joint commissioning, joint provisioning and a number of

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others. Like the noble and learned Lord, Lord Mackay, I still think that implementing the Bill’s changes effectively over time requires a statutory code of practice, and I would favour an amendment to achieve that. As noble Lords have said, the Bill needs strengthening on young carers, advocacy and human rights protection for those in private care homes. We have been over that latter ground a number of times in this House, and it is time to deal with this once and for all. I do not think the outside world is convinced by the Government’s position on this or, indeed, by the previous Government’s position on it. We need some careful drafting that gives proper protection to those in care homes who are paying their own way. It is not good enough to leave things as they are.

Let me flag up some issues around whether there will be a credible way of dealing with what is likely to be a considerable number of disputes over this legislation. The noble Lord, Lord Sharkey, mentioned this. There will be two types of dispute: disputes between service users and the local authority, and disputes between the local authority and service providers. We could leave things as they are, but if we really want a lot of judicial reviews and to clog up the courts, that is the right way to go about it. We need to hear a bit more from the Government about their further thinking on some tribunal-type way of dealing with these disputes without relying on the courts.

I am genuinely puzzled by the Bill’s drafting on the boundary between the NHS and social care, as is the noble and learned Lord, Lord Mackay. I am still unclear whether the boundary has been changed. I would very much like to hear the Minister’s response to the view of the noble and learned Lord, Lord Mackay, given the attention he has given to this issue in the Joint Select Committee and outside it.

The issue in Part 1 that is of greatest concern to most people is Clause 13 on eligibility criteria, as a number of noble Lords have said. They are to be dealt with by regulations and, as I understand it, drafts will not be published before the spending review announcement scheduled for late June. The Government have promised to establish a minimum national threshold of service need to be met under these criteria. It is still a bit unclear to me where in the Bill we find that. Will the Minister explain how this will be done?

More widely on Clause 13 there are widespread concerns that this threshold will be set too low to ensure that enough effort is put into preventive help to protect independence and preserve well-being. I think consideration will have to be given in Committee to placing in the Bill a stronger framework of requirements on eligibility criteria rather than leaving so much to ministerial discretion within regulations. I certainly feel a set of amendments coming upon me on this issue, and I welcome any contributions on this issue—the more, the merrier.

There are some other issues I want to raise on Part 1, such as including social care savings in auto-enrolment schemes for pensions, the right to die at home and free social care at end of life for patients suffering from cancer. However, the last point I wish to raise today on Part 1 is one that a number of other noble Lords have raised: funding for social care. The

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Dilnot commission’s report made it crystal clear that its proposals would not solve the existing shortfall in social care funding. I do not wish to trade figures today with the Minister on this issue, but what is beyond doubt is that there is a major funding shortfall relative to need. It is fair to say that historically under successive Governments social care has been less generously funded than the NHS, and promising a brave new future under this Bill without adequate funding for implementing the new system would be a cruel deception to inflict on many vulnerable people. More immediately, the funding crisis in social care is having a major impact on the NHS in terms of the major flow of people into A&E departments, especially at night, and the lengthening of hospital stays as discharge packages cannot be funded.

Social care has never had a review of its funding like the review that the late Derek Wanless carried out for the previous Government on the NHS. We should consider bringing forward an amendment to the Bill to provide for an independent review of the funding required for adult social care. I would like the Government to be willing to contemplate asking the Office for Budget Responsibility to conduct such a review, and I would like to be in a position to put down an amendment so that we can debate this issue fully during the passage of the Bill. I know that the King’s Fund will be undertaking a further review of social care funding, but Derek Wanless did one for it on this some time ago. It simply does not have the clout and authority that an organisation such as the Office for Budget Responsibility has.

There are a few issues on Part 2 that I will wish to raise. I shall not dwell on them for very long today, but I want to mention to the Minister some of the issues around Clauses 76 and 77, which are concerned with trust failure. As I understand these clauses, they relate to foundation trusts only, but the trusts with the possibility and risk of failure are those within the remit of the NHS Trust Development Authority. They are the trusts with the longer-standing financial problems and, by association, they present the greater risks to quality for patients. Indeed, the TDA’s mandate, in a ministerial letter of 7 May, says that the TDA is expected to “make a significant contribution to improving quality of care”. Can the Minister explain to us why the TDA trusts are not covered by the Bill when they appear to have a less robust approach to failure than Monitor? Does this not put patients in these trusts more at risk than those in foundation trusts?

7.30 pm

Lord Sutherland of Houndwood: My Lords, it is, of course, a pleasure to follow my colleague, the noble Lord, Lord Warner, whose experience contributed so much to the outcome of the Dilnot review, and who has regularly drawn the attention of this House to the importance of its conclusions. I also thank the noble Baroness, Lady Barker, for her kind remarks. Suffice it to say that I remain one of the usual suspects and will continue in that gang for the foreseeable future.

The context of this Bill has a history. The post-war creation of the modern welfare state as we know it was momentous, and many of us have benefited from that for most of our lives. The two Bs, Beveridge and

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Bevan, gave us two structures. The first is the National Health Service, which in principle offers healthcare free at the point of delivery, and the second offers other benefits that cannot be defined as healthcare, including care services deemed to fall outside healthcare. These are not free at point of delivery but are subject to two constraints. The first is means-testing and the second is that responsibility for delivering these benefits lies currently with local authorities, and so is not currently in national service as is the National Health Service. This Bill goes some way, but not the whole way, towards changing that situation, and I will come back to that. It contributes to a redefining, but I agree with the noble Lord, Lord Warner, that the role and the difference between healthcare and social care still remains unclear.

The second and last relevant point of difference from when the national services—the health service and the local authority care service—were set up is the growing demographic change in our country and in every country. Demographic shifts have created a completely new situation which, whether we like it or not, will have an impact on how and where we spend money. We simply live in a different world. For 50 years, we got away with trimming at the edges, changing bits here and there in relation to health and social care spending. That can no longer be the case. It is clear, at last, that something must be done. This Bill does something, and it is very welcome. That is the strength of the Bill. However, it is, at best, a good start, for many of the reasons that have been given already. Its strength is that a peg has now been put in the ground, and there is a commitment to having a national strategy and policy that we have simply avoided because of the huge fissure that runs between health services and social care services. That is part of the world in which we live and it has very significant consequences.

The fundamental recommendation of the Dilnot report, that a cap be put on the cost of care for any individual, has been accepted. All credit is due, for this is at last an acceptance by the Government, including, therefore, the Treasury, that the risks involved in the frailties of old age, like those involved in cancer, stroke and diabetes, should be shared across the whole community. I hope that that principle has been established in the Bill before us.

Of course, the fears of the Treasury, which are always there, are already being realised. Inevitably, a chorus of voices points out that there is less to this than meets the eye. The Bill does not commit the resources that we all know are necessary if you are to duplicate the quality in social care services that we have in the National Health Service. As we have heard, Dilnot’s proposal included the possibility that a cap might be as low as £25,000. In the event, it is eventually £72,000, with the possibility of deferred payment. Again, as we have heard from the noble Lord, Lord Bichard, local authorities are vigorously pointing out that there is already a shortfall in funds made available before account is taken of this new proposal. They estimate that the current round of cuts to the adult care budget amounts to £2.68 billion—or 20% of previous provision—and that is before the provisions of this Act are dealt with. At the same time, as has also been mentioned, care home owners often subsidise

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local authority-sponsored residents from the charges made to those who are self-financing. That cannot be right. There should be a single charge, and a single cost that applies to everyone. However, the rich—or the moderately rich—are subsidising others. That is the position in which they have been put.

Of course, we all know that we are now in the worst financial crisis in living memory. Account has to be taken of that—and I put it to you that account has already been taken of it. What that does—and the noble and learned Lord, Lord MacKay of Clashfern, made this point very fairly—is to raise expectations, in the way in which this Bill is being canvassed, which will come home to roost. People who have legitimate hopes that their old age will be comparatively secure will be disappointed.

Equally important in the Bill is an implicit bet—and that is the best of it, as far as I can see—that the principle of a cap on care costs will stimulate a strong insurance market to cover pre-cap and possibly post-cap costs. We shall see, but there is no guarantee about that. Of course, conversations have been held, but my previous experience on the royal commission was that those providing insurance products were not interested. We shall see if a cap makes all the difference. Let us hope that it does.

The Government, while being commended on a good start, or indeed on facing up to demographic change, must accept, however, that as we stabilise our economy—and the expectation and hope is that we will do that—a reordering of priorities will be the only rational response to the empirical realities of the huge demographic change. We must accept, as a Government and as a Parliament, that these priorities will have to be looked at. The world out there is different. The facts and the shape of the population are different. If there is no more money, priorities have to move around a bit. That is the reality, or we will be having desperate scenes in the houses, streets and care homes of our country.

One change which cannot and should not wait until then is the need to ensure that the huge sums already being spent on care, social care and even more so on healthcare—the noble Baroness, Lady Greengross, referred to this—are spent in the most efficient and effective way, and to maximum standards of the quality of care.

In two successive parliamentary Sessions we have had two relevant major Bills. The first, now an Act, was, despite its Title, almost wholly concerned with healthcare. It is called the Health and Social Care Act but there is not much social care in it. This second Bill, as its Title says, has to do with care. However, there is the rub. Why were these two not one Act? There is a legal, financial, and administrative fissure in our society that runs through our attitude to the provision of care. We simply cannot continue like this. It is at government and at professional level. Doctors and social workers are the best of friends in the pub, but you should hear them when they talk about each other when it comes to money. There is a fissure there.

On the royal commission, we reran the hoary old joke about the difference between a health bath and a social bath. You had to divide them up in those days to decide which fund provided the money to provide the bath. Both the commission and the Dilnot report

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firmly made it plain that bringing together health and social care provision and, ultimately, budgets, is essential if we are to maximise value for money in this massive and increasing spend—and it will not go down.

There are some good pilots taking place. I would find it very helpful if the Minister could tell us what the outcome of the pilots would be. What process is there for taking account of the evidence of what they provide in terms of shared facilities, budgets and provision? The message is very clear: combining budgets provides better administration, improves the effectiveness of spend and, importantly, has a huge potential vastly to improve the quality of care.

I would like quickly and briefly to make two points that have come up in the debate about the assessment and evaluation of what is going on. The first is that there is provision, rightly, to deal with what I can refer to only as the Southern Cross problem. We cannot have major providers going bust on us. That is right—but I wonder whether it is right to ask the Care Quality Commission, whose expertise is in a wholly different field, to take responsibility for this. Is there not even a group within the department of health economists, or economists, who know about running big businesses—they are essentially property businesses—and can give a proper health reading? Those responsible for assessing the quality of care are not those people. Yes, they will employ others. But if it is to be a kingdom within a kingdom, why not charge reasonably well paid civil servants with doing that?

Lastly, although it is not mentioned in the Bill, the Minister made mention of a new inspector. I simply ask whether we can have some information about the context in which such an inspectorate will work. It is canvassed as being like Ofsted, which is of course a great reassurance to those of us who were involved in setting up that body. However, it does not seem at all like Ofsted. Does this new inspectorate have a statutory basis? Is it independent of Ministers? We have had a row within recent weeks about who can close down a unit within a hospital—for example, for the heart surgery of children. Where are the lines of accountability? What is the new inspector responsible for? The chief inspector of schools is accountable to Parliament, not to Ministers. That gives it an independence and certainty about being taken seriously that will not necessarily be the case for an inspector within the employ of the department. So there is a lot of room for clarifying the provision there, but I am sure that we will come back to that in Committee.

7.43 pm

Baroness Uddin: My Lords, I come to this debate from the perspective of a professional in the social care sector, as well as with experience as a local authority councillor and, not least, as a carer for over 30 years. I agree that we are at a crossroads for our social care system. In my contribution, I shall draw on the evidence presented to us in the Joint Committee inquiry on the Promoting Independence, Preventing Crisis report, which was ably led by the all-party parliamentary groups on local government and disability. I take this opportunity to salute the work of my noble

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friend Lady Campbell, Anne McGuire, Heather Wheeler, and the noble Baroness, Lady Wilkins.

Much emphasis has rightly been put on the demands of our growing ageing population, and it is right that we do so, as is the fact that one in three of those who use our care services are disabled people of working age. I would like to focus on that aspect, and I make no apologies for unreservedly quoting some aspects of the inquiry, which I commend to the House.

For too long, Governments have used a sticking plaster approach and incremental improvements in dealing with adult social care, resulting in systems that are bewildering for the recipient and unwieldy for authorities to administer. So I, too, welcome the principle of adult social care reform. The Joint Committee inquiry took evidence from a long list of expert witnesses representing all sectors, all the major disability organisations and those involved in statutory provisions, as well as local authorities and academia. There was undeniable consensus, and a call for disabled people to be at the heart of social care policy reform as well as making decisions in their care. In doing so, we must not see them as passive recipients, but must uphold their human rights under the UN convention to which the United Kingdom is signatory, and embrace the fundamental principles of independence.

There are pervasive concerns that much of our provisions fall significantly short of providing dignity and choice, thus hampering independent living. Of course, the funding shortage is a reality, but we cannot allow those who may be voiceless to be sidestepped at the behest of what may be regarded as best value by locally set criteria. The evidence received by our Joint Committee points to local authorities struggling to achieve the best outcomes, resulting in raising their eligibility threshold for care provision. Many instances have been cited, implying that current eligibility criteria have led to many thousands of disabled individuals falling out of the care system altogether.

The statistics are astonishing. The Audit Commission on social care in England found with the fair access to care system in 2005 that 50% of 152 local authorities in England provide services to those with moderate needs and above but, by 2012, 84% were only providing services at the higher threshold of substantial need, with three councils now providing social care to people who fall into all four eligibility bands and only 24 councils providing care to those with moderate needs and above. The Care Bill will fail to improve the social care system for disabled people if eligibility is set so high that those in need will not receive even the basic help such as washing, dressing or getting out of the house. These changes, challenges and differences in eligibility are bound to lead to more disabled people left ineligible for care and support, contrary to the Minister’s claim that the Bill will provide compassionate and consistent care to those who need it.

The inquiry committee hopes that the Government will consider more uniformity in setting thresholds for eligibility right across the country, ensuring that the 2013 spending review will give due regard to adequate resources being made available so that the needs of disabled people are not compromised. I was surprised to hear the Minister say that legislation will not impact

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on the funding available. How can provision be efficiently provided, as he suggests, when the system is already stretched to its limits? Disabled people deserve to have confidence in any new care and support system, and I hope that we will be able to rectify some of these anomalies.

There is a significant body of opinion calling for prioritising the design of a new framework of eligibility, which should actively engage core stakeholders, addressing gaps highlighted already in the House today. The joint inquiry report suggests that the current fair access to care services criteria should be replaced by a system that is more objective and coherent and implemented across the country, where resource allocation is transparent and enables the disabled person and their carers to take part in the decision-making process. Worryingly, the evidence that we took suggests that there is little cohesion within various partners of care providers. This will stretch the ambition of the seamless services that the Care Bill envisages. Personalisation appears not to break down the barriers between care, housing, transport, leisure and community involvement, particularly when any person moves from one area to another. Therefore, I welcome the commitment in the Bill that continuity of care packages will not be interrupted by any move to another local authority or area. I would like to ask what mechanism will be in place to ensure a smooth transition if that happens, and whose lead responsibility it will be to manage the transition. I suppose that I am asking who will manage the “Oklahoma!” moment and who will provide the leadership.

This Care Bill is happening alongside the Government reassessing all those working-age disabled adults receiving disability living allowance and transferring recipients on to the personal independence payment. The House has voiced significant concerns to the Government, which were augmented last week by the whistleblower giving an insight to reports that individuals were not receiving even-handed services. The fact that supporting evidence given by applicants was not forwarded by the assessing company for assessors to use suggested a bias towards finding reasons to award points begrudgingly or not to award points, thereby affecting resource allocation. I have spoken to a number of carers and this is being seen by some as another cynical example of eligibility criteria being used to reset the goalposts for determining how much financial help people with disabilities require and ultimately receive.

A Member of this House recounted in a meeting last week the experience of being assessed. I hope that that respected individual will not mind my repeating what was said. The whole experience was said to have been so harrowing that the individual felt defeated by the very system which has the ambition of delivering dignity and choice through this Care Bill. I am deeply saddened that so little appears to have changed in the 30 years since I had a bitter experience with my son. Trying to access educational and social care was like asking for rain on Mars. In the end, we as a family were so defeated that we retreated into relying only on our own resources and ways and means.

I agree that reforms need to be made but they must and should be robust and intelligent in respectfully and professionally identifying genuinely deserving individuals, especially as regards those with disabilities

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which are difficult to understand and those with fluctuating conditions. Indeed, I have been made aware of the case of a disabled adult and her advocates who are trying to augment a personal budget. The person says that she felt bullied by a director of commissioning into accepting a package which represented best value for the authority but completely ignored her condition and needs and possibly violated her right to privacy and family life. If our society is to be judged by how we treat our weakest members, we have some distance to walk. I hope that we will be bold and ambitious enough to remember that social care must not simply be about basic survival but about supporting people to live independently. Independent living means disabled people of all ages having the same universal rights of freedom, choice, dignity and control as other citizens at home, at work, and in the community. It means having the right to obtain practical assistance and support to participate in society and live an ordinary life that others take for granted.

Your Lordships may not be surprised to learn that even in this context there is a distinct difference in the services provided to those from minority communities. It is a fact that 32% of all disabled people live in household poverty. Sadly, for minorities this figure jumps to 44% of disabled people living in household poverty. A report suggests that income for minority disabled people is 30% lower than for the general disabled population. The Equalities National Council and Scope in a report entitled Over-lookedCommunities, Over-due Change found that services are not fully inclusive for BME disabled people, who experience significant language and communication barriers, social isolation and stigma exacerbated by their lacking access to information and advice, including from well recognised NGOs. Many of the large NGOs operating within communities accepted that they had some way to go in addressing the needs of minority disabled people. In fact, a quarter of BME disabled people report difficulties receiving benefits and accessing independent living compared with 16% of others, indicating that additional unmet needs exist. Evidence on barriers to care shows that BME disabled people's conditions and impairments tend to escalate quickly to higher levels of need. I submit to the House that this is a costly process and that it is therefore even more important that the social care system provides effective coverage at lower care need equivalent to “moderate” within the current fair access to care needs system.

That is not all: meeting criteria and being eligible for support is not the end. An assessment determines the value of someone’s personal budget, and the resource allocation system ascribes a number of points to each eligible need which has been identified and, in referring to a table, sets out the financial value of each set of points, which then fleshes out the support plan to purchase and achieve identified independent living outcomes. Final decisions about the value of personal budgets are made by an anonymous panel of local authority social care professionals based on information provided by the disabled person, their social worker and the RAS calculation, often without ever having met the disabled person. The Sue Ryder report, The Forgotten Millions, highlights this point and found that a lack of uniformity among local authorities in

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allocating resources and calculating care packages for individuals is causing deep confusion and stress. A case was brought to my attention recently of a disabled adult who had all services stopped at 6 pm one evening. Apart from the legality of how and why this happened, an anonymous panel had turned down for the third time a request to increase travel by nine miles twice weekly, despite the social worker having great input from advocates on the matter. As the client had received an insufficient explanation from the social worker at 6 pm at night, she had to recall her father from business in London. He arrived at the social work offices the next day to petition the head of services as to why this had happened. Fortunately, services were immediately reinstated, with the family being offered a transfer from a direct service from the local authority to a personal budget.

Many carers claim that all these formal processes lack transparency regarding panels, their remit, obligations and decision-making. Disabled adults and their advocates are forbidden from having adequate details about the panel making the decisions. Surely transparency should be an obligation. If the objective is to provide care and support while maintaining the dignity of the individual, surely it is critical to have the individual or their representative present to ensure that their opinion is heard and valued as they are the experts on their own lives. The panel should have due regard to the contribution of disabled people in determining the nature of their care and support in any decisions that are made. Our report asks that the Government place resource allocation systems on a statutory footing through the Care and Support Bill and place new duties on councils to be transparent about these decisions. I welcome the move to put personal budgets on a statutory footing in Clause 25 of the Care and Support Bill. That should be enhanced to ensure that local authorities are transparent about decisions relating to the allocation of resources. All too often, personal budgets have care costed at one rate, with another rate available if external agencies are used.

Baroness Garden of Frognal: I apologise to the noble Baroness but she has been speaking for 15 minutes, which is normally the maximum time.

Baroness Uddin: I apologise. I am nearly finished. Anyone not associated with the care sector will become dizzy when encountering the array of acronyms and phrases such as RAS, FACS, DLA and PIP. Indeed, they are fortunate members of our society, with the ability to lead an active, fulfilled and independent life. They are fortunate enough to be able to perform everyday tasks such as getting up, washing, dressing, personal care, food preparation and eating without having to justify even the most basic daily tasks. For those members of our society who are reliant upon our care systems, this Bill represents a new hope that our social care system will enable disabled people to live an independent life which is just and equitable. I note noble Lords’ massive endorsement of the Bill and eagerly await its outcome.

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8 pm

Lord Turnberg: My Lords, when I spoke in the debate on the Queen’s Speech last week I concentrated on care of the elderly in the community which is one of the most critical issues facing society, as we have heard from some remarkable speeches today. If anyone has any doubt about the scale of the problem they will just have to read Hansard. I will not repeat what I said the other day, save to reiterate my specific plea that we pay attention to the screening of vulnerable elderly people in the community by primary care and social services staff so that we can introduce simple preventive measures to keep people at home. I hope the noble Earl might say something about that.

Tonight I want to concentrate on the proposals in the Bill to establish Health Education England and the Health Research Authority as non-departmental public bodies. These are, of course, extremely welcome proposals but inevitably there are a number of aspects where we need to seek clarification and improvement. The roles of the HEE and the associated local education and training boards—inelegantly abbreviated as LETBs—are spelt out in the Explanatory Notes but I fear that the Bill itself is fairly silent on how it will ensure high quality and standards in education.

For example, much is made of the fact that the LETBs are provider-led and dominated by the needs of NHS trusts for sufficient numbers and range in the workforce to meet those needs. So far so good, but what is missing is a proper recognition that the quality of training, the curricular content and the skills and knowledge of those going through training programmes will be taken care of. Where, for instance, is reference made to the need to include postgraduate deans on the boards of LETBs? It is not in the Bill and given only passing reference in the Explanatory Notes. Where is reference to the need to engage closely with local universities or training colleges—that is, with those whose whole raison d’être is education and all that that entails? Content of training programmes and maintenance of standards is their special expertise and for providers to ignore that aspect will be to their detriment. I am sure they are aware of that but we need mention in the Bill of a need to involve universities, either in the membership of the board, albeit in a minority, or, if not that, then an obligation to seek their advice in formulating their programmes of training.

At the national level, in the HEE, there is some recognition in the notes to the Bill, but not in the Bill itself, of a need to seek advice from the royal colleges—here I have to express my interest as an ex-president of a royal college—the GMC, the GDC and the NMC in developing its policy. It seems to me that all those bodies have considerable expertise in education and training. Indeed, the main functions of the medical royal colleges, for example, are in the development of all the curricula for medical trainees and in setting their exams and assessments to make sure that they have reached an acceptable level of skills, aptitudes and knowledge. Every cardiologist, orthopaedic surgeon and psychiatrist has to go through a training programme devised and run by a royal college. The regulatory bodies have responsibilities for the oversight of training and education to ensure that it is fit for purpose. Yet despite all this remarkable body of expertise, no mention

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is to be found in the Bill that the HEE will draw on any of this for advice and assistance.

Then there is a further issue of the need to take account of the importance of clinical researchers in programmes of training and education. We have heard much helpful comment from Ministers about the need to embed research in the NHS and to make every health professional a researcher and every patient a willing participant. The noble Earl was extremely helpful in getting research high up the agenda for the NHS in the Health and Social Care Bill. It is, of course, through research that we may in due course find some answers to the major diseases from which we suffer such as dementia, diabetes and Parkinson’s, so it is vital that research really is in the middle of the NHS.

While the new Bill is very helpful in stating that the HEE must promote research into matters relating to its activities, which is rather subtle, it hardly takes account of the need for LETBs to take account of this in their training programmes. Those embarking on a clinical academic career have to be able to take time out from their purely clinical training to train in research, perhaps for up to three years if they are going to do a PhD. All other trainees, at least in medicine, need to be able to carry out some research so they have experience of what research is about. They are then in a better place to take advantage of the results of research and not resist the rapid introduction of innovations when they go on into practice. I fear that the dominance of provider-led interests in LETBs will lead them to paying little attention to this aspect of training unless they have access to advice from their local universities and the research community. I fear very much that the shadow body of the HEE has shown little sign so far that it is aware of this particular point.

I come now to the Health Research Authority. I believe we are extremely fortunate in having Professor Jonathan Montgomery as its first chairman. He is clearly switched on to the need to be able to protect the public and the patient interest, while at the same time encouraging high-quality clinical research and not putting unnecessarily burdensome regulation in the way. It might be thought that these twin responsibilities—the need to protect patients and ensure their safety and confidentiality on the one hand while promoting and encouraging research on the other—are opposed to each other but they are closely aligned. Patients want not only to be safe but they are very keen for research to be done on their diseases. Furthermore, surveys of patients’ attitudes show that more than 90% of patients want to be involved in research themselves in clinical trials. They are desperate for innovations in treatments arising from research to be applied to them. Of course they want to be safe and protected but they also want high-quality research, so the two go hand in hand. It is pleasing to know that Professor Montgomery is well aware of this and the need for proportionality in regulation.

I welcome the clear statements in the Bill on this and in particular in Clause 98(3) where it is proposed that the HRA must promote standardisation of the regulation of research across England and ensure that such regulation is proportionate. It is clear, too, that for the HRA to gain credibility with the public and

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patients it cannot simply pontificate about safety from on high. It must actively communicate with the public and have processes in place for it to be able to listen to the views of the wider public. It needs access to the public view and should put in place mechanisms to achieve that.

I come now to another aspect of transparency. In addition to its own transparency, the HRA should also be encouraging transparency of researchers engaged in clinical trials in academe and industry and their results should be published as expeditiously as is reasonably possible. Results should become freely available, after careful checking for reliability, whether they are positive or negative. It is helpful to know that GSK is leading the way in industry by publishing its data more openly and others are beginning to follow. We do not want the HRA to be given too rigid a formula. That would be counterproductive, but we do want to be able to encourage and support the HRA in its efforts to use measured persuasion.

Finally, it is good to see in the Bill the confirmation that the HRA will continue its good work in co-ordinating the work of the ethics committees and in taking on the roles provided until now by the Secretary of State and what was PIAG in ensuring the safe use of patients’ data. It is gratifying to know, too, that the HRA is moving towards a single application process for entry into the jungle of research regulation. There remains at least one major barrier to research and that is the local R&D approvals that have to be given by each trust where clinical trials are being done. This is where we need a rational, proportionate and national system and if the HRA can incorporate trust R&D approval into that national scheme, the research community would heave an enormous sigh of relief.

I hope I have not given the impression that I am unhappy with this part of the Bill. I think the proposals to set up HEE and the HRA are extremely valuable but of course there is always room for some improvement.

8.10 pm

Baroness Masham of Ilton: My Lords, I thank the noble Earl for explaining this Bill so clearly. The idea of the Bill is good in theory but will it work in practice? Will there be enough resources to go round and will there be good communication and co-operation between professionals? Will this Bill eliminate the postcode lottery? As so much help is organised locally, this may continue to be a problem.

The Bill emphasises care for elderly people but one must not forget those people of working age who have disabilities. A little help can make all the difference. If eligibility is set too high, people will become isolated in their homes and unable to work. Children, if there are any, may have to help their parents, causing problems at school and putting a strain on their childhood. I am sure that care can become more co-ordinated and save resources if health and social care work in co-operation and co-ordination.

To give your Lordships an example, I speak as president of the Spinal Injuries Association. One of our members, who is paralysed from the neck down but is bright and motivated, goes out to work. The

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health service helps her with her toileting and the social services help her with dressing. It means that two lots of helpers come in for one person. I am sure that the skills of operational therapists can help with integration as they work in both health and social services. The wheelchair and equipment service needs improving, as does the speed of adaptations to people’s accommodation when they become disabled. This sometimes means that extra time is spent in hospital.

Part 2 of the Bill deals with the post-Mid Staffordshire NHS Foundation Trust. The aim is that no such appalling situation can arise again, but nobody seems to have taken responsibility for the failings. The people who knew about what was happening and witnessed the neglect and cover-ups were not listened to. I feel that throughout the health and social care systems, we need openness and honesty, and that a duty of candour would help. I would be grateful if the Minister would say what progress is being made, as this is a recommendation of the Francis report. A culture has developed among some nurses of doing as little as possible to make patients safe and comfortable. Not all staff are the same; some are exemplary and kind, which is what patients who are often worried and in pain need.

I am concerned that unacceptable practices are happening in many hospitals throughout the country; either they are unbeknown to management or it turns a blind eye. One foundation trust, which ticks all the boxes and always has a good review, had a hospital to which a friend of mine was admitted as an emergency. He had been chairman of the PCT and worked hard for the NHS. Time passed and he was given nothing to eat, so he asked if he was nil by mouth. “No”, said the nurse, “the last person in your bed did not fill in the menu card, so nothing was ordered”. He was then offered a sticky toffee pudding—the last thing his condition needed. He also said that the nurses chattered all night and did not help a critically ill patient in the next bed.

To make the situation better for patients there will have to be a huge change in attitude and practice throughout the health and social care systems. Only last Saturday the Yorkshire Evening Post reported appalling abuse of patients at the Solar Centre in St Catherine’s Hospital in Doncaster. There had been delays in the conviction of two care assistants who mistreated vulnerable patients. The newspaper stated that this was,

“an appalling abuse of trust and a violation of what society should be able to expect from people in the care profession”.

One of the problems seems to be that people who cannot get other jobs become care assistants. As there is such a demand they get work, even if they are undesirable and not fit for purpose. Should there not be better selection and vetting of those who work with vulnerable people? It seems vital that there should be registration of care assistants with adequate training. I am told that Australia is going back to state enrolled nurses. It has found that not having the practical, trained nurse has been dangerous to patients. There is need for a highly technical nurse, but also for a practical nurse to work alongside.

There seems to be an overall welcome for establishing Health Education England, and the Health Research Authority. Research is vital if progress is to be made.

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Resistance to much needed antibiotics is an example and new drugs and research are needed into such devastating diseases as motor neurone disease, neuroblastoma in children and all the rare conditions which need new and effective drugs. Some day a way may be found to join and regenerate the spinal cord.

I feel it was an unwise move by the Government to disband the Advisory Group for National Specialised Services—AGNSS. Will they consider reinstating this much needed service? I look forward to the Minister’s reply.

8.17 pm

Lord Hunt of Kings Heath: My Lords, we are approaching the end of what has been a serious and expert debate on the Care Bill, which has clearly drawn considerable support from your Lordships’ House. However as speaker after speaker has pointed out, there is a marked contrast between the Bill’s intentions and the reality of the health and social care system, which is under huge financial pressure at the moment. Of course, this Bill puts new pressures and responsibilities on local authorities, but there are no signs yet as to how those authorities are to find resources.

We are happy to co-operate in postponing deliberation of Part 1 of the Bill, to allow it to take place after the spending review has been announced. However, in a sense that concerns the future and future responsibilities. The fact is the crisis is here now in relation to social care. Very little has been heard from the Government about how they intend to respond to it. I hope the noble Earl will say something about it tonight. Many noble Lords have referred to the eligibility criteria and the intention to set this at a national level to get consistency and deal with the issue of the huge variation that is now apparent throughout the country. This has been widely welcomed, but I would tell the noble Earl that we certainly expect the Government to publish the all-important draft regulations before we go into Committee to deal with this important matter. I would be grateful if the Minister will confirm that he intends to do that.

He will know that there is widespread expectation that the Government will set the national level at the “substantial” level. I do not expect the noble Earl to confirm that tonight, but does he agree with the noble Lord, Lord Rix, that local authorities have increasingly moved the threshold up to the substantial level, with, of course, prevention and early intervention being unavailable? May I also ask him about the risk of those local authorities which do not at the moment set the threshold at the substantial level, actually raising it in the light of the national criteria being set at that level? That way, we will have national consistency, but it will be consistency where provision is at the meanest. That would cause considerable concern in many local authority areas.

The noble and learned Lord, Lord Mackay, and my noble friend Lord Warner raised the question of Clause 22 and the all-important boundary definition between the means-tested social care and the free-at-the-point-of-use NHS. The noble Lord, Lord Sutherland, hopes that at some point this might be a thing of the past, but at the moment this is a critical delineation between

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the two services. The Minister will know that the Select Committee was concerned that a court might view any changes in the wording as implying a change in the meaning of the provision. It is important that we hear a response from the Government about why we ought not to worry about that.

The noble Baroness, Lady Campbell, spoke so eloquently of the problems of people being shunted between the two services because of the cost implication between local authorities and the NHS. At the same time, the noble Baroness passionately promoted the need to support disabled people to be as independent as possible. This is not an issue that will go away and we will need to come back to that in Committee in terms of the new meaning—if it is a new meaning— in Clause 22.

This is not just a Bill for older people, but the challenges that older people face are formidable, as my noble friend Lady Bakewell said. Like my noble friend Lord Lipsey, I welcome the Dilnot provisions and the cap—as far as they go. However that is not the complete picture. The cap and increased threshold will reduce the risk of catastrophic costs, but there is a concern about the way that people of modest means will be treated. I listened with great interest to what my noble friend Lord Lipsey said about the operation of the means-tested tariff and the impact on people with modest income. My noble friend Lord Warner does not quite take his view on that, but it would be good to have a debate on this in Committee.

I would also be interested to know whether my noble friend Lord Lipsey has taken into account that in some benefits the first £6,000, and in others the first £14,000, are exempt from the tariff, which in itself is progressive, with those with the most savings hardest hit. It is important we come back to that.

My final point on Dilnot is about the insurance market, which a number of noble Lords raised. What is the noble Earl’s current assessment of the prospects of an insurance market developing? Has his department been in recent communication with the ABI and can he say any more about the confidence that he has in insurance products developing? This is very important in reaching a conclusion about the likely success of the Dilnot proposals in this legislation.

Finally in this area, I turn to a point raised by my noble friends Lord Lipsey and Lord Warner. The actual administration and assessment that will have to take place, particularly as thousands of self funders will need to be assessed under these proposals, will lead local government into a major administrative task and to an increase in disputes and legal challenges. The Joint Committee was not confident that Ministers had fully thought out the implications for local authorities of these changes. Will the noble Earl comment on that and also on my noble friend Lord Warner's suggestion that we need to establish tribunals in order to deal with disputes to keep them out of the courts as far as possible?

Very good points were made about the need for impartial information in relation to Clause 4. When one thinks about some of the financial consequences of the decisions made, it is a powerful argument. I also hope that the noble Earl will respond to my noble

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friend Lord Patel in relation to Clause 68 and the question of aftercare and the implications that it has in relation to Section 117 of the Mental Health Act 1983. We had extensive debates on these matters only a few months ago. I hope that this is not opening up the question and is not a reinterpretation.

On carers, my noble friend Lady Pitkeathley spoke eloquently about the importance of these provisions, and we welcome them. But there is a question about why they do not relate either to parents caring for disabled children or young carers. As Barnardo’s has said, young carers represent a uniquely valuable group of people whom the Government should be ensuring receive help to address the very serious effects that caring has on their lives. The noble and learned Lord, Lord Mackay, made an important point about the need to ensure that, in the case of children caring for adults, the impact on the child must be given due consideration.

My noble friend Lady Wilkins talked about housing. The point she raised is surely right. What concerns me is the lack of very much reference to housing provision or housing authorities in the Bill. I am sure that we can look forward to some amendments in that direction from my noble friend.

On safeguarding, it is a matter of regret that there is no duty on providers to report to local authorities where they suspect the risk of abuse. It is also a matter of regret that there is no clause allowing for power of entry. This was raised by the Joint Committee and it was clear that there should be a power of entry for local authority representatives where a third party is refusing access to a person who may be at risk of abuse. I know that the Government will say that the consultation produced a lot of people opposed to that. But if we are to take abuse seriously, we should come back to examine whether a power of entry is necessary and should be required.

On Part 2, there is the NHS failure regime. I was pleased that the noble Earl’s officials gave us a briefing on this. It is rather complex and there seems to be a risk of confusion of roles between the two regulators, CQC and Monitor. Will he respond to the question raised by my noble friend Lord Warner about non-foundation trusts? I should have declared an interest as chair of an NHS foundation trust and indeed as a consultant and trainer with Cumberlege Connections. Why are the weaker organisations subject to a much less regulated framework than the foundation trusts? Why are the non-foundation trusts not covered in the Bill?

I am disappointed that there is only a partial implementation of the Francis recommendations, particularly as far as primary legislation is concerned. For instance, where is the duty of candour? We have the offence in Clause 81 of publishing false or misleading information. But Francis wanted a statutory duty of candour on healthcare providers to inform patients or appropriate persons if treatment has caused death or serious injury to the patient. Why is that not in the Bill? Where is the registration of healthcare support workers, as the noble Baroness, Lady Emerton, suggested?

On public health, I agree with noble Lords who regret that there is no provision for standardised packaging

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for cigarettes. I look forward to a continuing debate on that matter. On Health Education England, some very important points were raised by noble Lords. I would particularly refer to my noble friend Lord Turnberg’s comments about the LETBs and the need to ensure high quality in training and the involvement of postgraduate deans. As regards research, again, the provisions are very welcome but there is real concern that this country is losing out in terms of the number of multi-centre trials that take place here. Does the noble Earl thinks that the HRA should be given more authority over both the local research ethics committees and NHS trusts in terms of R&D approval? We cannot just leave it to these different bodies when the whole prosperity of our country is in many ways based on this kind of investment.

This has been an excellent debate. We look forward to the responses from the noble Earl. He will know that there are a lot of provisions here that command general support but, ultimately, the real concerns relate to current and future resources, and to the need for the Government to respond strongly in convincing argument about the kind of integrated services that are required to ensure that the provisions of this Bill will be implemented. The Government need to show that they really do get it and are going to come forward with those proposals.

8.31 pm

Earl Howe: I begin by thanking everyone who has spoken today. There have been some excellent and highly informed contributions from all sides of the House. Health and care matter to us all throughout our lives; the quality of the contributions today demonstrates how important the issues are in this Bill. I am grateful in particular for the welcome given to Part 1 of the Bill by many noble Lords. A large number of questions have been raised during the debate and I will endeavour to cover as many of them as possible in the time that I have. Unfortunately, there is unlikely to be time to address all of these issues but I will, of course, write to follow up on any unanswered questions.

I listened with care, as I always do, to the speech of the noble Baroness, Lady Wheeler, but I must confess that I was disappointed by the somewhat negative tone that characterised her remarks. Anyone listening to her could be forgiven for thinking that the Labour Party opposed the principles set out in the Bill. I was very glad to hear the noble Lord, Lord Hunt, correcting that impression. I hope that, at the very least, we can look forward to a constructive approach in Committee from all noble Lords opposite. As ever, I stand ready to work with the noble Baroness and the noble Lord, Lord Hunt, and indeed all noble Lords to ensure that we explore the Bill thoroughly so that we can, in due course, send it to another place in a form of which we can be collectively proud.

A number of noble Lords referred, unsurprisingly, to the funding envelope for adult social care. We recognise that the last spending review provided local government with a challenging settlement and that is why we took the decision to prioritise adult social care and provide extra funding to help local authorities

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maintain access to services. In the White Paper, we committed to additional support for social care over the next two years. However, it has to be remembered that local authorities ultimately have discretion over how they use their resources. Of course we agree that the level of funding available in future will have an impact on how far the reforms are realised, but noble Lords should appreciate that we have committed to funding the reforms set out in the Bill in full.

For example, as the noble Lord, Lord Lipsey, pointed out, funding reform will cost the Exchequer £1 billion a year by April 2019 and there will be an additional £175 million a year to fund the new legal rights for carers in 2015-16. I assure the noble Baroness, Lady Wilkins, that the needs of social care will be at the front of Ministers’ minds as we approach the spending review. However, noble Lords will understand the realities facing us. We cannot improve care and support by simply putting more and more money into the system, and in this financial climate it is therefore more important than ever that councils review their practices, drawing on the work of the sector’s efficiency programmes, to ensure that they are using their resources in the most effective and efficient way possible.

The noble Baroness, Lady Wheeler, and others criticised the level of the cap on care costs. It is surely to be welcomed that, for the first time, there will be a cap to protect people from spiralling costs, and that people will no longer have to live in fear that their home will be sold while they are in a care home or that all their life savings will disappear. The level of the cap is not set in the Bill, but will be set in regulations. Why do we propose to set it at £72,000? We want to strike the right balance between supporting people in paying for care and managing the public purse in a sensible, sustainable way. We believe that a cap of £72,000, which is equivalent to around £60,000 in Dilnot terms, along with the increase in the means test threshold to £118,000, achieves this balance. I was grateful for the broad support provided by the noble Lord, Lord Lipsey, in that context.

The noble Baroness, Lady Bakewell, in her characteristically eloquent and powerful speech, contended that the formula we have arrived at protects the wealthiest. The current system, as she knows, exposes those with few savings or modest housing wealth to the greatest risk of losing everything to pay for their social care. That is unfair and it needs to change. Yes, we are expanding the scope of the means test benefit so that more people will get help, but the vast majority of state support will be provided to the 40% of older people with the lowest incomes and wealth. This is about protecting people with the greatest lifetime care needs, not the greatest wealth.

The noble Baroness, Lady Wheeler, asked me to confirm the details of the sliding scale of contribution towards care costs. People with assets above the lower capital limit, which will be £17,000 from April 2016, will have to make some contribution to the costs of residential care. The sliding scale determines the amount they must contribute. Individuals are deemed to be able to contribute £1 for every £250 of assets above the lower capital limit. We are extending the upper capital limit to £118,000 in residential care, which removes the

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cliff edge in the current assessment and will result in a gradual increase in support towards an adult’s care costs.

I have noted the hopes and concerns of a number of noble Lords, including the noble Lords, Lord Rix and Lord Warner, and the noble Baroness, Lady Bakewell, around the eligibility threshold. There has been widespread support for a national eligibility threshold and noble Lords are understandably keen to see the regulations that set it. In determining the threshold, we must consider the funding settlement to local authorities; the national minimum eligibility threshold will be announced as part of the spending review on 26 June, and the regulations will follow. Indeed, in answer to the noble Baroness, Lady Campbell, and the noble Lord, Lord Hunt, we will make available a draft of the regulations under Clause 13 to provide for the national eligibility criteria in order to support debate of the Bill in Committee.

The noble Baroness, Lady Uddin, said in her powerful speech that care and support was harder to access for minority ethnic people. I would say to her in that context that information is central to ensuring equality of access to care and support, a point rightly made by the noble Lord, Lord Hunt. Clause 4 sets out clearly and places the duty on local authorities to provide information which is accessible to people needing care and support in the local community. The information must be accessible to those for whom it is provided. So, for example, it should be translated into the languages that are used in the area. The noble Baroness also said that a disabled person should be involved in decisions about how their needs are met and their personal budget is settled. Clause 25 sets out important new duties for the local authority to involve the adult in care planning and to take all reasonable steps to reach agreement with the adult or carer on how their needs are to be met.

My noble friend Lord Sharkey and the noble Lord, Lord Warner, expressed their concern that the Bill contains no provision for a right of appeal against eligibility decisions. The Bill sets out, for the first time in primary legislation, how eligibility decisions will be made by local authorities and the new right to a written record of the decision and the reasons for it. These are important new rights, which will promote transparency and aid decision-making. Where people are unhappy about a decision, there is an established right to make a complaint, which is set out in the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. There is no need to set out another system in the Bill. I say to the noble Lord, Lord Hunt, that we will look at the existing complaints arrangements, including considering how best to provide for effective challenge to local authority decisions, in the light of the findings of the review of NHS complaints led by Ann Clwyd and Professor Tricia Hart and our consultation on the capped-cost scheme.

The noble Lord, Lord Patel of Bradford, drew attention to Clause 2(3) and the power to charge for prevention services. He was concerned about how people will pay for this. Local authorities already have the power to charge for preventive services. We do not

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expect this to be the norm for lots of simple preventive services but we think it important to retain the ability to do so. We intend to use regulations to ensure that services which must currently be provided free, including intermediate care and minor aids or adaptations, remain provided free of charge.

The noble Lord, Lord Sutherland, drew attention to the cross-subsidisation issue. Local authorities and individuals can pay different prices for care, as he well knows, and this can be because individuals have chosen premium facilities or because the local authority has negotiated a lower price in exchange for buying care for a large number of people. The Bill places new duties on local authorities to promote an efficient and effective market for high-quality care services. The local authority must ensure that it has regard to factors such as the sustainability of the market.

The noble Baroness, Lady Wheeler, asked how the Bill interacts with benefit changes. My department is in regular contact with the Department for Work and Pensions on the relationship between welfare reform and our proposals for care and support in order to understand the interaction and impact on people who use care and support, carers and families.

My noble friend Lady Barker asked whether the development of the deferred payment scheme would take into account existing case law. The answer is yes. We have committed to a universal scheme for deferred payments for people who need residential care. In designing this scheme we will of course take into account all relevant case law.

The noble Baroness, Lady Wilkins, spoke about the Independent Living Fund. Following the closure of that fund, we have committed to passing funding to local authorities in order to allow for ILF recipients to be brought into the mainstream care and support system. Final details will be announced as part of the spending round on 26 June.

The noble Lord, Lord Hunt, and the noble Baroness, Lady Wilkins, stated their view that the Bill does not do enough to reference the importance of housing to care and support. In actual fact, the Bill does a lot to recognise housing as a determinant of health and well-being. In response to comments during consultation and pre-legislative scrutiny, we have included “suitability of living accommodation” within the list of matters which well-being relates to in Clause 1. Clause 3 requires local authorities to integrate the provision of healthcare and support and health-related services, which includes housing, while Clauses 6 and 7 require local authorities to ensure the co-operation of their housing officers, both internally and with the authority’s “relevant partners”, in care and support.

The noble Baroness, Lady Donaghy, stated her view that Clause 8 should include transport as a way of meeting needs. I agree that the provision of transport is an important way of meeting people’s needs but we do not believe that there is any requirement to set this out in Clause 8. That clause provides high-level examples of ways of meeting needs so as to leave maximum flexibility to the local authority and the adult to agree on how their needs should be met. Of course, that could encompass transport.

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The noble Baroness, Lady Wheeler, and the noble Lord, Lord Hunt, asked whether we had been talking to the insurance industry about the reforms. It is encouraging that many companies support the change. We have been talking to the industry. The Association of British Insurers has welcomed the announcement as a,

“positive step forward in tackling the challenges of an ageing society”.

My noble friend Lord Sharkey asked why the Bill does not implement Dilnot’s recommendations for an awareness campaign. Legislation is not required for that but the Government agree on the need to raise public awareness. The Government will adopt a strategic approach to maximising the public’s understanding of the new care and support system, and that is a crucial part of our plans to implement Dilnot.

My noble friend Lady Jolly and the noble Lord, Lord Patel, spoke about the proposal to legislate for free end-of-life care. The palliative care funding review recommended that social care should be provided free at the end of life. The Government are funding eight pilot sites to test this and other recommendations, which are gathering evidence over two years until 2014. Before making any decisions we want to consider the evidence collected from the pilots. I can, however, confirm that primary legislation will not be required to enable social care to be provided free at the end of life.

My noble friend Lady Browning spoke about autism and people with Asperger’s. The autism strategy and its statutory guidance mark a great step forward for adults with autism in England, as I know she acknowledges. What it does not do, however, is guarantee that everyone with a diagnosis of autism will receive support or services from local authorities. If your needs do not meet the eligibility criteria set out by your local authority you will not receive social care services. The Bill will ensure that you are given information about what other support is available in your local area. As local areas gain a better understanding of autism needs locally and develop autism commissioning plans, we expect local authorities to look more at the cost benefits of more low-level and preventive services such as befriending services or social skills training.

A number of noble Lords, including the noble Baronesses, Lady Pitkeathley and Lady Wheeler, my noble friends Lady Jolly and Lady Tyler, and my noble and learned friend Lord Mackay, referred to young carers. The boundaries between children and adult legislation ensure appropriate distinctions between what can reasonably be expected of adults and children. It is of course crucial that adult and children’s services work together to ensure that young people are not carrying out inappropriate caring roles or are disadvantaged in their education and losing their childhood because of caring. First and foremost, however, young carers should be seen as children and assessed in that context.

Several amendments to the Children and Families Bill on support for young carers were debated in the other place. My honourable friend the Parliamentary Under-Secretary of State for Children and Families, Mr Timpson, recognised that the effective identification

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of young carers and assessment of their needs for support are best achieved by children’s social care, health and education services working together and considering the whole family’s needs. He explained that he would reflect on the arguments put forward and the evidence from the National Young Carers Coalition. Ministers in his department are very happy to meet noble Lords who are interested in this area as the Children and Families Bill moves to this House. Officials are in contact with the National Young Carers Coalition and other key stakeholders as part of the consideration of the evidence that they have provided. I should say, however, that the Care Bill encourages local authorities to take a whole-family approach in assessing an adult, which means that adults’ needs for care and support are not seen in isolation from their family circumstances, including the contribution of young carers. Regulations about assessment procedures to be made under Clause 12 will put a duty on councils to have regard to the family of the adult to whom the assessment relates.

The noble Lord, Lord Rix, spoke about the transition into adulthood, and I completely agree that transition between childhood and adulthood is an important time when young people and their families are thinking about their goals and aspirations for the future. The Bill gives young people and child carers the right to request an assessment before they turn 18 in order to help them to plan for the transition to adult care and support in order for them to have the information that they need to prepare for their future. The Bill will ensure that no child reaching the age of 18 should go without the care and support that they need around the point of transition. It will require local authorities to maintain children’s services until a decision has been taken about whether they require adult care and support in place for there to be no gap. The Bill will therefore incentivise local authorities to focus more closely on the relationship between these services to improve the experience of transition for all.

The noble Lord, Lord Patel, said that care plans should be in place from the age of 14, and for five years thereafter. As he well knows, the difficulties that some young people and their families face as they move into adult care and support are well documented. The Care Bill aims to smooth the transition. It sets no restrictions about whether the child is already receiving a specific service under children’s legislation in order to request this assessment, nor does it contain any restriction or stipulation about the age of the child for whom the request may be made, or their proximity to their 18th birthday. Instead, the local authority must consider whether the individual child is likely to have needs for care and support after they turn 18 and whether there would be significant benefit in undertaking the assessment.

My noble friend Lady Barker said that Clause 9(4) needs to be clear that people’s needs are assessed on the basis of what their family can provide and not what they are expected to provide, so that there is no pressure on them. I completely agree with what she said. The assessment is to include whether any carer is able, and is likely to continue to be able, to provide care. The intention is also that the regulation supporting

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assessment will require the local authority to have regard to the needs of the whole family, as I have just mentioned.

The noble Lord, Lord Low, stated his view that Clause 12(1)(f) is weaker than it was in the draft Bill. I will write to him about that, but that is not our intention and we will look at that point. My noble friend Lord Sharkey referred to the Clause 9 duty to assess where it appears to the local authority that a person may have needs. He thought that might be too passive. The duty is worded on the basis of the existing duty that it will replace, Section 47 of the National Health Service and Community Care Act 1990. It implements the Law Commission’s recommendations on what should trigger the duty to assess, and it is not intended to be passive. In fact, we do not think that it is.

The noble Baroness, Lady Campbell, spoke powerfully about the portability provisions in the Bill. The Bill will ensure that no one should face discontinuity in their care and support when they move local authority area. This is an important reform which will improve well-being for many people who use care and support. The Care Bill will place duties on local authorities that will ensure continuity of care. This will provide clarity on which local authority is responsible, and should ensure that there is no disagreement between authorities which might result in disruption to a person’s care.