With this it will be convenient to discuss the following:
Government amendment (a) in lieu of Lords amendment 11.
Lords amendment 51, Government motion to disagree, and Government amendment (a) in lieu.
Lords amendment 80, Government motion to disagree, and Government amendments (a) to (n) in lieu.
Lords amendment 81, and Government motion to disagree.
Lords amendment 90, Government motion to disagree, and Government amendment (a) in lieu.
Lords amendment 105, Government motion to disagree, and Government amendment (a) in lieu.
Lords amendments 1 to 10, 12 to 28, 31 to 41, 49, 50, 65, 83, 102 to 104, 106 and 107.
Let me repeat, quite legitimately, what I said in opening the debate on the previous group of amendments. It is a pleasure to serve opposite the shadow Minister, the hon. Member for Bristol South. It was also a pleasure to serve opposite her in the Bill Committee. She was not the shadow Minister then, but she brought her expertise and, as I said earlier, her forensic knowledge of these areas of the Bill—occasionally to my slight discomfort—and, overall, a degree of informed deliberation to our proceedings.
The amendments in this group relate to integration, commissioning and adult social care. The Government’s amendments strengthen our expectations of commissioners, especially in relation to mental health, cancer, palliative care, inequalities and children. Lords amendments 1, 25, 27 and 49 strengthen our approach to mental health. Amendment 49 makes it clear that “health” refers to both physical and mental health in the National Health Service Act 2006.
I want to thank my hon. Friend for making that clear, because there was some concern that the Bill broke with parity of esteem by not recognising that mental health was as important as physical health. A number of Members raised concerns about that, and I want to thank my hon. Friend and his team for getting it right. They should be congratulated.
I am very grateful to my hon. Friend. He has come in at just the right time, because I was about to thank and pay tribute to him and, indeed, to my right hon. Friend Mrs May. Both of them have, in their typically determined and persistent but very courteous way, pressed this issue and highlighted the need for it to be explicit in the legislation. I think we have made the Bill stronger and clearer through Lords amendment 49, and I pay tribute to my hon. Friend for that.
Lords amendments 1, 25 and 27 also require the Secretary of State to publish, and lay before Parliament, a document setting out the Government’s expectations for mental health spending for the financial year ahead. Lords amendment 105 requires a member with experience of mental health to sit on each integrated care board. Although we have adopted a permissive rather than a prescriptive approach throughout, we are persuaded of the need and the benefits—given the parity of esteem—of having that experience on the ICBs, and, while we are proposing some changes in the drafting, we agree with the principle. I hope that the shadow Minister shares that view.
I pay tribute to my hon. Friend Mr Baron, and to Members of the other place, for their engagement and continued support in relation to Lords amendments 2, 3 and 4, which relate to cancer objectives in the NHS mandate. The amendments change the focus of the cancer outcomes objectives so that they capture all cancer interventions. Those objectives will have priority over any other objectives relating to cancer, not just those relating specifically to “treatment”. I also pay tribute to Baroness Finlay, who has long campaigned to add explicit reference to palliative care services to the list of services that an integrated care board must commission. That is why we are accepting Lords amendment 12.
Lords amendments 22, 83, 102, 103 focus on addressing the needs of babies, children and young people. Lords amendment 22 would require the ICB to set out any steps it proposed to take to address the particular needs of children and young people, while Lords amendments 83, 102 and 103 specify that the Government must publish a report describing the Government’s policy on information sharing by or with public authorities in relation to children’s health and social care and the safeguarding of children. I pay tribute in that context to my right hon. Friend Dame Andrea Leadsom, who has long taken a keen interest in these issues.
There are also a number Lords amendments relating to how an ICB must discharge its functions. As the House knows, this Government are committed to tackling health inequalities, and Lords amendments 5, 7, 8, 10, 13, 14, 16, 17, 24, 31, 32, 38, 39 and 41 take us further in tackling disparities and levelling up opportunity and outcomes across the country. These amendments received cross-party support in the other place and I am sure that they will be welcomed here too.
I thank my hon. Friend and neighbour for giving way. On the duties of integrated care boards, he knows that one of my grave concerns about health inequalities relates to rural settings. In Rutland, our citizens receive care in Peterborough, Stamford, Kettering, Corby, Leicester and sometimes even beyond. The big problem at the moment is that their health records are not shared across those different clinical commissioning groups, leading to big problems with them getting the care and support they need. Will ICBs be able to help us to overcome these issues? I have been lobbying the Department of Health and Social Care for months to help us sort out this problem.
I can reassure my hon. Friend that under the changes we are putting in place through the integrated care systems, ICBs will continue to be able to commission services and to send patients to hospitals outside the ICS area. They will also be obliged to co-operate and work with other organisations in the patient’s best interests. We are setting this alongside the broader work that we are doing in the Department on the interoperability of data. I hope that that has reassured her to a degree.
We are also committed to supporting research, and I ask the House to agree to Lords amendments 6, 15, 26 and 28, which further embed research and provide increased clarity, transparency and oversight in respect of ICBs, NHS England and the Secretary of State’s research duties.
I want to ask the Minister about two matters. First, why are health inequalities not explicitly mentioned among the triple aims of the Bill? Secondly, on the membership of ICBs, I am sorry if I misheard, but I did not hear him discuss the amendment on how to avoid any conflict of interest involving private providers on those boards.
The reason for that is that an amendment was brought forward on Report, and the matter was settled at that stage; things have not changed since. In lieu of what had been tabled, we tabled our own amendment on Report, which—even though in our view it was unnecessary—we felt further clarified how to avoid conflicts of interest. In the previous group of amendments, we tabled an amendment to extend that conflict of interest policy and approach to the sub-committees of the boards, in order to ensure that it is explicit that the policy applies to both. It is essentially the same principle, but widened out to the sub-committees to avoid them being inadvertently left out of the legislation.
I really welcome Lords amendment 12 on palliative care. Can the Minister give us any more information about whether statutory guidance will be given to the ICBs? It is important that they get proper guidance on what is expected of them. Can he also reassure us that palliative care will be a priority objective for the trusts?
I can give my hon. Friend an assurance that we expect that to be the case. I will turn to palliative care in the context of other amendments shortly, and I might address some of his points then.
We are also committed to tackling climate change. Lords amendments 9, 18, 33 and 40 place duties on NHS trusts, foundation trusts, ICBs and NHS England to have regard to the Government’s key ambitions on climate change and the natural environment in everything they do. The amendments include a guidance-making power for NHS England that will assist in the discharge of these duties by different bodies.
There are also a number of amendments relating to how integrated care boards should operate as statutory bodies. Amendments 19 to 21 and 23 require an ICB to consider the skills, knowledge and experience it needs to discharge its functions and, where there are gaps, to consider what steps it can take to mitigate them. The amendments also require the forward plan to include detail on how the ICB intends to arrange for the provision of health services, as well as its duties under sections 14Z34 to 14Z45. The annual report must also include an explanation of how it has discharged these duties.
Debbie Abrahams mentioned conflicts of interest. We amended the Bill in this place, and the Lords amended it further with Lords amendment 11. We understand the motivation, but the drafting does not fulfil the stated aim, which is why we tabled an alternative amendment in lieu of that amendment.
I want to make a little progress. If I make good time, I may be able to give way, but I am conscious of the need to give the shadow Minister and other colleagues plenty of time to speak—about, I suspect, one aspect of this group of amendments in particular, but we will see.
We commend a number of additional amendments to the House. Lords amendments 34 to 37 limit the powers to set capital expenditure limits for NHS foundation trusts, so that they cannot apply for periods longer than a financial year. I reaffirm my commitment to ensuring that these powers on expenditure limits are used only as a last resort, as NHS England agreed with NHS Providers. I also ask the House to accept Lords amendments 50, 65, 104, 106 and 107, which are minor and technical changes required to ensure that the Bill functions as intended.
Although we have made progress on a number of amendments, we urge the House to disagree with the other place on others. First, we ask the House to disagree with amendment 90 on dispute resolution in children’s palliative care, and instead support the amendment we tabled in lieu. Our approach will require the Secretary of State to commission a full independent review of the causes of disagreements between the providers of care and persons with parental responsibility on the care of critically ill children, how these disagreements can be avoided, and how we can sensitively handle their resolution.
We also seek to reject Lords amendment 81. Although we agree on the need to make good progress on the Care Act 2014, it is not in the interests of good government to be forced to implement reform of this complexity and scale through a deadline set in primary legislation. We are getting on with implementing social care reform, and operational guidance is out for consultation. We have announced a small number of local authorities that will act as trailblazers to test the reforms from January 2023, but we must take time to engage with local authorities as they build the necessary infrastructure, and use these trials to refine delivery systems and guidance ahead of the national roll-out. We encourage the House to reject Lords amendment 81, which we believe affects the financial arrangements to be made by this House and, as such, is subject to financial privilege.
I would be grateful if the Minister answered my question about the triple aims, and the impact of not including in them an explicit reference to health inequalities. The Bill refers to health and wellbeing, but not to health inequalities. My main point is on the care cap. More than one in six of my constituents with dementia will not reach the cap, as it stands. The Lords amendments mean it would be one in five, so I would be grateful if the Minister could say exactly why he is prepared to let one in six of my constituents not reach the care cap.
I will address the care cap, because there is a fair bit to say. I was just addressing the noble Lord Lansley’s amendment. I apologise for missing the hon. Lady’s first point. We do not think it is necessary to have health inequalities explicitly among the triple aims, as we believe that the issue runs through everything that ICBs do and everything the Bill sets out. We therefore feel that the Bill is effective, and that each ICB’s ICS will have regard to health inequalities and will see them as central to its objectives.
Before I turn to Lords amendment 80, I will briefly address Lords amendment 51, which relates to consultation with carers during hospital discharge planning. We have heard about the strength of feeling in the other place on that issue. We wholly agree that we must ensure that, where appropriate, unpaid carers are involved in planning around discharge. Although the Government appreciate the intention behind the amendment and want to address the concerns raised, we want to do so in the most effective way, and in a way that does not create unintended delays to discharge. I ask Members to support our amendment in lieu, which would achieve much of what Lords amendment 51 sought to achieve. It will introduce a new duty on trusts and foundation trusts to involve carers during adult discharge planning. Unlike schedule 3 to the Care Act 2014, this duty applies to all carers where the patient has care and support needs following discharge; and it applies to young carers as well as adults. Our amendment in lieu and the new statutory guidance will ensure that patients and carers are involved in discussions about post-discharge care as soon as they start.
I am pleased that that concession has been made. However, a number of points of clarification would be really helpful to carers. One is about being given a choice about caring, carers having the right information, and carers being able to express their needs properly. The second is about disabled children, who are not referred to here, and the third is about ensuring that young carers are clearly covered by any guidance issued. Will the Minister say how those issues will be addressed?
I hope that I can give the hon. Lady reassurance. When we refer to “carers”, we intend that to be a broad term, rather than a narrowly drawn one. She is absolutely right to highlight young carers; they are carers. They also face particular challenges, because they often juggle school and similar things with caring. It is our intention that all carers will be covered by this duty on trusts and foundation trusts to involve carers during adult discharge planning. That would apply to all adults who are being discharged, where a carer is involved. I hope that that gives the hon. Lady some reassurance. We would look to ensure that these points were suitably emphasised in guidance and in the advice we give to ICBs and ICSs. As she will know, the Department works with NHS trusts and NHS England, and has various mechanisms for guiding and informing trusts. I recognise the importance of the issue.
We ask that this House rejects Lords amendment 80, and that it reintroduces the clause that the Government originally inserted on Report in this House, alongside further amendments to support the operation of charging reform that were originally tabled in the other place. The Government have set out their plan for a sustainable social care system. We want to end unpredictable care costs for everyone by introducing a universal £86,000 cap on an individual’s personal care costs. I pay tribute to the Minister for Care and Mental Health, who, since taking up her post last September, has made driving this agenda forward a personal priority. I should also pay tribute to her predecessor, my hon. Friend Helen Whately, for her work in this area.
We entirely recognise and respect that there are strong views on this issue across the House, and it is vital that our approach is fair. The Government believe that the fairest version of the cap would be based on what people contribute towards their care, rather than our counting local authority contributions as well. It simply cannot be fair that two people living in different parts of the country, contributing the same amount, progress towards the cap at different rates because of the differences in the amount that their local authority is paying.
The Government’s plans are regressive when compared with the proposals under the 2014 Act. They are less equitable to those with moderate assets, including those living with dementia and working-age adults with disabilities. It would be fairer to keep to the original Dilnot proposals, but can the Minister outline how the £900 million saving that, it is estimated, will result from the Government’s proposals and the use of means-testing will better protect those with lower-value properties?
I am grateful to my hon. Friend, who has been open and consistent in expressing his concerns about this issue. He cites the 2014 Act, but it is important to note that those proposals were never implemented and were not deemed to be financially sustainable or deliverable. There were other proposals, including in 2015, but although no proposal is perfect, the proposals before us are a dramatic improvement, in terms of the protections offered and the crippling care costs that many face under the existing regime. This is an important step forward. Let me make a little more progress, after which I may touch on some of my hon. Friend’s other comments.
I have given way to the hon. Lady already in this debate, as I did in the debate on the previous group of amendments, so I shall make a little progress. She knows that I am always tempted to give way, but I do want to make some progress.
If we did not make the change I have described, the situation that I outlined before I took the intervention from my hon. Friend Peter Aldous is exactly what would happen. If a less well-off person living in Hertfordshire or Hackney had more of their care paid for by their local council than somebody making exactly the same contribution towards their care in Hartlepool, the person from Hertfordshire or Hackney would hit the cap first, and more swiftly. As a Government, we are committed to levelling up, but it does need to be fair. We should not treat less well-off people in different parts of the country differently; rather, we should make sure that they benefit to the same extent and that support for levelling up comes because more people in less well-off regions will benefit than in better-off regions.
I wish to tackle head-on the idea that the cap on care costs is somehow a target that everybody should want to hit. That is absolutely not the case. Nobody should want to hit the cap, which is not a target designed to be hit: it is a backstop protection for people. The nature of the means-tested support will dramatically reduce the amount that less well-off users will have to spend on care. For example, wealthier people who entirely self-fund their own residential care are likely to have to spend £86,000 of their own money if they live in a residential home for just over three years. Older adults have around a one-in-three chance of living in a residential home for that long once they have entered it. Somebody who starts with £100,000 of assets would need to draw on care and support in a residential home for about 10 years to have to spend the same amount. They have just a one in 50 likelihood of that being the case. Somebody who starts with even lower assets is even less likely to spend that much of their own money. The reforms are therefore fair, because they mean it will be far less likely that less well-off people will face very high costs.
We believe that the approach I have set out is fair and is a significant improvement on the situation today, so we must insist that the House disagrees with Lords amendment 80 and the clause is reinserted.
I am reminded of some training I had a few years ago, when my trainer said, “Karin, people will often thank you for your brevity at this time of night,” so I shall not detain the House for too long.
As the Minister kindly alluded to, I spent some six weeks in the Bill Committee trying but failing to alter the original Bill from the Back Benches. I therefore praise the work done by my colleagues and others in the House of Lords. The list of improvements that have already been made is impressive. Unlike in Committee, when the Minister batted away every single proposal for change, the Government have adopted some changes and there has been some progress.
We support Lords amendment 90, on palliative care, which is a really difficult and complex subject that involves distressing issues for the people affected. The Government should further consider that amendment.
On unpaid carers, we support the finely crafted solution in Lords amendment 51 to protect carers. The intent behind the amendment is to prevent any further problems with discharge to assess. We need to enhance people’s rights as carers, not take them away. I know from personal experience that the removal of an assessment prior to discharge may result in less priority being given to the assessment once someone has left hospital. Families clearly worry that patients may be “out of sight, out of mind” once they have left hospital. It would be helpful if the Minister clarified the Government’s commitment to ensuring that carers are consulted as part of the discharge process. It is vital that steps go much further than simply “involving” the carer; we need to ensure that the carer is both willing and able to provide care for the patient and that the necessary community services are in place. Community services and primary care are currently badly stretched.
In Committee, I raised many issues relating to the membership of integrated care boards, particularly in respect of their lack of accountability to local people. None of my proposals made it into the Bill, so I was delighted to see that one proposal made it through the House of Lords. We are happy to support the approach agreed in Lords amendment 105, to give some positive recognition to parity of esteem for mental health. The broader issue of who else gets to be on an integrated care board will rumble on for years, but this is a good first step, and we expect it to happen. It is vital that there is a mental health voice on our integrated care boards, but as well as the Minister confirming that he expects that to happen, it would be really helpful if he could clarify what recourse or consequence would be available should that mental health representative somehow be blocked at a local level from serving on the ICB.
Let me turn to the broader issues. As I said in Committee, this is fundamentally another NHS reorganisation Bill. It is a restructuring of the NHS and a centralisation of power within the NHS. It does not nothing to achieve integration and nothing to improve accountability to the public, to patients and to communities. With the publication of the Ockenden report and the deeply worrying staff survey and patient satisfaction surveys, it is not a good day for the health service. It is clear that centralising control in the NHS is very much the wrong approach. Local representatives need much more power over local services, and accountability needs to be much better at a local level.
The Bill also does nothing to improve the appalling state of social care provision. No wait for care will be shortened because of this Bill and nobody excluded from care will now receive it, but we do now have a Bill that lays to rest the worst of the Health and Social Care Act 2012, the Lansley Act. Those of us who were on the other side of that Act and its implementation—in fact, it was that Act that brought me to this place, so appalling was it—and who fought and campaigned against it really should be having a bit of a party to celebrate the disappearance of some of the worst excesses of that Act.
With the changes to procurement and the many assurances given from the Government Dispatch Box, the main threats detected in the original Bill have largely been allayed. Compulsory tendering has gone; we have preferred provider in all but name. Procurement from the private sector must now be on a proper, open and transparent basis, which means no more crony contracts or jobs for friends and family, and Virgin Care and other large corporates no longer influencing commissioning.
With Lords amendment 11 excluding private interests from commissioning, we see a dramatic shift that is most welcome. We may start to get back to a public service model. That could start a journey to build an NHS where adequate investment and support means that patients do not have to start relying on the private sector.
The most serious issue in this bunch of Lords amendments has been ducked. The dead hand of the Treasury has clamped down and common sense has departed. Shoehorning the change in the calculation of contributions to the care cap into the Report stage of this Bill was parliamentary sharp practice of the highest order, designed to minimise scrutiny and stifle criticism. Our position is encapsulated by Lords amendment 80. This provision should never have been in the Bill. It is hugely significant to our constituents, and it has never been properly considered and cannot be today. I listened very carefully to the Minister outlining various scenarios. I, too, could outline various scenarios from the Dispatch Box, but I will not do so today. This is not the place to do that; there needs to be proper consideration and proper scrutiny. The Department has sneaked out the view that restricting contributions to the cap for those being means-tested for their care charges would save an estimated £900 million by 2027-28 in cash terms. Surely that means that there is time to look at this properly, and we are willing to work with the Government to do just that.
Let us be clear: if that is the true estimate, then that is what the Treasury is talking about saving from the poorest—from working-age adults with a disability and older people with few assets. That is where that money comes from. That is not fixing social care; that is asking people with less to pay more to protect the assets of the wealthiest—the less a person has, the more the Treasury will take.
Members of Parliament from across the north-east of England, Yorkshire and the Humber and the midlands really need to take note, because, from what we can gather at the moment—we do not know enough about this to be totally clear about how it impacts people—it looks like those areas will be worst hit by the Government proposals. Why are those MPs not here? Why are they not outraged by this? I suspect that it is largely because they do not know, and the Government do not want them to know. It is so hard to follow the detail of this.
It has been almost 3,000 days since the Care Act 2014—a carefully crafted piece of legislation, agreed across party lines and after a huge engagement with stakeholders— was granted Royal Assent. If the calculation towards the cap is to be changed, that change must come the same way, through cross-party working with the sector, patients and people involved, understanding the evidence on impact and considering the consequences—not through this half-arsed addition to an NHS reorganisation, which is essentially what the Government are doing.
If the Government are determined to leap into action, they should accept amendment 81 and get on with implementing the Care Act and the Dilnot proposals as originally agreed. I followed the implementation of the Act very carefully when I came to this place in 2015, and I think I have heard from the Government Dispatch Box today for the first time that it was never agreed, that it was undeliverable and not financeable. That is not what the people producing the Care Act or the Conservative Government of the time led us to believe. They moved the implementation to April 2020, expecting there to be a general election in that year, and never really came back to explain the rationale.
We will not get mired in details tonight because, as I said earlier, this is not really the place for it, but our constituents are being led up the garden path by this Government. This place should be considering the proposals properly. That is what the Lords have asked us to do, and the Opposition will support them in doing that. This question is too important to be left to a last-minute addition.
I will speak briefly in favour of Government amendment (a) in lieu of Lords amendment 51. I draw hon. Members’ attention to my entry in the Register of Members’ Financial Interests and the fact that I am co-chair of the all-party parliamentary group on carers. My predominant interest is that this is a cause that I care very deeply for.
Ultimately, the aim of Lords amendment 51 is to focus on carers and the safe discharge of hospital patients. The Government’s amendment (a) in lieu will achieve most of what the noble Baroness Pitkeathley originally attempted to achieve in her amendment, ensuring that carers are involved at the point of hospital discharge.
Across the UK today there are about 6.5 million carers supporting a loved one who may be older, disabled or seriously ill. That is one in every eight adults providing unpaid care for their family or friends, whether around the clock or for a few hours a week. It is an enormous contribution and saves the health and social care system billions of pounds a year. It has an untold impact on carers’ own lives and livelihoods, but for the people they care for, it is literally a lifeline.
The amendment in lieu recognises the vital role that carers play and avoids any suggestion of their losing their rights, which could have been an unintended consequence with the wrong wording. It is important that carers are recognised in this legislation; it is clear that the Government have listened and reflected the strength of feeling about that, and I am grateful. We must do more to equip carers to care safely and well, and to juggle other aspects of their lives. That is why the requirement to consult carers prior to patient discharge is so important. The Lords amendment had cross-party support in the House of Lords, and I hope the amendment in lieu will achieve the same thing in the Commons.
According to Carers UK, there are still some worrying statistics on discharge: 56% of carers were not involved in decisions about discharge from hospital and what care and treatment the person they cared for needed, 82% of carers did not receive a carer’s assessment and 68% of carers were not asked about their willingness and ability to care at discharge. I am sure the House will agree that those are deeply distressing statistics, and that we have a lot of work to do to address them.
There are a few important points of clarification and assurances that I would like from the Minister. He mentioned earlier that young carers were covered, but the language is a little opaque, so can he confirm for me that he is talking about not only young carers who are looking after adults, but young carers who might be caring for brothers or sisters? Some young people perform that incredibly difficult task at enormous disadvantage to themselves, and I want reassurance from the Minister that this House and this Government have not forgotten them.
The second point of clarification is that the original amendment 51 included a test on whether a carer was willing and able to care, as in the Care Act 2014, and I want to ensure that this amendment in lieu will secure that. There are also important clarifications to be made around what “feasible” means; I hope the Minister can help me with that, so that carers are absolutely sure what he means by their rights.
Unpaid carers are so often invisible, their efforts unacknowledged, and I am pleased to see the Government taking steps to address that through their amendment in lieu. It is a start. There is much further to go to give unpaid carers the support and recognition they need—that is a discussion for another day, but it is a discussion I intend to have.
I would like to start by talking about carers and safe discharge. I welcome the Government’s concession on this point. It is a pleasure to follow Dame Caroline Dinenage, who talked so eloquently about the fact that unpaid carers are often, in effect, invisible. She is seeking a number of assurances from the Minister, and I wonder if I might add another.
The Minister will be aware that on Report I tabled an amendment calling for a new NHS duty to recognise and identify unpaid carers who come into contact with the NHS so that their health and wellbeing could be taken into account when decisions are made concerning the health and care of the person or the people for whom they care. The amendment now before us is not as strong as that. In fact, it is not as strong as the Lords amendment. I welcome the Government’s concession on this, but I wonder whether the Minister might provide some assurances that the nub of my amendment at an earlier stage could, for example, be included in some of the ICB guidance. It is important that carers are consulted but also important that their health and wellbeing is taken into account when decisions are made about those for whom they care.
I have a couple of thoughts on the social care cap. First, it is a really terrible way to come up with policy to change a policy halfway through a Bill, because it starves important policies of public debate and parliamentary scrutiny. It is a very bad habit. We have seen it with other Bills, such as the Building Safety Bill—a national scandal that I have spoken about many times. This is a bad way of making law. It is important that the Government do not fall into bad habits.
The other point is on broken promises. The Prime Minister stood on the steps of No. 10 and pledged to
“fix the crisis in social care once and for all”.
He also promised that no one would have to sell their home to pay for care. He has now broken both those promises, because this Bill does not fix the social care crisis and it does continue to see people facing the prospect of losing their home to fund care costs. Quite frankly, it is appalling that the Government are arguing that they cannot afford to accept this amendment when the savings that are going to be generated for the Treasury come off the backs of the poorest people in our society. The Government really should think again.
I have sat through all this debate and taken issue with the Government in some places and supported them in others. I am going to take issue with them on amendment 51. It is always hard to take issue with this Minister, but I seem to have done it twice already today. My hon. Friend Dame Caroline Dinenage and I did not compare notes but seem to have exactly the same comments, which suggests that this is an important amendment.
I want to make a few points about young carers in Hampshire and nationally who have been in touch with me about amendment 51. The amendment that we are being asked to strike out says at paragraph (5)(b) that
“a ‘carer’ means any person, including any child under the age of 18”.
It does not say that in the Minister’s amendment in lieu, but I have heard what he has said today and I hope that it will be heard clearly, because what is said at the Dispatch Box matters a great deal. The Minister in the Lords said on Report that there will be statutory guidance that hospitals “must have regard to” and that that is a sufficient measure for carers. Again, I hear that, but what is said at the Dispatch Box in the Lords matters as well. As young carers have said to me, ahead of today, this is not the same as primary legislative rights and it can be withdrawn or changed at the stroke of a Minister’s pen, intentionally or unintentionally. It does not mean the same for carers and young carers in the daily operation of the system. I would suggest that very few carers, especially young carers, have the energy, the means or the knowledge to go to judicial review if their rights are not followed.
When the Minister winds up, I beg him once again to make it absolutely crystal clear that his amendment in lieu does the same as the Lords amendment that he is asking us to strike out, because young carers, in particular, want and need that reassurance. Other than that, it is a good amendment that is worthy of our support, but I just want to hear a little bit more from my excellent Minister—and now that I have flattered him he cannot deny me.
I rise to speak in support of Lords amendments 51, 11 and 105. With this Bill, the Government are legislating so that a controversial approach known as “discharge to assess” can be used when discharging patients from hospital. This would see patients discharged from hospital before their social care needs have been assessed, with vulnerable patients potentially sent home without the support that they need in place, leaving families to pick up the pieces and those without family at risk of neglect. Lords amendment 51 is important in relation to that.
The amendment would retain the principle and duty on a hospital, whether an NHS hospital or an independent hospital, to ensure that a patient must be safe to discharge from hospital, and it mirrors carers’ rights established by the Community Care (Delayed Discharges etc.) Act 2003. This important amendment would recognise the vital role played by carers across the country in looking after their loved ones. However, it does not stop the Government from legislating for discharge to assess, a policy that has been piloted and was included in the Coronavirus Act 2020 as a temporary measure. I am concerned that the Government are not only going ahead with an approach fraught with risk for vulnerable patients, but are doing so in the knowledge that an independent evaluation commissioned by NHS England of the implementation of the hospital discharge policy has still not been published, despite the Government promising that the evaluation was due to report in autumn last year.
I am concerned, too, that the Government do not even understand the clinical outcomes of discharge to assess. When I submitted a question last year asking the Government how many patients discharged in this way were readmitted within 30 days, the Government said that they did not hold the data. I believe that to be a dereliction of duty.
Lord amendment 51 would put in place important rights for patients and carers at what can be a very difficult time. I note that the Government disagree with the amendment and have tabled an amendment in lieu, but I believe that it waters down carers’ and patients’ rights. It merely proposes that
“the relevant trust must, as soon as is feasible after it begins making any plans relating to the discharge, take any steps that it considers appropriate to involve…the patient, and…any carer of the patient.”
That gives inappropriate levels of discretion to trusts over patients’ and carers’ involvement, instead of guaranteeing their rights.
Lords amendment 11 is a step in the right direction, although it does not go far enough. It would ensure that conflict of interest rules that apply to integrated care boards would apply to commissioning sub-committees of integrated care boards. The Government have said that they disagree with the amendment and have proposed an amendment in lieu that would prohibit a chair of an ICB from approving or appointing someone as a member of any committee or sub-committee that exercises commissioning functions
“if the chair considers that the appointment could reasonably be regarded as undermining the independence of the health service because of the candidate’s involvement with the private healthcare sector or otherwise.”
I am concerned that the phrasing is clearly open to interpretation, and it by no means rules out people with interests in private healthcare from sitting on these sub-committees.
It is wrong, too, that the power should rest with one person, namely the chair of the ICB. If we are serious about providing governance that rules out the possibility of the private sector influencing the expenditure of public money, an organisation carrying out the functions of an ICB on its behalf should be a statutory NHS body. It is a great pity that the Government have not legislated for that.
We cannot forget that NHS guidance last year stated that the Health and Care Bill, if enacted, would enable ICBs to devolve budgets to provider collaboratives, which are one of a complex array of sub-committees that could take on commissioning functions. Representatives of private companies, which are accountable to shareholders, should not be able to influence these commissioning sub- committees in any way. Lords amendment 11 at least improves the original Bill, and I therefore welcome it.
I also welcome Lords amendment 105, which would mean that the membership of an ICB must include at least one member with expertise and knowledge of mental health in the integrated care board’s area. The fact that the Government did not provide for that originally shows that they are still not treating mental health with the level of seriousness it deserves. It is disappointing that the Government have indicated that they disagree with the amendment.
The amendment in lieu that the Government have proposed makes provision for the chair of an ICB to act
“with a view to ensuring that at least one of the ordinary members has knowledge and experience in connection with services relating to the prevention, diagnosis and treatment of mental illness.”
The Government have watered down the amendment, and it is regrettable that they have removed expertise in mental health as a characteristic that this member of an ICB must have. It is feasible that that person could be a manager who once dealt with mental health rather than a mental health clinician or health professional. I noticed that in the Minister’s opening remarks, he commented that ICBs would be able to commission out of area. I would be grateful if he gave some clarity about how A&E services will be guaranteed to people should they happen to fall ill out of area.
This is a devastating piece of legislation and it is all the more shocking that the Government have pressed ahead with it at a time when NHS staff are exhausted and patients and people across the country are still struggling with the pandemic. It will embed a postcode lottery and open up the NHS to widespread privatisation. In so doing, it does a disservice to patients in England and to NHS staff.
The Bill provides for the scope of “Agenda for Change”, the pay and terms and conditions of about a million people who work in the health service, to be undermined; it allows for NHS professions to be taken out of regulation; and, as I have mentioned in relation to Lords amendment 51, it will allow for vulnerable patients to be discharged from hospital before their social care needs assessments have been carried out. The NHS is our most treasured institution and I pay tribute to all those campaigners across the country who have fought hard to oppose the Bill.
I congratulate the Government on their amendments on mental health. As a former Minister with responsibility for mental health, Madam Deputy Speaker, you know that I have long taken an interest in the subject, so I am delighted that parity of esteem is included in the legislation. It is a very important amendment.
Parity of esteem must mean something, however, and should not be a jumble of words. It was the case that too many voices on both sides of the House fell silent during the covid pandemic. That may have been due to the fog of war, but the scarring of that silence runs deep in the communities that we represent—there are some very ill and damaged people out there. It is fine for us to talk about parity of esteem, but we have to live it and deliver it, and I am afraid that we fell short for 18 months.
I welcome the amendment and the recommitment of hon. Members, but we were all found wanting when it counted. I have the witness statements of more than 2,000 people who suffered with mental health problems during the pandemic and who wrote to me detailing what that was like. One day, I will make those statements available to the Government and to the inquiry, but today, I just thank the Minister and my right hon. Friend Mrs May, who joined me in initiating the amendments. I hope that the next time that the country and this place are challenged, we rise to it, because mental health is as important as physical health.
It was not my intention to speak in the debate, but I need to ensure that the point that has been raised about Lords amendment 80 and the cap is not missed. The Minister talked a great deal about fairness, but how can it be fair that my constituents and people across the north-east and the north generally will face what the King’s Fund described as
“people with low levels of wealth” being
“exposed to very high care costs”?
It cannot be right that the northern regions and other areas will face that unfairness. The Government should reconsider the issue and come forward, as other hon. Members have said, with further discussions about how to resolve it. The proposal in the Bill is very different from that originally presented to the House on care costs.
On carers, I agree with other hon. Members who have raised the issue. As I mentioned earlier, we need much more detail and certainty for those carers and we need to be able to take part to ensure that the guidance issued is effective and represents and meets their need.
I believe that everyone should have high-quality, personalised palliative care, and that is why I am speaking in favour of Lords amendment 12 on palliative care. I wholeheartedly welcome the benefits that this Bill can bring to those in need of that care. I must mention the tireless campaigning of Baroness Finlay, as referenced by the Minister in his opening statement, and Hospice UK, which acts as the secretariat for the all-party parliamentary group on hospice and end of life care, of which I am a co-chair along with Baroness Finlay. Without their campaigning, we would not have been able to welcome this step forward. I should also declare my interest as a trustee of a hospice, and I draw the House’s attention to my entry in the Register of Members’ Financial Interests.
On the day of the publication of the Ockenden report and our discussion of good births, it is time that we started to talk about good deaths, too. There is far more that we need to do to ensure that hospices and palliative care providers have the tools they need to achieve this, and Lords amendment 12 certainly moves us forward. We need to ensure that the impact of the measures in this Bill are maximised. The Bill specifies appropriate palliative care, but we should expand on this to ensure that a fair minimum standard of care is provided. We should be providing statutory guidance to integrated care boards on the commissioning of palliative care, ensuring that the new requirements are clear. That point was ably raised by my hon. Friend Craig Tracey.
Funding certainty for hospices is essential. Certainty can enable them to better plan, support the needs of their local community and give commissioning boards confidence in relying on them as an integral part of local services. Certainty of funding will allow hospices to invest, innovate and integrate with the NHS and care system. Before the pandemic, adult hospices on average received 34% of their funding from Government, with some receiving little or none. Hospice funding came primarily from charitable donations, with the sector needing to raise £3.1 million every day. The pandemic saw donations, retail sales and fundraising activities fall dramatically, at the same time as an increase in service delivery. I want to put on record my thanks to the Government for the support that was given to all our hospices during the pandemic—and, in particular, to St Teresa’s in Darlington—but we need to see some certainty of funding for our hospices to deliver on this promise.
I am pleased that the Government accept Lords amendment 12. It is an important step forward for hospices and palliative care, and I welcome it.
It is a pleasure to speak after my hon. Friend Peter Gibson. He made some very strong points in his speech with which I absolutely concur. I want to speak to Lords amendment 80, and his constituency—I know it pretty well, having been there and spent a bit of time there prior to the last election—is the kind that will be affected by it. The Government’s decision is to resist that Lords amendment, which I cannot support. In my view, this is a classic policy for levelling down, not levelling up.
The Minister is absolutely right—both Ministers involved in this Bill are good friends of mine, and I do not want to make their lives more difficult in any shape or form—when he says that the policy across the board is a significant improvement on anything we have had before. That is absolutely right. He said that in his speech, and I agree with it, but I do not agree with him when he says that it is fair. I do not believe it is fair, and that must be the basic criterion on which we judge any proposals, not least these.
I think everybody, including the Minister, accepts that it is quite clear that a £900 million transfer is happening here, which was introduced just as the Bill went on to Report stage. That is a direct transfer of £900 million from household wealth to somewhere else. That is what it is: a transfer of assets—household wealth—to healthcare, the Treasury or wherever else it is going, because that is the way that council contributions are used when it comes to the speed at which somebody reaches the cap.
I could live with that, if we were trying to make the system more affordable, as the Minister says—if the burden was going to fall equally on everyone’s shoulders in different parts of the country. It also true to say that most people will not be affected, because only people on very long care journeys tend to be affected badly, but there are quite a few of them: according to the Department’s own figures, about 6,000 a year—10 people per constituency—would be affected in this way, and most of them have dementia. We know that there are 900,000 people with dementia in the UK today; according to the Alzheimer’s Society, there will be 1.6 million by 2040; and 70% of care home residents are dementia sufferers, and they are the sort of people who will suffer because of the changes. They have very long care journeys, and they move out of their house so it becomes one of the assets that we take into account when assessing how much people contribute to the care cap.
The Minister says we are making these changes to make the system sustainable. Well, okay, make it sustainable, but make it fair too. I do not believe that this is fair. I know I am comparing this with a system that never existed—my hon. Friend is right to say that—but one was proposed in which the council contributions would count in calculations of people’s contribution to the care cap. That is the change we have made—the specific measure to make the system more sustainable is that change, and that affects people with limited assets and wealth. We are balancing this on the shoulders of people with fewer assets and less wealth, and on certain areas as well, as people in some of the regions in the north that we represent tend to have fewer assets and less wealth.
Particularly affected are people who have wealth or assets worth between £75,000 and £150,000. The research provided by the Alzheimer’s Society is clear: under the Dilnot proposals, about 50% of people living with dementia benefited fully from the care cap—they reached the care cap. That was true across all the wealth quintiles—it was very fair. This is not. Only 13% of people in the least wealthy quintile will reach the cap, whereas 28% of the most wealthy will. Such huge disparity cannot be right, yet that is the change that we have made. That £900 million has been found from people with less wealth. That cannot be right, nor is it consistent with levelling up. Look at how different regions are affected: only 13% of people in the north-east reach the cap whereas 29% of people in the south-east do so. Previously, in almost every part of the country, about 50% of people did so. The cap was not as generous, but it was very fair across different wealth quintiles and different regions of the country. I cannot see how this is fair.
Instead of each of us having 10 people in our constituency affected, some will have more and those representing wealthy constituencies will have fewer. I and other Members representing the north-east will have more constituents affected by this change and less generously treated because of it. For that reason, and because in my view it levels down, I cannot support the Government and will vote against them this evening on Lords amendment 80.
I am grateful to all colleagues who have spoken this evening. A number of the arguments were made on Report, and rightly, right hon. and hon. Members have reiterated some of those points where they felt it was appropriate. I will address a number of the points raised relatively briefly.
What we are legislating for in this Bill represents an evolution of our health and care system, and improved integration. My hon. Friends the Members for Gosport (Dame Caroline Dinenage) and for Winchester (Steve Brine) both spoke about carers. Young carers are included, which I hope reassures my hon. Friend the Member for Gosport. In respect of the statutory guidance, I hope that it will provide reassurance if I can set out that we will develop that guidance in partnership with Carers UK to ensure its input and so that it captures exactly the things that hon. Members have alluded to. Again, in statutory guidance, we will look at how to ensure that the duty to give people the information that they need is properly and effectively discharged.
I am grateful to my hon. Friend Sir Charles Walker and my right hon. Friend the Member for Maidenhead—she is now in the Chamber—for the work that they have done on the Bill to ensure that parity of esteem for mental and physical health is not forgotten and is explicit.
On a point made by Debbie Abrahams, I will clarify what I said earlier on the triple aim, which may give her a little reassurance, even if not necessarily sufficient reassurance. We have not created a quadruple aim or a fourth limb, but we have included a reference to health inequalities under the existing triple aim in the other place. It is not forgotten. I hope that gives her a degree of reassurance on that specific point.
Lords amendment 80 was the crux of much of the debate. I fear that many are comparing our proposals with something that was never done. We are significantly improving provision around the sustainability and affordability of social care. The Prime Minister was clear that he would grapple with the issue and resolve it. When the Opposition were in power, they had two Green Papers, one royal commission and one spending review priority on the issue and they utterly failed to address it. We are a Government who have made huge strides in creating a better system.
I listened, as always, with great care to my hon. Friend Kevin Hollinrake. I am sorry that he will not be joining me in the Lobby tonight. While I respectfully disagree with him, I know that he has thought long and hard about this matter and has strong and sincerely held views. With that in mind, I regret that we will have to ask the House to disagree with the Lords amendment on care metering.
Lords amendment 11 disagreed to.
Government amendment (a) made in lieu of Lords amendment 11.
Lords amendment 51 disagreed to.
Government amendment (a) made in lieu of Lords amendment 51.