Baroness Greengross:

Moved by Baroness Greengross

290: After Clause 148, insert the following new Clause—“Social prescribingThe Secretary of State must seek to ensure that health professionals are aware of any benefits of practising social prescribing of music and the arts for dementia, in particular for patients at the onset of symptoms so as to preserve their brain health and resilience in the community.”

My Lords, I wholeheartedly support Amendment 297A in the name of the noble Baroness, Lady Hodgson, and Amendment 291D in the name of noble Lord, Lord Hunt, but I will speak only to Amendments 290 and 291 in my name in this group. Amendment 291 calls on the Secretary of State to

“publish a plan for dementia care” which recognises

“the different types of dementias and the specific care needs of each type”.

It also places a duty on local authorities and the

“NHS integrated care system to implement this plan for their own areas”.

Some 70% of care home residents and 60% of home care recipients in the UK have some form of dementia. When we talk about the crisis in social care and the urgent need for social care reform, one of the major drivers of this crisis is the growing number of people living with dementia, with one in 14 people over 65, and one in six people over 80, living with some form of dementia. By 2040, the number of people living with dementia is expected to have grown to 1.5 million. Globally, the World Health Organization reports that over 55 million people are currently living with dementia; by 2050, this number will have grown to 153 million.

It is easy to get caught up in the numbers, but we need to remember that these are usually people with family and loved ones who often become carers, even once the person with dementia ceases to recognise their loved ones, and in many cases spend prolonged periods of time in a state of distress and even anguish. It is not just unpaid carers who struggle to help those with dementia: Skills for Care has recorded that only 44% of care staff have any form of training in dementia. Social care staff should have tier 2 training in the dementia training standards framework to support the delivery of more personalised care for people with dementia.

As co-chair of the All-Party Parliamentary Group on Dementia, I work closely with the Alzheimer’s Society. This organisation has been working with the small team at the Department of Health and Social Care that has been trying to develop a new national dementia strategy. With no co-ordinated strategy for dementia since 2020, and with the conditions of people living with dementia deteriorating during the pandemic, the strategy needs to be published promptly. There also needs to be dedicated funding to deliver it.

There are over 100 types of dementia. We know that the most common are Alzheimer’s disease, which accounts for over 50% of dementia cases; vascular dementia, which accounts for roughly 20% of cases; Lewy body dementia, which accounts for just over 10%; and frontotemporal dementia—FTD—which affects 2%. Each type of dementia has its own symptoms and has different care needs. Also, some forms of dementia can develop tragically at a younger age, and some may cause deterioration of memory and cognitive function for many years.

Dementia is a condition that uniquely cuts across social care and healthcare, because it has no disease-modifying treatment, meaning that the main support someone receives is through the social care system. As I said on Amendment 235 on the social care cap, there is a clear inequity where, if someone is diagnosed with cancer the NHS will cover the full treatment cost, whereas if someone is diagnosed with dementia they may require many years of care, which will cost them and their families thousands of pounds, as this is not covered. That is made much worse by the fact that, despite best intentions, the care being delivered may not even be suitable for the type of dementia the person needs care for. That brings me to my next amendment.

Amendment 290 requires the Secretary of State to ensure that health professionals are aware of the benefits of the social prescribing of music and art for those with dementia, especially at the onset of symptoms to preserve brain health, and protect against cognitive decline, loneliness and fear in the months and years leading to diagnosis. Over 200,000 people are expected to be diagnosed each year. A third more do not even have a diagnosis, so the arts have a vital part to play for them. When I spoke in support of the amendments in the name of the noble Lord, Lord Howarth, on social prescribing, I and others who spoke on that group outlined the many benefits of social prescribing for the social exercise of arts activity, which empowers patients to preserve their brain health. This amendment specifically outlines the importance of this for those affected by dementia as part of an overall care plan, so links to Amendment 291.

If we look at the four main types of dementia I spoke of earlier, we can see how different forms of art can play an important role. The charity Arts 4 Dementia has found that, for those with Alzheimer’s disease and vascular dementia, participating in music, dance, visual arts, poetry and drama, and trying new techniques and art forms, stimulates interest and joy, relieves anxiety, preserves confidence and improves cognitive functioning. Some musicians continue to play for years, artists to paint and dancers to dance. People with frontotemporal dementia are better able to read words and music and are more interested in dialogue around pictures and the mechanics than creating art. Musicians and artists with frontotemporal dementia can often continue to enjoy singing, playing and painting for years after diagnosis. Researchers have found that those with Lewy body dementia are happier to be involved in social arts programmes, poetry and dressing up than physical drawing, or going to arts events, galleries, concerts or the theatre rather than performing. For those with Parkinson’s-related dementia, dance can be helpful.

Social prescribing is important because it provides social contact; one of the many factors that may hasten the advance of dementia symptoms is loneliness and isolation. Engaging in weekly social, cultural and creative activity at the time of the initial diagnostic process—when people’s anxiety and fears are at their worst, prior to a diagnosis of our most feared, incurable condition—plays a positive role in mental health. Arts activities give people a sense of accomplishment at a time when dementia will reduce a person’s confidence.

I thank the Minister for sharing the recording of his blues band and for his personal pledge to support Music for Dementia—that is really lovely. His video has inspired my researcher Nick Kelly to learn bass guitar, but more importantly, the noble Lord, Lord Kamall, has shown leadership by helping to raise the profile of social prescribing and is an example to others.

Many people have described the Health and Care Bill as a framework Bill, where the structures are set up and the detailed delivery plans are left to communities, who will decide what works best for them. I broadly agree with this approach. However, for the reasons outlined already, with dementia, there is an urgent need for a national strategy. With the growing number of people being diagnosed with dementia and the huge pressure this is putting on our social care system, I believe this national strategy proposal needs to be included in the Bill. Given that the demand on social care is set to increase due to the projected increase in the number of people living with dementia, we need to get this right. I beg to move.

My Lords, the noble Baroness, Lady Masham of Ilton, is taking part remotely. I invite her to speak.

My Lords, Amendment 297D is very important. Unacceptable practices of bullying and intimidation of the most vulnerable people must not take place. I thank the noble Lord, Lord Hunt of Kings Heath, for bringing this amendment to the Committee. I support it.

I congratulate “Panorama” and those who worked undercover to expose these unacceptable wrongdoings in the past in care homes, nursing homes and hospitals for residents who are very vulnerable. The programme showed one girl who was a resident and had asked to be looked after by female staff only. This did not happen, and the film showed men taunting her and seeing her get upset, as they carried on with their bullying and tormenting. All sorts of abuse has been exposed in some of the homes, which were spread across the country, such as Whorlton Hall in Barnard Castle, Winterbourne View near Bristol, Ashbourne House in Rochdale, and many, many others. This is not easy work and staff need to be well trained and suitable candidates, with patience and dedication.

During Covid-19, this situation has been a great risk. Many of the residents are a long way from home and they are very isolated. There should be independent inspections and spot checks; there should not be closed doors. There should be regular safeguarding in the regulations.

I hope that the Government will take this seriously. There should be a duty of candour so that whistleblowers are not victimised when reporting what they think is bad practice. I look forward to the Government’s reply, and I hope it will be helpful.

My Lords, the noble Lord, Lord Howarth of Newport, is also taking part remotely. I invite the noble Lord to speak.

My Lords, I pay tribute to the noble Baroness, Lady Greengross. No one has done more than she has to champion the elderly and the frail. I support all the amendments in this group but will speak only in support of Amendment 290.

There is much evidence of the benefits of creative activity to dementia. Some of this was set forth in the Creative Health report, and more recently in the document A.R.T.S for Brain Health, edited by Veronica Franklin Gould, the founder and now president of Arts 4 Dementia. I pay tribute to her passionate and indefatigable work.

As noble Lords, we have the opportunity to exercise our aging brains in trying to understand amendments to the Health and Care Bill. Others at our time of life take even greater pleasure and benefit to their health through music, painting, poetry, dance, drama and other art forms. Of course, that range of cultural opportunities is there for us too—the cultural scope of Peers is not limited to “Iolanthe”.

Veronica Franklin Gould has very well said:

“music-making provides a tool for a total brain workout”.

The mental activity of learning poetry, performing drama and creating painting or craft opens new neural pathways and connections. Research shows that creativity benefits the plasticity of the cortex, enhances cognitive abilities—perception, motor function and memory—and improves cardiovascular strength. In more humane language, engagement with the arts allows creative self-expression, offers sociability, reduces stress and increases resilience—all leading to joy and achievement. These are profound and measurable benefits. Arts 4 Dementia offers programmes in creative arts venues for people, from the onset of early symptoms of dementia. I draw the attention of the House to the very important work of Manchester Camerata, in partnership with the University of Manchester, in its Music in Mind dementia programme.

There can be years between the appearance of early symptoms and the moment at which someone receives a memory assessment and a diagnosis. This can be a lonely and fearful time, during which the arts can be particularly sustaining. Creative activity slows the deterioration of the brain. The benefits of engagement with creative activity continue for a long time.

Professor Martin Marshall, chair of the Royal College of General Practitioners, has recognised this. He said:

“The shift for us in general practice is not just engaging with the medical activities which are core, but to engage with social activities, and make sure the two are aligned.”

Will the Minister accept amendments to this legislation to ensure that the structures and requirements that it creates encourage, facilitate and drive the shift of which Professor Marshall speaks, and bring the crucial support of the arts and other forms of social prescribing to people with dementia and others? If he does not believe that the legislation needs amendment, will he explain how, as presently drafted, it will drive that change?

My Lords, the noble Baroness, Lady Brinton, is also taking part remotely. I invite the noble Baroness to speak.

My Lords, I thank the noble Baroness, Lady Greengross, and others for the amendments in this group, which would help transform some of the long-standing problems in social care, as well as improve the quality of life of patients and their families, especially those who care for them. I will speak to Amendment 297D, in the name of the noble Lord, Lord Hunt, which seeks the establishment of a review into institutional abuses in care settings within six months of the passing of this Act.

Amendment 297D talks about the effects of restrictive visiting and eviction notices

“on the emotional, psychological, social and physical health of service users, and on the well-being of service users” and their families. Obviously, “restrictions on visiting” has taken on a whole new meaning throughout the Covid-19 pandemic. I note that the Rights for Residents campaign group has secured more than 270,000 signatures on a petition for a law that ensures that

“every resident has the legally enforced right to the support of an essential visitor”.

Currently, homes are meant to support an essential caregiver for all residents—but this is advisory and some homes are still imposing blanket bans on visits. That may be because they have some Covid infections inside the home, but that is not universally true.

There is still no clear picture of how visits are going on in care settings. These could be difficult for residents with dementia, for example, if there is only a very small window for visiting—and perhaps it is just not the right time or the right day for them.

Unlock Care Homes is also doing work on this, including highlighting good practice. It is important to remember that most care homes are not just doing their best, they are doing really well with looking after their residents, despite the constraints of the pandemic, staff shortages and burnout.

Time and again, investigative journalists are uncovering practices going on in care settings that are inhuman, breach vulnerable residents’ human rights and damage patients’ mental, physical and psychological well-being. The noble Baroness, Lady Masham, referred to a long list, and that list is indeed shameful.

A series of scandals led to a CQC report into restraint, seclusion and segregation for autistic people and people with a learning disability being commissioned in 2018. It was published in October 2020. The report said:

“We found too many examples of undignified and inhumane care in hospital and care settings where people were seen not as individuals but as a condition or a collection of negative behaviours … We also found that a lack of training and support for staff meant that they are not always able to care for people in a way that meets those individuals’ specific needs. This increases the risk of people being restrained, secluded or segregated.”

However, the Government have not yet commissioned a review of the entire sector, to understand and learn from the causes and poor practices that have resulted in those institutions failing their residents. Commissioning such a review would demonstrate that the Government really want to bring a halt to these practices.

My Lords, Amendment 297A is in my name and those of the noble Baronesses, Lady Smith and Lady Cumberlege, but I am also supportive of the other amendments in this group.

With people living ever longer, looking after older people so that they can stay healthier for longer is critical, as is ensuring that they receive the care they need and have a dignified and secure old age. Amendment 297A seeks to introduce a new clause that will not only lower, from 75 to 65, the age at which every patient is assigned a named GP but sets out to ensure that named GPs will actually have to meet and have some knowledge of each patient they are responsible for, and will communicate directly with them and the family.

We need to encourage everyone to take responsibility for their health. Having good and regular health checks is an essential part of the prevention of ill health, as well as leading to earlier identification of conditions and earlier interventions. I am sure that other noble Lords who are doctors will put me right, but I was once told that 65 is an age where things can start to go wrong. Therefore, it is important to start monitoring people’s health and being able to identify changes from this age. This will deliver better outcomes and may also enable people to stay at home and lead a fuller life for longer. The role of the GP in all this is absolutely critical.

Last October, a study based on Norwegian health records, published in the British Journal of General Practice, talked about the benefits of having the same GP for years. In Norway, all residents are assigned a named GP. The study found that, compared with a one-year patient-GP relationship, those who had the same doctor for between two and three years were about 13% less likely to need out-of-hours care, 12% less likely to be admitted to hospital, and 8% less likely to die that year. After 15 years, the figures were 30%, 28% and 25% respectively. A senior researcher at the National Centre for Emergency Primary Health Care, part of the NORCE research centre in Bergen, added:

“It can be lifesaving to be treated by a doctor who knows you. If you lose a general practitioner you’ve had for more than 15 years, your risk of needing acute admission to hospital or dying increases considerably the following year.”

As the study showed, it is of benefit to the NHS as it is less likely that a patient will have to be admitted to hospital.

Yet in the UK, GP practices are becoming bigger, and the relationship between doctors and patients less constant. Patients over 75 in the UK are currently given a named GP, and I asked the department what exactly their duties were. The Minister, Maria Caulfield MP, wrote to me, for which I pass on my thanks. She set out that named GPs

“oversee patients’ care and support”.

She particularly highlighted: working with patients to develop a personalised care plan that recognises and responds to a patient’s physical and psychological needs; regularly reviewing patient care at an interval agreed with the patient; taking lead responsibility for ensuring that all appropriate services required under the contract, including health checks, are delivered to the patient; and working with any other health and social care services that care for the patient to make sure that there is continuity of care.

However, sadly, I know from personal experience with my mother that this does not always happen and that some doctors interpret the role of the named GP as just having to look at patient records. We have had discussions on previous clauses in the Bill where it was emphasised that there needs to be a patient-centred approach, but I am afraid that some GP practices just take it as an administrative one. Notes on a screen will never replace the intimate trust of a doctor-patient relationship—and neither is that a patient-centric approach.

I understand that patients who wish to be seen urgently cannot always be seen by their GP on that day, but how can a doctor be responsible for the care of a patient, covering everything the Minister listed in the letter, if they have never met them? Also, surely, if a doctor has some knowledge of a patient, it is easier for them to diagnose what the matter is, and sometimes it will save them time as they will not have to inquire about a fuller history.

However, the BMA advice which sets out named GP responsibilities does not mention that the named GP should actually see the patient. Given that there should be a patient-centred approach, as we have discussed before, what is the point, as things stand, of a named GP?

This amendment will ensure relationships between named GPs and patients, enabling the positive benefits discussed in the British Journal of General Practice. It also sets out clearer responsibilities of that role, ensuring that they meet and communicate with both patient and, where needed, family members liaising on their behalf.

To conclude, this amendment is beneficial, both to patients in delivering continuity of care and therefore better healthcare, and, by keeping more people out of hospital, relieving some of the burden from the NHS.

I thank the noble Baronesses, Lady Cumberlege and Lady Smith of Newnham, for supporting this amendment, and I hope the Minister will consider it favourably. If not, I reserve the right to bring it back. I beg to move.

My Lords, in speaking to my Amendment 297D, I thank the noble Baronesses, Lady Masham and Lady Brinton, for their support. However, I also express my general support to the noble Baroness, Lady Greengross, the noble Lord, Lord Howarth, and the noble Baroness, Lady Hodgson, for their amendments. The common theme of this collection of amendments is the question of how we support vulnerable people.

My amendment is about the experience of many of us who have seen the harm caused to our loved ones in care homes during Covid when visits were not allowed for so long. Even now, it can be difficult to visit in some homes because of the Covid restrictions that continue or where a member of staff or visitor has Covid and then 14-day long impositions are imposed. It is a bit rich when one hears in the media that all restrictions are being lifted, because for many of us, in practice those restrictions have not been lifted at all.

The Joint Committee on Human Rights in its report on care home blanket bans and other excessive restrictions recommended that regulations for care and treatment should include a requirement to ensure face-to-face contact wherever possible between residents and the people most significant to them. I do not underestimate the difficulties faced by care homes in the past two years. They have faced huge challenges. My personal experience is that many of them have risen to the challenge and provide high-quality care. But even before the pandemic, serious concerns were growing about the use of care home visitor bans to punish relatives for complaining about standards of care. Indeed, as far back as 2016, the “Victoria Derbyshire” programme reported that hundreds of care homes were guilty of this method of what it described as institutional abuse. In 2019, the Relatives & Residents Association was coming across at least one case per week and warned the problem was increasing.

One woman found her mother dressed in other people’s clothes, left in her own urine and with her hair unwashed for weeks. The Local Government and Social Care Ombudsman upheld the daughter’s complaint, reporting that after raising her concerns with the care home, she and a doctor were prevented from seeing her mother when they tried to visit. The care home later told the ombudsman the ban was because of a previous incident reported to the police of the daughter and her partner’s behaviour, but could not provide any evidence that an incident had occurred or was reported to the police.

As visiting restrictions are, hopefully, going to be relaxed in the weeks ahead, I am afraid we have the prospect of seeing more residents’ families being victimised in this way. Helen Wildbore, director of the Relatives & Residents Association, has found from its helpline calls that relatives and friends play a vital role in spotting potential human rights violations, particularly around abuse and neglect. When they are locked out by bans, people in care lose crucial support: their advocate and confidante—they might be the only person they tell about their concerns. Sometimes residents are even threatened with eviction or actually evicted in reprisal for complaints about their care. The Joint Committee on Human Rights was told about a family whose mother was threatened with eviction after they merely asked to discuss concerns with the head office of a care home.

These are the kinds of abuses my amendment seeks to tackle and get over the problem that regulations are not sufficient. These regulations may specify the standards of care against which care providers are regulated by the CQC through its inspection process, but the CQC is not going to pick up individual complaints, so there is a gap. There is a strong case for a statutory duty of care sitting alongside CQC regulations to require care providers to facilitate such contact with families as is reasonably practical and to prohibit evictions where non-vexatious and non-repetitive complaints are in progress. In my amendment, I am not proposing that. All I am asking for is a review; an independent review charged with examining these options. I hope that the Government will agree that there needs to be some reflection on what has happened and how we can prevent this kind of abuse in the future.

My Lords, I should like to speak to the amendment proposed by my noble friend Lady Hodgson.

From the age of five, I was a child of general practice; it was my world. I accompanied my father on home visits, patients came to our house and the telephone rang constantly—my mother was the secretary and took all calls. My father loved his patients and they loved him. He knew them inside and out, and their families as well. He attended road traffic accidents, of which I have to say there were plenty, and he delivered babies at home—he never lost one. I remember him telling me one day when he came back from a birth that it had been a very difficult birth, but the mother praised my father for having helped her to produce a very healthy little boy. “Doctor”, she said, “we will call the baby after you. What is your name?” My father replied, “Lambert”. “Right”, said the father, “we will call our son Tom.” I mention this only because maternity has been the love of my life, and in this area relationships are critical to a safe and good experience. In my youth, maternity was part of general practice.

After being appointed much more recently to chair the maternity review for England by Simon Stevens—as he was then; now, of course. the noble Lord, Lord Stevens of Birmingham—I was determined to introduce relationship care, sometimes called “continuity of carer”, where the final “R” stands for relationship. We have much respected and credible research from the Cochrane Collaboration in Oxford which shows that women who receive relationship care are less likely to have a preterm birth, less likely to lose their baby before 24 weeks and less likely to lose their baby overall.

We now have in the NHS 371 relationship teams with 2,355 midwives in place where the midwife provides all three elements of midwifery care: prenatal, birth and postnatal care, which is sometimes called follow-up care. In the James Paget Hospital, 90% of maternity care is provided through continuity and it has a waiting list for midwives to join the hospital. Through this initiative, we are transforming maternity care. The women and their families value hugely the relationship with their known midwife, and the midwives who are providing this care absolutely know that what they are doing is the right way to work. They would leave their hospital and go to one that provided such care if their hospital gave it up.

Listening to my noble friend Lady Hodgson, is not this what she seeks for general medical practice? Her amendment is well drafted and reflects an interesting report produced by the Royal College of General Practitioners, entitled The Power of Relationships: What is Relationship-based Care and Why is it Important? and published in June last year. In his foreword, Professor Martin Marshall, chair of the college, writes:

“COVID-19 has radically changed the face of general practice. We have moved from a predominantly face-to-face service to one in which most consultations are delivered remotely, either by telephone or video call … Remote consultations are certainly here to stay. For many patients, they enable quicker and more convenient access to a GP appointment, which of course is hugely important.”

But then he asks the following questions:

“But should speed and ease of access be our primary measures of effectiveness? They are certainly easier to quantify. But what about the quality of care? What about the relationship between doctor and patients which, to me, is the essence of general practice?”

He goes on to say that

“The evidence for the benefits of a trusting relationship is compelling—better patient experience; better adherence to medical advice, fewer prescriptions, better health outcomes, better job satisfaction for doctors and even fewer deaths.”

Indeed, he says that the relationship between the patient and their GP is as important as the scalpel is to a surgeon:

“If relationships were a drug, NICE would mandate their use.”

This is a very compelling and well-researched document. It goes with the grain of modernising general practice. General practice does need modernising. We need to make it more interesting and more satisfying to fulfil the vocation of young doctors and to meet the needs of patients now and in the years to come.

The world is certainly not the same as it was in 1948, when the NHS was designed. Some things are still true, such as GPs needing to be able to fulfil the holistic role for the patient. To do this today, they need access to diagnostics. They also need specialist help in the community from consultants and, on occasions, a network of support from nurses, physios and other health professionals.

Hospitals are now more specialised. There are fewer of them, and they serve much larger populations than they did in 1948. As the noble Lord, Lord Crisp, reminded us in an earlier debate, “Health is made at home; hospitals are for repairs.” If one is to believe the headlines in last week’s Times, GPs will be “nationalised in Javid plan to reduce hospital admissions.” Was this really a power grab by a hospital to take over general practice? I do not believe the headlines, but we need flexibility if primary care is to flourish—even to survive. A scheme in Wolverhampton had fired the imagination of the headline writer, but he did not explain that, in this area, practices were struggling. One or two were failing and one or two could not survive. If the patients wanted to keep a local primary care service, something had to be done. I understand the scheme, whereby GPs are linked to and employed by the hospital. It required a huge amount of work by its leaders—the hospital managers and the GPs, who needed to be convinced. They needed to be assured that it was in their interest to agree to a scheme which would work for the benefit of patients and of all those providing a service. The idea that this could be rolled out nationwide is simply erroneous. In other areas, it has not worked well. Patients feel that they have been denied a choice of hospital care. Hospitals have refused to refer patients to GPs when the hospitals are not busy. Out-of-hours has collapsed.

All of us, in this Chamber and outside, are for ever saying that one size does not fit all—of course it does not. As Andrew Mawson—the noble Lord, Lord Mawson —has taught us, every community is an entity with its own history, geography and personality. We should respect that.

Since my father’s time, much has changed in general practice. There are no night visits, no weekends, no accidents and no births. The preference is for living away from the practice area. A GP is available 40 hours a week, with the majority opting for part-time work. For the other 128 hours? Well, ring a number or go to A&E for excellent medical care. When the Royal College of GPs says that the prime duty of a doctor is triage, why bother to go to the GP when you are ill? Cut the triage. Go direct to the hospital where diagnosis and a prescription will be made. Once that has happened, follow-up care can be done by a nurse prescribing a regime. But we do not want that. We want to learn from the best of general practice, general practice prepared to give a full service with total commitment to its patients and a valued relationship. The good news is that there are many like that across the country. There are remarkable GP practices in tune with the communities they serve—inner-city, suburban, coastal, deeply rural areas that are isolated but resilient, isolated but vulnerable—

My Lords—

I understand that I have overrun so I will say to my noble friends on the Front Bench that we should value general practice. We should build with the best. We should learn from the best. I know that there are hundreds of general practices; it is up to us to applaud them and cherish them and ensure that we see another era of general practice which is different but which values patients and relationship care.

My Lords, I support Amendment 297A in the name of the noble Baroness, Lady Hodgson, to which I have added my name. I shall speak briefly, given that that I am only an irregular participant on this Bill. This amendment is particularly important. I come to an understanding of general practice from a very different perspective from the noble Baroness, Lady Cumberlege, as somebody who has only either received the care of a doctor or seen my parents receive or not receive that care.

When I was a young baby, I was extremely ill. I realise in these days where people talk about conspiracy theories about vaccines that this might be something that should not go into Hansard, but I had a reaction to the smallpox vaccine and my mother went to the public telephone box and called the doctor. The family doctor who came was equally concerned and brought a consultant from the local children’s hospital to our home to see me. That would be the sort of gold standard that we could only dream of now. However, it is the sort of care that we need to be looking to in terms of having a family doctor or a doctor in the community who actually knows individuals. As the noble Baroness, Lady Hodgson, said, this is particularly so for the over-65s, when a range of issues might be beginning to affect them.

The situation today is so very different. The Minister in answer to an Oral Question a few weeks ago repeatedly said that everyone has the right to see a doctor in person and the doctor must give a clinical reason for refusing to have an in-person consultation. I assure him that this very rarely happens, because ordinary patients cannot simply ring up and speak to the doctor and say, “I need to see you”. They will get to a receptionist who will triage them and decide whether they feel that it is appropriate for this person to see the doctor, or to have a telephone conversation or maybe some other virtual consultation.

There is a real need, particularly for older people, to have the opportunity to know that there is a doctor who understands their medical situation and can join up the dots. Somebody who seems now to have low blood pressure might have that because of the previous set of medication that another doctor has prescribed for them. If somebody rings up and gets a telephone consultation or is sent a prescription without proper assessment, the danger is that the whole picture is lost and individuals’ lives can be blighted because they are not getting the medical care they need.

This is not the fault of any individual practice or of any individual general practitioner. However, we have ended up with a system where that traditional idea of a family doctor who knows their patients has disappeared, and somehow we need to get an element of that back. The other three amendments in this group in many ways fit as part of a suite because, if your GP knows that maybe you have early onset dementia or another sort of dementia and you need different types of therapies, they will know what to recommend.

Furthermore, if your GP knows that you have gone into a care home, visits you and thinks, “That person has lost a stone and a half in weight in the last six weeks”, a GP who knows the individual will be able to respond. Somebody who randomly sees a patient will not. I strongly support the amendment in the name of the noble Baroness, Lady Hodgson, and the other amendments in this group.

Finally, I note that the amendment in the name of the noble Baroness, Lady Hodgson, comes immediately after the amendment in the name of the noble Lord, Lord Forsyth of Drumlean. If anyone were minded to support assisted dying, they should certainly support the following Amendment 297A, because how on earth could any doctor reasonably say that we can sign somebody off when they have no idea who that individual is?

My Lords, I would like to use one example to illustrate the importance of Amendment 291 in the name of my noble friend Lady Greengross, and her call for a dementia care plan. It relates to the second point: that the plan must recognise the different types of dementia and their specific care. It is also true that it needs to recognise the different groups of patients affected by dementia and their needs.

I am thinking from personal experience of people with Down’s syndrome. Noble Lords may know that something like 50% of people with Down’s syndrome who reach the age of 60 also have Alzheimer’s; there is some genetic connection between the two. However, the field of dementia has not really caught up with this yet. This is a developing field. The real importance of the plan that my noble friend advocates is that it constantly develops as knowledge develops about particular groups of patients and how they are affected.

The truth today is that patients such as the person I am thinking of are too often let down by the system, because too few clinicians understand the links between the two diseases and the particular needs of people with Down’s syndrome who also have Alzheimer’s.

My Lords, I support the majority of these amendments, but I want to reflect on something that my noble friend Lady Greengross said about the lack of treatment for people with dementia. In fact, there are emerging treatments, and having had the benefit more than 40 years ago of working at a second referral unit at the Maudsley Hospital, I know that people who present with dementia so often also have quite severe depression at the beginning of recognising that they are losing some of their cognitive function. That can be treated very effectively and people can be enabled to live much happier lives for the first part of their care.

I want to give one other example. As a clinical nurse, I was called to help a unit that had severe problems. I do not think there was any maltreatment, but there was certainly a lack of competence in care in the place that I visited. There was a gentleman who was tall and extremely thin who, they told me, had two people with him all the time because he was so agitated. They could not get him to sit down to eat and his relatives did not want him to have any medication.

I am pleased to tell noble Lords that I got involved and we got a consultant psychiatrist in. The family were persuaded that a small amount of anti-psychotic medication might improve the quality of this man’s life. It did; his agitation significantly reduced and he was able to sit to eat. He lived for only another nine months, but those nine months were much happier than they would have been without that medication.

Although I firmly believe in all the social prescribing that we are talking about, we do not necessarily need a dementia care plan; we need a dementia care and treatment plan with an associated workforce development plan. Will the Minister seriously consider those issues?

My Lords, I support Amendments 297A and 297D. I will be brief, because we have already had a very lengthy and wide-ranging debate. The amendment in the name of the noble Baroness, Lady Hodgson, is important, and she has set out the case for a named GP very well. As people become older, they tend to develop a more complicated and interrelated set of healthcare needs, and a GP who has that overview and can liaise with the family is extremely important.

I will add two quick points that have not come up in the debate so far. First, it might sound like a statement of the blindingly obvious, but for this very desirable amendment to happen, there need to be enough GPs in the system. Frankly, I am concerned that, despite commitments from the Government to increase the number of GPs by 6,000 by 2025, there is no current plan for how this will be achieved. The number of qualified full-time equivalent GPs is smaller today than it was in 2015.

Secondly, in relation to health inequalities, it is matter of real concern that GP practices serving more deprived populations receive less funding and often serve much larger numbers of patients than GPs in more affluent areas. I looked at the figures, which I will not repeat, and there are huge disparities in the size of the lists that they serve. I feel that passing an amendment of this sort on continuity of care would most likely benefit patients in the most deprived areas. With this debate, and if this amendment were accepted, I hope that there would be more pressure on the system to relieve that very unhelpful trend.

Amendment 297D is an extremely important amendment, and I am very grateful to the noble Lord, Lord Hunt, for raising it. I do not want to repeat what he said, save to say that I would see this review as a first step towards strengthening the rights of care home residents and their relatives to visit, to keep in touch and to spot the signs of abuse. We all understand how hard the pandemic has been. Most care homes have done their level best, despite a lack of access to PPE and testing in the early days. None the less, many of the visiting restrictions that have been imposed have far too often been blanket restrictions, rather than restrictions that took individual cases and individual needs into account.

We had the repeat Statement from the Minister last week on vaccinations, and we were told that there is now no limit on the number of visitors allowed in care homes. I can tell noble Lords that I have not been able to visit my mother inside her care home since before Christmas, because there have been continuous outbreaks of Covid. Often it affects only two people, but that is enough to shut the care home down. This is why there needs to be a more proportionate and individually judged approach to these things.

Finally, if we had a review of this sort and could strengthen rights, I would hope that we could also strengthen the human rights of care home residents, including self-funded residents who currently have no recourse to the Human Rights Act, which is fundamentally unfair.

My Lords, I attached my name to Amendment 290 in the name of the noble Baroness, Lady Greengross, but I support all these amendments. The comments made by the noble Baroness, Lady Watkins, on Amendment 291 were particularly important as an improvement, but it is still crucial that this is all looked at holistically.

I will confine my remarks to Amendment 290, which is about social prescribing for dementia, focusing in particular on music and the arts. We have discussed social prescribing extensively and I will not go back over that ground. However, I will note how much the Alzheimer’s Society website stresses the importance of music and the arts for the quality of life and care of Alzheimer’s patients, and dementia patients more broadly.

I want to join up a couple of dots. The amendment talks about ensuring that health professionals are aware of the benefits, but I would like to word it much more strongly to ensure that this is regarded as an essential part of care, not a luxury add-on extra—“If we can find the money we’ll do this nice thing”—which all too often is how it is regarded. On that point, I link back to my Amendments 237 to 239, which were debated in a previous Committee session, on ownership of care homes and the flow of funds into care homes, and the fact that 16% to 20% of money in the average care bed is going into financial instruments. If we took two-thirds of that money and put it into more traditional medical, social-type care, and put in some more money for carers to be paid a little better, we would still have some money left for this kind of social prescribing. If we look at that in this context, we see how we join all this up. We really need to stress that social prescribing is an essential part of care, not some luxury add-on extra.

In one more effort to join up the dots, I will make the point that often in your Lordships’ House different people work on different areas and things are not joined up. We have some noble Lords, particularly on the Cross Benches, who do a lot of work in the creative industries, which, financially, are suffering enormously through the Covid pandemic. There is something to be done here in joining up with government-funded projects that help people in the creative sector do some training and get some skills, to enable them to take their skills, knowledge, enthusiasm and energy into social care—thereby spreading economic prosperity and improving people’s quality of life. Let us try to join these things up a bit more and not look at them in silos.

My Lords, I am very reluctant to intervene in this long debate, but I have travelled down from Manchester specifically for this group of amendments. I have not been involved with this Bill previously, partly because of my own ill health, and also because of my teaching outside London, but I will make a short intervention here.

My noble friend Lord Hunt has raised the very important issue of the nature of interaction between human beings, which is absolutely essential in considering some of the issues raised by the noble Baroness, Lady Greengross, and others. I am not going to advocate music therapy, dance therapy, exercise therapy or art therapy here, because, speaking as an academic, one of the problems here is that we simply do not understand the truth of the interaction that makes these things work. One of the big problems is that really good randomised controlled trials are still very much lacking.

I am reminded, for example, of a very good randomised controlled trial, by Dr Nair in Australia, of quite a large number of demented people in a care home to whom he played music. From his results, there was no question but that the music, which was extremely tranquil baroque music from sixteen different composers, actually made them more disturbed, more sleepless, more angry, less able to eat their food and more likely to come into conflict with the nursing staff.

So it is very unclear what is actually happening in the brain. During the debate today we have heard claims made about changes in brain structure, but the truth is that we have not done sufficient research to really be clear about this. The research is very expensive, and one of the problems is that it involves very complex things such as time on scanning machines, for example—functional MRI. There is simply not enough research going on into the dementias—whatever they are—to fully understand the nature of what we are talking about.

I am not suggesting that we do not do music therapy but, speaking with my interest as an ex-chairman of the Royal College of Music, I say that we have seen that some of the things we do simply do not work or, if they do, it is not understood how. One of the things with music therapy, for example, is that you see individual patients interacting with somebody else, and it may be that the interaction is more important than the actual music. For example, watching musicians play in person may be better than watching them on a screen or just listening to music. There is a lot of work that needs to be done here before we can make big claims.

These are important amendments that are well made and well put, but we need to be really clear in debating this legislation that, until we understand the mechanisms—the phenotype—of what we are discussing, we have to recognise also that much more money is required for research into the dementias. That is really critical and there is a risk here of making legislation that will not fundamentally change the real problem that we are facing.

My Lords, I rise to say that Amendment 297A is obviously very desirable. But, as an economist, I have to say: if we implement this, who will be deprived? GPs’ time is limited and GPs’ numbers are limited, as we all know. Through much of my life in the NHS, all that the GP did for me was prescribe what I needed. It took about five minutes, and the GP did not even have to talk to me; they could look at the computer to find out who I was and what I was doing. It is, quite rightly, only people over 65 who need a caring GP, so we have to devise a system for those who do not need extensive consultation and familiarity with the GP but can be dealt with in a summary fashion. Perhaps we could have junior and senior GPs, so that we could release the senior GPs for this sort of work and have other people for prescriptions and simple tasks.

My Lords, I was going to speak for two minutes but now I am going to speak for only half a minute. I have one question for the Minister. I know that his department has a small team developing the National Dementia Strategy. Can he can tell us whether any additional capacity is being planned to add to that small team doing this important work? Frankly, without a national strategy, the new ICSs will not be able to measure their performance in their dementia care plans against a national standard. The matter is urgent, because the position of people living with dementia has worsened during the Covid-19 pandemic and, while we are trying to tackle the backlog of treatments for patients with physical health needs, we must not forget those with dementia.

My Lords, I thank the noble Baroness, Lady Greengross, for tabling her amendments, which ensure that we consider dementia care in respect of this Bill and return to recognising the impact that the social prescribing of music and arts can make to dementia sufferers, particularly for patients at the onset of symptoms—although I also heard what my noble friend Lord Winston said about the research needed on this issue. Noble Lords have on many occasions stressed their strong support for Music for Dementia and Singing for the Brain, and it would be good to hear from the Minister what progress is being made. We have also had extensive debates on the importance of social prescribing, and of the arts across health and social care settings, so, again, I think we do not need to repeat what has been said.

On Amendment 291, the key thing is the call for the duty to be placed on each local authority and integrated care system to implement the National Dementia Strategy for their own areas. It is a timely reminder of the need for the promised National Dementia Strategy: can the Minister provide a publication date for it, and update the House on its progress and on the increased funding that the Government have promised will be provided for the implementation of the dementia care plan?

My noble friend Lord Hunt’s Amendment 297D is a stark reminder of the Joint Committee on Human Rights’ concerns over the visiting bans operated in some care homes before the pandemic, following relatives’ complaints about their loved ones’ treatment and standards of care. As the noble Baroness, Lady Brinton, stressed, we know that during the pandemic itself the ban on outside visits of relatives and friends caused huge anxiety and suffering among residents and their families alike, and it is very welcome that visiting rules have now been eased, although the need for maintaining PPE, testing and infection control routines and constant vigilance continues.

The noble Baroness, Lady Masham, and other noble Lords have cited serious cases of abuse. However, we also know that the CQC has found that the majority of care homes provide good-quality care against a backdrop of inadequate funding, substantial staff shortages, endemic low pay, and lack of appreciation and recognition of the skills and dedication of care home staff.

My noble friend’s call in his amendment for a proper review into the existing legislative and legal framework on the circumstances under which notices are issued banning relatives from visiting, or under which service users are denied visits or contact with family members or informal carers, or residents are required to leave the homes altogether following disputes between the care home and relatives, is a way forward to ensure that the concerns raised on this issue by noble Lords, the Relatives & Residents Association, the Joint Committee on Human Rights and Age UK are addressed.

Amendment 297A, from the noble Baroness, Lady Hodgson, concerns named GPs for the over-65s. I am sure that is something we would all like to see for general practice patients. How practical it is in the light of the current pressures on GPs and primary care remains to be seen, and I look forward to the Minister’s response on this.

As was mentioned, a key part of the Secretary of State’s recent big idea on future reorganisation was a plan to end GPs’ private practitioner status and bring all GPs under NHS control, even as we speak on this Bill and as we read recently in the media. How would the integrated care systems we are focusing on in this Bill fit into this further NHS reorganisation?

My Lords, this has been a long debate but it has touched on a number of different and important subjects. I join noble Lords in paying tribute to the work of the noble Baroness, Lady Greengross, and her work.

I turn first to Amendments 290 and 291. I reassure noble Lords that the Government are absolutely committed to the rollout of social prescribing across the NHS. We exceeded the targets in our manifesto and the NHS Long Term Plan of 1,000 new link workers by 2020-21 and are aiming for at least 900,000 people to be referred to social prescribing by 2023-24.

NHS England, the National Academy for Social Prescribing and Music for Dementia have produced guidance for social prescribing link workers to expand music prescriptions for those with dementia. The department has also published two resource guides for social workers on embedding music in personalised social care plans for people living with dementia and their carers.

While the Government are committed to promoting the benefits of social prescribing of music and arts for people living with dementia, it would be inappropriate to focus in the Bill on one form of therapy. Instead, we rightly provide scope in the Bill for the NHS to undertake a range of social prescribing.

Turning to Amendment 291 and the need for a dementia strategy, I reassure the noble Baroness and others that the Government are committed to publishing a new strategy this year. As part of this, we will be looking at arts and music-based interventions. More broadly, the strategy will focus on the specific health and care needs of people living with dementia and their carers, including looking at dementia diagnosis, risk reduction and prevention, and—importantly, as noble Lords have mentioned—research. Our priority is for the strategy to be credible and shaped by a range of experts, including people living with dementia and their carers. At the end of last year, we established a stakeholder-led task and finish group to help develop the strategy and deliver it in a timely way.

Moving on to Amendment 297D, we fully agree that visits from loved ones are of vital importance to care home residents’ health and well-being. DHSC guidance emphasises that visits to care homes should be facilitated, based on individualised risk assessments. Care home residents should also be supported to nominate an essential caregiver, who may visit in most circumstances, including if the care home has been closed to visiting for any reason.

There is an existing process in place if a resident or their family are concerned that guidance is not being followed. We encourage anyone with concerns to raise them. That can be done both with the care home, which has a legal obligation to operate a complaints procedure, and with the CQC. The CQC will follow up on concerns and take regulatory action if needed. It has provided mechanisms for people to feed back on concerns over care. The CQC responds to all concerns passed to it, and can receive concerns anonymously via representative groups, such as Rights for Residents. Where those concerns have named the provider or service in question, the CQC has followed up the cases. Some 54 concerns regarding care home visiting arrangements have been raised during the pandemic. The CQC gained reassurance in all cases that visiting is now in line with guidance. In 12 cases the CQC secured this assurance by inspecting the service.

My department has not seen any data or reports on evictions of residents following complaints against care homes. If a care home were taking such action, it would be in breach of guidance. A complaint should not lead to a resident being asked to move to a different home, and the terms of evictions and processes followed should comply with consumer law, as per the CMA guidance. People should feel confident that complaining will not cause problems for them.

I recognise this has been a difficult time for care home residents. However, the existing powers in legislation are robust and give protection to those who need it. We therefore do not feel at this time that an independent review is necessary.

I turn to Amendment 297A. Continuity and oversight of care is crucial in meeting the needs of all patients, including those aged over 65. That is why, since 2015, all practices have been required to assign their registered patients a named, accountable GP. This GP must lead in ensuring that any GP services that they are contracted to provide, and are necessary to meet the patient’s needs, are co-ordinated and delivered to that patient. Practices must take reasonable efforts to accommodate patients’ requests to be assigned a particular accountable GP and must endeavour to comply with all reasonable requests to see a particular practitioner. Practices are also required to take steps each year to identify any registered patient over 65 who is living with moderate to severe frailty. The practice must undertake a clinical review of any such patient and provide them with any other clinically appropriate interventions.

The noble Baroness, Lady Tyler, is right that delivering on this is linked to the number of GPs in the system. I assure her and others that the Government remain committed to growing the number of doctors. There were 1,841 more full-time equivalent doctors in general practice in September 2021 compared to September 2019. In 2021-22, a record-breaking number of doctors started training as GPs. I therefore consider that existing regulations already address the welcome intention of my noble friend Lady Hodgson, and I regret that the Government cannot accept the amendment for that reason.

I hope I have given noble Lords and noble Baronesses some reassurance on the amendments in this group and that the noble Baroness will feel able to withdraw the amendment.

My Lords, I have listened to an extraordinary range of speeches and addresses. People have spoken from the bottom of their hearts. I am very moved myself by what I have heard. I thank all colleagues and Ministers who have spoken today. I will look very carefully at the record of today and come back, but, in the meantime, I beg leave to withdraw the amendment.

Amendment 290 withdrawn.

Amendment 291 not moved.