Clause 5 - Promoting diversity and quality in provision of services

Care Bill [Lords] – in a Public Bill Committee am 4:45 pm ar 9 Ionawr 2014.

Danfonwch hysbysiad imi am ddadleuon fel hyn

Photo of Paul Burstow Paul Burstow Democratiaid Rhyddfrydol, Sutton and Cheam 4:45, 9 Ionawr 2014

I beg to move amendment 32, in clause 5, page 5, line 18, after ‘of’, insert ‘appropriate’.

Photo of Andrew Rosindell Andrew Rosindell Ceidwadwyr, Romford

With this, it will be convenient to discuss the following: amendment 33, in clause 5, page 5, line 37, at end insert

‘, in particular by collecting information from users as well as providers to inform assessment of the quantity, quality and appropriateness of services and support provided.’.

Amendment 79, in clause 5, page 5, line 40, at end insert—

‘(g) the importance of ensuring the diversity of the market, to ensure that adults with needs for care and support have a choice of types of providers of services, such as the choice between—

(i) private sector providers of services;

(ii) third sector providers of services;

(iii) public sector providers of services; and

(iv) mutual or co-operative providers of services.’.

Amendment 81, in clause 5, page 5, line 42, after ‘sufficient’, insert ‘and appropriate’.

Photo of Paul Burstow Paul Burstow Democratiaid Rhyddfrydol, Sutton and Cheam

Amendments 32 and 33 are about ensuring that services meet the well-being principle and the outcomes that people want to achieve for themselves, and that services are right for them. I have been approached by a number of organisations with examples that speak to this point about the appropriateness of a service. For example, deafblind people, particularly those who are born deafblind, have specialist needs. They need day services, residential or supported living and support from communicators, guides or interveners. Sadly, however, all too often deafblind people are offered services that are not designed with them in mind; instead, they are offered services designed for people who may have one sensory impediment but not two or more. As a result,  deafblind people do not have services commissioned for them, and they are invited to use other, inappropriate services.

Another example is that of people diagnosed with multiple sclerosis, in particular those who receive the diagnosis in their late 20s and those with the secondary, progressive form of the disease. In such cases, there can be pressure on the individual to accept an inappropriate care setting, perhaps a residential care home. The majority of residential care homes in this country cater for older people and, to one degree or another, are designed and tailored to meet their needs.

Another example brought to my attention is that of an outgoing and fun-loving 55-year-old lady with Angelman syndrome, which is a rare genetic condition that affects the nervous system and causes severe physical and intellectual disabilities. In this lady’s case, no appropriate accommodation was apparently available at the time of assessment, so she was placed in residential care for older people. She is 55 years old. She is not an older person. Worst still, she was strapped into her wheelchair all day. One can only just begin to scratch the surface of understanding just what that would mean for her—bring trapped in a home and in an environment that was really not appropriate. I am pleased to say that eventually her case was reviewed, and that led to the right accommodation being made available.

Amendment 33 would place a duty on local authorities to collect data that would support them in their market-shaping duties. It would create a duty to understand and shape the diversity of providers and range and choice of types of services to meet a diverse range of individual needs and wishes. As part of that, the White Paper raised the issue of contracting by the minute and 15-minute visits. The Minister will be aware of the work that Leonard Cheshire Disability has been doing to highlight its concerns, and of the concerns of a large number of organisations and charities that work for disabled people and with older people, about this poor practice. The Minister has been clear about the desire to eradicate it. The collection of data is not the be-all and end-all of addressing the issue, but it helps to understand how the local care market is operating. In that sense, it is an aid to better delivery of the purpose of the legislation. We are talking about bad commissioning practice, which goes back to the earlier point that we will return to later.

There are also other ways in which 15-minute contracting can be removed. I briefly cite the example of Wiltshire council. By visiting and talking to its officials, I discovered that it has moved from a traditional approach to contracting such services to one that is focused on outcomes. That focus has allowed the council to concentrate on restoring function and independence and promoting well-being. It employs no one on zero-hour contracts, which is possible even in a resource-constrained world. Local authorities can do that by doing things differently and having a political will.

Photo of Sarah Wollaston Sarah Wollaston Ceidwadwyr, Totnes

Does my right hon. Friend agree that the distance from one appointment to another is also an issue, particularly in rural areas, where it puts many health care assistants below the minimum wage? As a result, it is almost impossible to find a health care assistant in some rural areas.

Photo of Paul Burstow Paul Burstow Democratiaid Rhyddfrydol, Sutton and Cheam

Absolutely. That was one of the motivating factors behind the redesign of services in Wiltshire, and I recommend that other local authorities look at what Wiltshire council has done. Services are still being implemented and delivered, but by consolidating the number of contractors, focusing on outcomes and empowering the front-line workers to plan with the individual the care and support pathway back to independence, the council is making the job much more rewarding. Removing zero-hour contracts ensures that workers who have to travel miles between appointments are not penalised.

Photo of Anne Marie Morris Anne Marie Morris Ceidwadwyr, Newton Abbot 5:00, 9 Ionawr 2014

The right hon. Gentleman is being generous with his time. What he says about trying to improve the genuine choice and diversity that is available is much to be commended, and I support the amendments that he has tabled. Does he agree that we have perhaps come to a time when we should review splitting commissioning and provision, as we do in the NHS? In social care, a local authority can be both a commissioner and a provider. Ensuring true choice and diversity will therefore be difficult because, inevitably, local authorities will have an inherent conflict of interest. Is this the time to make that consideration?

Photo of Paul Burstow Paul Burstow Democratiaid Rhyddfrydol, Sutton and Cheam

The hon. Lady raises an important issue, and it may be beyond the narrow confines of the two amendments. Most local authorities now commission, and 80% of care in this country is provided by the private sector, and another proportion is provided by the independent sector. Local authorities provide very little care directly; most of what they provide is assessment services and perhaps some initial re-ablement services.

Fundamentally, the amendments are about basic human dignity and finding mechanisms by which the objective in the White Paper, the concern of the draft Bill scrutiny Committee and the concern of the Minister are translated into tangible action that addresses the 15-minute contracting issue. I look forward to the Minister’s response.

Photo of Liz Kendall Liz Kendall Shadow Minister (Health) (Care and Older People)

I will follow on from the right hon. Gentleman’s points on the diversity of providers in social care.

Amendment 79 would require local authorities to ensure a diversity of providers from the public, private and third sectors and from mutual and co-operative organisations. Some of the best home care providers that I have come across are mutually, co-operatively owned or employee-owned and led organisations such as Sunderland Home Care Associates, which by genuinely involving staff in determining what the organisation is doing and how resources are used, and by ploughing money back into training, has reduced high turnover rates. The staff are very committed and are paid above the minimum wage.

There are some important developments that we should see, not just in home care visits. As hon. Members may know, organisations such as Shared Lives Plus essentially help families to take older and disabled people into their homes and lives as members of the family. At Shared Lives Plus, I have met shared life carers in Leicester. I met a fantastic couple who have had many people to stay with them, sometimes during the day and sometimes permanently. Those people are older people with learning disabilities who were considered  to be challenging in institutional settings but, of course, were not when they got personalised care and support and were able to say things such as what they want for lunch or what they want to do with their day and were able to develop a personal relationship.

Many organisations working in the care sector—we have been contacted by Leonard Cheshire Disability—are concerned that the Bill needs to take steps to ensure the diversity of service providers. It is interesting that the CQC’s review of the quality of care services is increasingly finding better outcomes from smaller providers, but many councils are increasingly buying care and services support from larger providers that might be able to offer a cheaper rate but are not paying staff the minimum wage, let alone a living wage, because they are not paying them for travel time. Those providers are not getting the quality of outcomes; they are doing the 15-minute home visits. There is a real concern, as Leonard Cheshire Disability has said, that if proper attention is not paid to that issue in the commissioning process, many smaller providers of high-quality services that really work for disabled people may be forced out of the market.

Photo of Bill Esterson Bill Esterson Llafur, Sefton Central

That quote is particularly important because the amendments are designed to ensure that the most vulnerable in our society, who most need help, receive the best quality of care. They have a right to that and they deserve it, but at the moment, the opposite often happens. We must do something about the work force and the organisations that employ people in the care sector. My hon. Friend gave great examples of how to do that. That should happen right across the sector, which is why the amendments are so important.

Photo of Liz Kendall Liz Kendall Shadow Minister (Health) (Care and Older People)

I absolutely agree with my hon. Friend. The hon. Member for Newton Abbot—who is chatting to the Whip—and the hon. Member for Totnes raised the commissioning process, and the right hon. Member for Sutton and Cheam spoke about local councils commissioning for outcomes. We all want to see that happen. The reason why we have tabled the amendment, however, is that the Care Quality Commission used to carry out quality checks on how councils commissioned care to see whether they were doing so effectively but the Bill removes that element of the CQC’s role, which is a real problem. We are all in favour of devolution and giving local government more responsibilities, but we must be able to check the quality of a council’s commissioning process.

Photo of Norman Lamb Norman Lamb The Minister of State, Department of Health

The Care Quality Commission will still be able to do themed inspections on specific issues of concern. It is important that those powers are exercised in order to hold the commissioning of local government to account.

Photo of Liz Kendall Liz Kendall Shadow Minister (Health) (Care and Older People)

The Minister will know that themed inspections tend to focus on groups of particular users.

Photo of Liz Kendall Liz Kendall Shadow Minister (Health) (Care and Older People)

That is how it has worked in the past. The Government have made NHS England responsible for ensuring that CCGs commission effectively and to good-quality outcomes, but no such body will check that councils are doing the same. Hon. Members who  have worked for councils, or who have perhaps been cabinet leads for councils, will know that it is possible to change how services are commissioned. There must be some ability to check that that is happening.

Amendment 79 is designed to ensure that the Bill contains a clear requirement for councils to commission from a diversity of providers, so that innovative smaller organisations, which cannot compete with big private companies that may undercut them, are not crowded out. I am not saying by any stretch of the imagination that all private companies do so, but smaller providers are concerned that they will be crowded out. In the context of the CQC’s specific role in monitoring councils’ quality of commissioning, the amendment is vital.

Amendment 81 echoes many of the points that the right hon. Member for Sutton and Cheam has made. Giving someone a sufficient service is not the same as giving them an appropriate one. People may think that that is hair splitting, but appropriate is a much better word, and we bother about words.

Photo of Emma Lewell-Buck Emma Lewell-Buck Llafur, South Shields

It is a pleasure to serve under your chairmanship, Mr Rosindell. I want to speak briefly to amendments 79 and 81. It is essential to the personalisation agenda that was introduced under the previous Labour Government that people can make informed decisions about their care and support, and that they can choose from a diversity of providers. It is understandable, because of austerity measures and rising demand for adult social care services, that local authorities often feel pressurised to default to the cheapest service provider, but this can be of huge detriment to the service user. It leads to an effective monopoly for the cheapest provider as alternatives leave the market. This is obviously made worse if there is a collapse of provision, such as that experienced in the case of Southern Cross. Not only does this impact on service user choice, but it means that those with more complex and specialist needs may no longer be able to access appropriate services. They may have to move out of their locality and go elsewhere at greater cost.

For this reason I support my party’s amendments. There needs to be a requirement on the face of the Bill making it incumbent on local authorities to ensure not just market diversity, but equality of services. I hope that in the spirit of common purpose shown so far throughout the Committee, the Government will support these amendments also.

Photo of Norman Lamb Norman Lamb The Minister of State, Department of Health

It is getting rather boring, but again I agree with virtually everything that has been said by the contributors to this debate. My right hon. Friend the Member for Sutton and Cheam drew attention to what is happening in Wiltshire—a very interesting change from commissioning on a time basis, which has the inevitable consequence of a race to the bottom, with the cheapest offer winning the contract, which may well end up cutting corners. The hon. Member for Totnes made the point that such commissioning often ends up with care workers receiving pay that is far too low and not being paid the minimum wage because they are not paid as they travel between visits.

A recent HMRC inspection of the care market found quite widespread failure to comply with the national minimum wage. I regard that as totally unacceptable and it has to be confronted. When we see what is being  done in Wiltshire, with the focus on outcomes, quality and results for people, and individuals being paid a salary rather than an hourly rate, we see how it should be done in the future. The Department is working closely with the Association of Directors of Adult Social Services and with the Local Government Association to ensure that we get best practice commissioning across the country.

In tabling amendments 32, 81, 79 and 33, my right hon. Friend the Member for Sutton and Cheam and the hon. Members for Leicester West and for Copeland bring to the attention of the Committee the important role that local authorities have to play in promoting diversity and quality in the market of care and support services for people in their local area. To support choice and control for individuals and to improve quality of care, it is critical to have a range of types of care and support available locally and that the market they service is able to grow and adapt over time to meet people’s needs.

The Bill marks the first time that local authorities’ responsibilities to promote the market in local care and support services have been captured in law. That is an incredibly important advance. This recognises the importance of ensuring a variety of high quality services to meet the needs and preferences of all local people, not just those whose care is arranged by the local authority.

Clause 5 sets out the local authority’s core duty to promote the effective and efficient operation of the market as a whole, with a particular focus on diversity, quality and sustainability. The duty is about ensuring that the market meets the needs of local people with a choice of quality services, not just promoting a market for its own sake.

Photo of Bill Esterson Bill Esterson Llafur, Sefton Central

Does the Minister agree that one of the roles of local authorities in ensuring service quality is to set the benchmark by its own services, as long as those services are set at a very high level? That is a way of raising standards in all sectors.

Photo of Norman Lamb Norman Lamb The Minister of State, Department of Health

Services, wherever they are, if they happen to be provided by the local authority, should be set at a high standard and quality. The point that my right hon. Friend the Member for Sutton and Cheam makes is that in the vast majority of areas 80% of care—I think that was the figure—is now provided by providers other than local authorities, so it is becoming a minority pursuit. My hon. Friend the Member for Newton Abbott raised the question of separating commissioning from provision. In many respects I think that is a good thing, because the commissioner can then, without fear or favour, hold those providers to account to ensure a high standard of provision.

The duty is about ensuring that the market meets the needs of local people with a choice of quality services; it is not about promoting a market for its own sake. The focus on quality should be understood in a broad sense. High quality services will be fit for purpose and appropriate to an individual’s needs. When facilitating their local markets, local authorities must consider the demand for services in their area and therefore what people actually need.

With amendments 32 and 81, my right hon. Friend the Member for Sutton and Cheam and the hon. Members for Leicester West and for Copeland raise the important issue of making sure that, in shaping local markets, local authorities focus on ensuring that people have a choice between available services that are appropriate to their needs. I would like to take this opportunity to reassure them that it is implicit in the clause as it stands that appropriateness is an important component of quality. In fulfilling their duty, it is vital that local authorities ensure that people have access to a wide and diverse range of service providers when considering how their needs may be appropriately met, as emphasised by the hon. Members for Leicester West and for Copeland in amendment 79.

The shadow Minister made the point that mutuals and social enterprises— excellent organisations such as Sunderland Home Care Associates, which she mentioned —with a social mission and purpose, but independent and often more fleet of foot than local authorities have been in the past, can often demonstrate excellent standards of care. She also drew attention to brilliant organisations such as Shared Lives Plus—we often find that people who have been in institutional care, leading a pretty miserable life, I suspect, end up growing as individuals when they become part of a family. That is an inspiring concept.

However, we do not think that it is appropriate to specify in the Bill the types of organisation that make up a diverse range of providers as they will vary, depending on the specific conditions and communities in a local authority area. We could also exclude new future types of organisation that might evolve, potentially in response to moves to integrate health and social care and, critically, in response to the personalisation of services. I would like to take this opportunity to reassure my right hon. Friend the Member for Sutton and Cheam and the hon. Members for Leicester West and for Copeland that through supporting programmes and guidance we will emphasise the importance of diversity in types of provider organisation within the contexts of individual local authorities.

With amendment 33, my right hon. Friend the Member for Sutton and Cheam has emphasised the need for local authorities, in fulfilling their duty to shape local markets, to consider engaging with the adults using services, their carers, and providers. The Bill requires local authorities to consider and understand how providers can meet current and future demand for services in their area, and the importance of fostering innovation and improvement. Consequently, I would like to reassure my right hon. Friend that we do not believe it would be possible to gain that full understanding without engaging providers, adults who are using care and support services, and carers. Again, I am happy to make that clear in guidance.

I hope that I have succeeded in reassuring the Committee that the Bill as it stands already places sufficient requirements on local authorities to work with people and providers in their areas to develop sustainable and high quality markets in care and support services. I therefore ask my right hon. Friend and the hon. Members for Leicester West and for Copeland to withdraw their amendment.

Photo of Paul Burstow Paul Burstow Democratiaid Rhyddfrydol, Sutton and Cheam 5:15, 9 Ionawr 2014

Briefly, I am grateful to the Minister for his response to this helpful debate. It is useful to know that he will clarify a number of these issues by way of guidance. However, I ask him to reflect a little further on appropriateness.

If that is not in the Bill because it is implicit, I accept that, but it is also not in the explanatory notes. Therefore, when it comes to the construction and understanding of this part of the Bill, what the Minister said today was helpful, but that will not be enough if that is not repeated in the other documentation that will be used by the practitioners who will implement this measure.

I therefore request that the Minister gives that some further thought to ensure that we do not lose sight of that point. There are some really quite tragic cases where people are not getting appropriate services; in fact, what they get is far from that. However, with those  remarks, and in the spirit in which the Minister constructively engaged with the debate, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Ordered, That further consideration be now adjourned.— (John Penrose.)

Adjourned till Tuesday 14 January at five minutes to Nine o’clock.

 Written evidence reported to the House

CB 01 Age UK

CB 02 Macmillan Cancer Support

CB 03 Imogen Parry

CB 04 United for All Ages

CB 05 Inclusion London

CB 06 Marie Curie and Help the Hospices

CB 07 Tim Kendall

CB 08 Hampshire Law Society

CB 09 The College of Social Work

CB 10 David Hawker