I thank the noble Lord for his anticipatory support of my amendments, and perhaps I may return the compliment by saying that my name is on five amendments in this group and I have the most copious set of notes I have ever had in any debate. I hope that noble Lords will bear with me at this time of night, but with five amendments, there is quite a bit to go through.
As the noble Lord, Lord Hunt, said, I have put my name to his Amendment 79A and to that tabled by the noble Baroness, Lady Greengross, and in the names of the noble Lords, Lord Hunt and Lord Touhig, Amendment 79K. There are the same group of Peers on Amendment 80A, but Amendments 80C and 87F are in my name only, so I shall obviously spend a bit more time on them.
Before that, I shall say a few words on Amendments 79A, 79K and 80A. Clause 2 would be stronger if local authorities were also placed under a general duty to take prevention into account in exercising any of their functions under Part 1, not just those relating to direct provision of care. Amendment 79A would ensure that local authorities act to “prevent, delay or reduce” individual care needs across every one of their functions. Amendment 79K would ensure that the prevention duty focuses on what a local authority must do to prevent a deterioration in well-being, in addition to preventing, delaying or reducing the need for care and support. Amendment 80A would oblige authorities to have regard not just to the importance of identifying adults and carers with needs for care and support and the services available to meet those needs, but,
“the steps it could take to improve and enhance the provision of services, facilities or resources in its area”.
The idea would be to ensure that local authorities actively consider what more they could do to prevent needs for care and support above and beyond identifying existing services, facilities and resources in the authority’s area.
The Bill currently stops short of that, which is bad news for the hundreds of thousands of older and disabled people who are not deemed eligible for adult care and support. It is also bad news for the Government’s aspiration to rebalance the system away from crisis interventions in a more preventive direction. The amendments suggest a more strategic approach which, by putting in place services at the community level, not just directed at individual care, could ensure that those who did not reach the eligibility threshold were, nevertheless, not bereft of support entirely. In other words, they provide a means of enabling available resources to go further by deploying them strategically in aid of prevention.
The kind of preventive services I am thinking of might be of six types. First, there are enabling services, preventing harm before it occurs—as you might say, working well away from the cliff edge. Secondly, there are services that prevent care needs from developing: for example, reablement or specialist rehabilitation to help an adult with sensory loss or a falls prevention service for older people discharged from hospital. Thirdly, there are prompt interventions, detecting and responding to early signs of difficulty, forestalling problems which could lead to more serious consequences —as you might say, working just over the edge of the cliff. Fourthly, there are services that help to delay care needs once they have started to emerge, for example, home adaptations for those no longer independently mobile or befriending services for the recently bereaved, perhaps funded by the local authority but delivered by a local Age UK. Fifthly, there are services that reduce care needs once they have started to intensify, for example, a stroke rehabilitation service provided alongside the NHS to help adults to regain control over key activities of daily living.
Sixthly and finally, there are acute interventions reducing the impact of a situation spiralling down—working well done the cliff, you might say. Wales furnishes an example in the Social Services and Well-being (Wales) Bill, which is currently before the Welsh Assembly. I hope the Minister might be willing to take a look at that. The corresponding section of that Bill, Section 6(4), explicitly states that a local authority must, in the exercise of its other functions, have regard to this preventive services clause in the Bill.
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I turn now to the amendments in my name only. Amendment 80C is a probing amendment aimed at drawing out the Government’s thinking about creating an accountability mechanism for the prevention duty. The suggestion is to use the legal framework contained in the Local Government Public Involvement in Health Act 2007. I remember it well. Local authorities have responsibilities under that Act to produce joint needs assessments and joint health and well-being strategies under Section 116 of that Act. This amendment would lay on them, in partnership with clinical commissioning groups, a duty to have regard to their duty to prevent care needs as part of discharging those responsibilities.
Successive Governments have produced ambitious plans to rebalance our care and support system away from crisis interventions in favour of preventive support. Some of these have succeeded to a degree, but what all these strategies have had in common is a desire to prevent individual care needs from developing or getting worse, providing early support that makes sense for the individual adult, their carer or family, but also makes more efficient use of public resources. Notwithstanding this, we still have a care and support system where all the legal duties and funding structures are aligned towards meeting acute or, for want of a better word, substantial care needs.
The recent ADASS survey reveals a startling lack of attention paid to preventive forms of health. Only 37 councils—that is 25% of those which responded to the survey—had formally agreed a plan on how to spend reablement money transferred from local health services as part of the 2010 spending review.
Spend on prevention of £588 million in 2013-14 represents only 4.2% of adult social care budgets. This is the consequence of the tough budget settlement for local authorities, but it is also about the inattention local authorities inevitably pay to prevention when all their legal responsibilities are focused around acute interventions—in other words, not preventing but meeting care needs.
The announcement in the Government’s latest spending review that £3.8 billion of pooled funding, including an additional £2 billion through the NHS, will be dedicated to improved and integrated care services can only be sensible at the time of rising demand. However, how certain can we be that this pooled funding will be used in the way that is clearly intended, for local authorities, their partner CCGs and other members of local health and well-being boards to redirect resources towards preventive types of care?
Clearly, there is a danger that this money and all future packages like it will be swallowed up by councils struggling with reduced budgets and be spent on care and support for people who have already reached their own personal crisis point. What we need is a legal framework that actively enables this joined-up work, not just in 2015-16 but over the longer term.
Clause 2 therefore needs to be amended so that when local authorities and their partner CCGs prepare an assessment for a health and well-being strategy under Section 116 of the Local Government and Public Involvement in Health Act, they do so with regard to local authorities’ prevention duty in this Bill. This will strengthen accountability for fulfilling the duty under Clause 2, and there will be greater clarity about whether local authorities need to do this as part of their wider role within the health and well-being board. This is not a reporting requirement or an additional burden on local authorities. Rather, it ensures that there are proper mechanisms and fora through which local authorities can discharge these responsibilities for preventing care needs: namely, joint strategic needs assessments and joint health and well-being strategies.
I turn to Amendment 87F. Clause 9(1) gives local authorities responsibility for assessing needs for care and support. This amendment would give them additional responsibility for assessing whether needs can be prevented
from getting worse and how they may be reduced. The aim is to ensure that local authorities assess preventing needs and look to reducing them as an integral part of their duties on assessment. In the Government’s report in response to pre-legislative scrutiny of the draft Care and Support Bill, The Care Bill Explained, they said that,
“the Bill now requires that as part of assessments of needs … local authorities must consider whether other support is available that could contribute to the outcomes the adult wishes to achieve, and provide information on how to prevent or delay future needs”.
Clause 9(4)(d) ticks one box, placing a responsibility on local authorities to consider the other support that might be available to an adult from friends or family. However, it is not clear where Clause 9 actively enables a local authority to assess the ways in which adults’ needs for care and support could be prevented from getting worse or, indeed, how assessed needs might be reduced.
If the Bill is truly to refocus care and support on promoting individual well-being and preventive health, Clause 9(1) is a major gap that needs plugging. It needs amending to ensure that local authorities actively assess the needs that could be prevented from getting worse, or which could be reduced. Clause 9 is the critical section governing an assessment of an adult’s needs, but it would be a major omission if it did not provide some means by which a local authority is required to assess which needs are in fact capable of being reduced. In practice, not including this requirement would mean authorities inevitably concentrating on needs that have already emerged and the degree to which they could be categorised as eligible needs. Of course, a local authority must fulfil that duty but in doing so it should also consider which needs, if any, can be prevented from getting worse. Not doing so surely puts in question the Government’s ambition to refocus the system on postponing, preventing and minimising the need for care and support.
In assessing whether needs can be prevented from getting worse and how they could be reduced, an authority would in effect be making a determination on the existing impact of a need, the risk that it will deteriorate and develop into an eligible need and, crucially, what an authority and the adult themselves can do to proactively prevent a deterioration in their well-being. The idea would be to assess whether an individual’s needs could be prevented from getting worse through the provision of a structured programme of intermediate care or reablement, or some other form of preventive support—for example, a communicator guide, some intensive therapy at home, advice on suitable housing options or adaptations, mobility training or even access to a local befriending scheme. This would not only be in the interests of the individual adults, their carer or family; clearly, it would be in the authority’s interests too.
There is extensive literature which demonstrates, time and again, that preventive services deliver savings. An economic evaluation of British Red Cross services estimates that the support delivered to five typical adults created savings of between £700 and—