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Community Care

Volume 130: debated on Thursday 31 March 1988

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12.28 pm

Community care is in crisis. The plight of the elderly, the mentally ill, the mentally handicapped, the physically disabled and the frail, and the millions—mainly women—who care for them tells us something about our society. For it is right that we should be judged on how we treat the most vulnerable of our fellow citizens.

All the evidence suggests that most community care is provided by a member of the family, a whole family or close friends. Community care should therefore not be considered a marginal policy for a marginal group of people. It involves mutuality — the responsibility of people to each other — which creates the fabric of a society that is worth being part of. There is a clear role for Government nationally and locally.

I hope that we can today examine the Government's record and, perhaps more important, their intentions in these matters, especially following the plethora of reports from Griffiths, to Wagner, Firth and the Social Services Select Committee in the previous Parliament. Almost all of them have met a deafening silence from the Government. Deafening silence is not something that we normally associate with the Under-Secretary of State, so perhaps she will correct that today.

The hon. Lady may be able to tell us why the Griffiths report on community care has all but disappeared. Time and again, when Ministers were pressed on social services, they said that the report would deal with such matters. They advised the House and voluntary organisations to wait for Griffiths. What happened? In contrast to the Griffiths report on the Health Service, the report on social services was quietly published on the morning after the Budget. There was no ministerial statement and no press conference. If ever there was a case of shooting the messenger and attempting somewhat clumsily to hide the message under the carpet, this was it.

The Government may be disappointed with the Griffiths report because it emphasises the role of local authorities. We ought not to be too surprised by that. The former Secretary of State for Social Services, as long ago as 27 December 1986, gave us a hint that, because the Government do not give community care a high priority, and because Sir Roy might feel that there was a role for local government, the Government might not say too much about his report. The Guardian of 27 December 1986 reported as follows:
'Mr. Fowler has become the odd man out in a Cabinet so plainly contemptuous of local government. He has actually been heard to praise the work of council social services departments, which he knows are pivotal to the success of community care."
The fact that Sir Roy Griffiths may have reached the same conculsion may be the reason for the Government's remarkable silence. I hope that the Minister will correct that silence today.

The Minister will also be aware that Sir Roy Griffiths gave a great deal of attention to the quite staggering report on these issues by the Audit Commission, which found that Government policies were "in disarray". It accused the Government of trying to muddle through in the hope that community care would somehow materialise as long-stay hospitals were closed.

If there were not problems in community care, the Government's social security review and their intentions for what is to happen after April have added considerably to the difficulties of many communities and people. There has been a collapse of any recognisable strategy for community care. I should like to give the Minister some examples. If time allowed, I could give many more. I am sure that she is in the same position.

The Edinvar housing association in Edinburgh has written to the Secretary of State for Scotland explaining that six mentally handicapped persons who had moved into a excellent community care project are in danger of losing housing benefit to the extent that their position in community care is in jeopardy. The director, Mr. Robin Burley, recently wrote to the Secretary of State for Scotland. I understand that he will await a reply. He wrote:
"Not only will the April changes compound the perversity of the incentives which encourage residential care but in this small scheme six people who last summer moved from hostels to their own homes may have no alterntive but to move back to residential care."
If that happened, it would be an absolute scandal. I regret to say that it is not a isolated case.

My hon. Friend the Member for Gower (Mr. Wardell) has written to the Secretary of State for Social Services about elderly persons who will have to sell their homes if the property is thought to be worth more than £6,000 before they can even be considered for income support for residential care after 11 April.

Yesterday I received a letter from Age Concern telling me about funding for emergency alarm systems which will cost many of our most vulnerable elderly people about £5 a week. That simply will not be recognised by housing benefit, income support or even the social fund.

Most worrying of all is the problem of school meals and milk for the mentally handicapped and special school pupils. The Minister is rather fond of lecturing the nation about nutrition. It would be a scandal if such vulnerable young people were not thought to be deserving of decent nutrition through meals and milk as of right. I am delighted to learn from my colleague, Councillor Charles Gray, the leader of the Labour group on Strathclyde regional council, that the Scottish Office appears to be taking a civilised view in its interpretation of the measure. I welcome that, and I would welcome still more the hon. Lady's confirmation that the same will be true for meals and milk for mentally handicapped children in the rest of Great Britain.

Hospital discharge and bridging funds worried Sir Roy Griffiths. The Minister must be aware of the many problems which are commonly called the "revolving door syndrome." In the absence of assessment, proper bridging funding and proper arrangements, many people are being discharged from long-stay hospitals to community care which simply does not exist and then find themselves back in hospital. The hon. Lady will be aware of the Association of Metropolitan Authorities' letter to the DHSS about the withdrawal of funding from regional health authorities to local authorities, especially in the north-west and the northern region. She will also be aware of the letter from the Association of Directors of Social Services to my hon. Friend the Member for Birkenhead (Mr. Field), who is the Chairman of the Social Services Select Committee, expressing its anxiety on these issues.

On 15 March the hon. Lady gave me some replies when I tried to find out whether information on these important matters was kept centrally. She told me that she did not have that information. That is an indication of Government priorities. After all this time we ought to know what the problem is, why there are variations from one part of the country to another and why people are suffering. When people are forced to leave hospital— sometimes after a short stay — they are often thrown into a community which is not prepared to receive them. The hon. Lady must know that relevant legislation exists in the shape of the Disabled Persons (Services, Consultation and Representation) Act 1986.

I was happy to note that Sir Roy Griffiths went a step further on this point. That certainly does not allow the Government to sit back and do nothing at all. It is a scandal that should be dealt with and we cannot claim to be giving priority to community care when there are so many people leaving hospital without proper assessment or arrangements. It is a disgrace by modern civilised standards.

Some aspects of the Act would and should apply to any reasonable strategy for community care. That represents true consumerism. When the 1986 Act, which has not by any means been fully implemented, dealt with the right of advocacy and with representation, when it recognised the needs of carers — for example, women in this country who are saving the Chancellor of the Exchequer about £6 billion a year and whose dedication should not be exploited — when it dealt with the issue of hospital discharge and when even the title referred to consultation, we were attempting to establish that people in the care of the social services were entitled not just to be considered as consumers, but to be treated by society in a way consistent with their rights as fellow citizens.

The Minister may agree that that is not always possible in the absence of resources. Although I disagree with many of Sir Roy Griffiths' recommendations in respect of YTS, competitive tendering, vouchers, and the social fund, I do not see that as any reason for not having a full debate on his recommendations, especially in the light of the cost of producing his report. When he said that we considered that community care was the distant relation and nobody's baby, that reflected his view of successive Governments' attempts to pursue a policy, while not being absolutely clear about resources. Of course local authorities are often concerned that they are asked to carry out duties and responsibilities without the resources being made available. There are wide geographical variations of provision. I have never believed that community care should vary from region to region. There should be national standards based on the local knowledge of councils and of those who deal with those matters, principally the consumers.

I find it difficult to understand why, for example, in Devon, 8,000 people in residential homes receive supplementary benefit compared with 1,000 in the Lothian region, although the population is about the same. Perhaps the Minister will be able to explain the wide variation in home help provision, respite care and occupational therapy. Surely, as a society still rich in resources, we are not prepared just to dismiss the problems of the mentally handicapped and send them into families which are unable to cope, and to leave the elderly to deal with the appalling problem of loneliness unassisted. We should act as a genuine community in response to those problems.

I do not regard this as the major debate on the Griffiths report, but it is a start. In the Audit Commission's withering indictment of Government policies on these matters it said:
"The only option that is not tenable is to do nothing".
I hope that the sheer volume of concern about community neglect and human suffering will shame even the Government into doing something.

12.44 pm

The Parliamentary Under-Secretary of State for Health and Social Security
(Mrs. Edwina Currie)

I congratulate the hon. Member for Monklands, West (Mr. Clarke) on his success in the ballot and on raising this debate about community care. He has raised many questions and I shall endeavour to answer him in what is inevitably a short debate. I may need to write to him later on some of the topics particularly in respect of detailed examples.

I can answer two of the hon. Gentleman's questions very quickly. First, we do not collect national statistics because we believe firmly in local arrangements. If the hon. Gentleman stays to listen to the next debate on the East Yorkshire health authority, he may hear how that authority is tackling the problems that he has outlined. Secondly, fewer people in Lothian may be obtaining supplementary benefit for care than in Devon because people in Lothian are much better off. The average income in Scotland is the second highest in the United Kingdom. It lags behind only London and the south-east. It is much higher than in my constituency of Derbyshire, South.

The hon. Lady has just confirmed the need for a national survey and for information to be made available on a central basis. She has displayed an appalling ignorance of the problems of Lothian region and of Scotland. If that information were made available nationally, perhaps she would be better informed.

The hon. Gentleman did not call a debate on the problems of Lothian region. I propose to answer his points.

The hon. Gentleman asked particularly about the Griffiths report. As he knows, we asked Sir Roy Griffiths to
"review the way in which public funds are used to support community care policy and to advise …on the options for action that would improve the use of these funds as a contribution to more effective community care."
Sir Roy presented his report on 12 February and we published it shortly afterwards. We have made it clear that we regard it as a basis for discussion, along with the other recent work mentioned by the hon. Gentleman, such as Lady Wagner's report on residential care, the proposals drawn up by Joan Firth in my Department and the timely comments made by the Audit Commission in 1986. The hon. Gentleman also mentioned the Select Committee on Social Services, which reported in the 1984–85 Session on community care for the adult mentally ill and mentally handicapped. He may recall that I was privileged to be a member of the Committee at that time.

The Government are not suffering from a lack of advice. Sir Roy drew attention to the findings of the Audit Commission to the effect that better value could be obtained from extra resources. We shall take careful note of all that has been said, including the points raised by the hon. Gentleman, and we shall make our views known in due course.

I can report progress on the Disabled Persons (Services, Consultation and Representation) Act 1986, which the hon. Gentleman piloted through the House and which received a great deal of support on both sides of the House, not least from myself. Following the successful outcome of discussions with the local authority associations, sections 5 and 6 of the Act, which relate to the assessment of needs of disabled young people leaving school and which many of us regarded as being very significant, were implemented with effect from 1 February 1988. We implemented sections 4, 8(1), 9 and 10 on 1 April 1987 and we propose to implement section 11 as soon as possible. Discussions have already opened with local authority representatives on section 7, as part of a continuing dialogue on implementation of the Act. My officials intend to resume discussions shortly with the aim of determining costs and a timetable for implementation. Health authorities and the voluntary sector will also need to be consulted. Section 7 is likely to be the next section to be implemented.

As for the sections relating to Scotland, sections 12 and 14 were implemented on 1 June 1987, section 15 was repealed by the National Health Service (Amendment) Act 1986 and section 13 was implemented on 1 February this year. That is the Scottish equivalent of the English sections 5 and 6. Technical sections 16 to 18 were implemented on 16 April 1987.

Further discussions are planned with the local authority associations on the cost of other outstanding sections of the Act, and implementation of those will take place as and when the necessary resources can be made available. I should just remind the hon. Gentleman that some of the sections of the Children Act 1975, which was passed at the beginning of the previous Labour Government, took many more years than that to he implemented.

I would be grateful if I could get on, as the hon. Gentleman has asked me many questions.

The hon. Gentleman knows that community care is the special brief of my noble Friend Lord Skelmersdale. As I read through the voluminous literature and papers on this matter, I was struck how often I came across phrases such as "Our aim is to provide better services." Our aim is to do all that we can to strengthen and support a competent and responsible society. The aim should be to help individuals achieve their potential within such a society. That means putting our hospitals, homes, doctors, care-workers, services and so on into some kind of context. They are not the aims but the means by which we achieve our aim.

As the hon. Gentleman has said, most people who need help and care live at home. Most are cared for by their families. Children, particularly mentally handicapped children, are now overwhelmingly at home with their families. As we go up the age scale, that gets harder, as the number of old people now match the numbers in the younger age cohort, which would be the caring cohort, so it becomes relatively more difficult for caring families to manage.

I can offer an example from my own family. My mother was one of 10 siblings. They had little difficulty in caring for their parents. My mother and her brothers and sisters, of whom eight now survive, are all aged between 65 and nearly 90. Between them, the eight produced only seven children. That problem is not just common to Britain but to the western world. The whole pattern of demography in the free world has changed dramatically and some aspects of patterns of care will also have to change.

But other changes are more positive. Elderly people are fit, active and, in large numbers, play a far bigger part in society now than ever before, perhaps not always with a pay packet attached, but with their time and experience. We particularly undervalue the role of such people, particularly in the caring services.

We also forget that elderly people are not a separate species and they expect the same degree of choice and control over their lives as they had when they were younger. The elderly, and those who are mentally ill or handicapped or disabled, are not a separate species but citizens. For them, as for everyone else, the job of the state is to enable them to live their lives to the full and make their contribution to society, whether they are able or disabled, frail, failing or as fit as a fiddle. That is the aim of policy and everything else is a means to that end.

Nor should we forget that the part played by the state, particularly in the provision of services, is much smaller in the overall context than we all imply. We have mentioned the family. We should mention friends and neighbours, particularly in constituencies such as mine, a scattered rural area. We should mention what is called the voluntary sector — that always sounds like a product on a supermarket shelf — and the more formal carers' organisations, many of which existed long before the welfare state was established some 40 years ago.

The state's role is to provide and pay for a great deal of care. Roy Griffiths rightly pushes us to think how that might be organised in future. But the state side is only a small part of the considerable, often unseen, network of care. Let me quote someone who described that far better than I can nearly 200 years ago. It was Tom Paine in "The Rights of Man" who said:
"Society performs for itself almost everything which is ascribed to Government."
I hope that the hon. Gentleman, who has a distinguished record as a Socialist mayor of a great city, will not mind too much if I offer him the words of the philosopher-founder of Socialism as an example of what I am getting at.

The hon. Gentleman particularly mentioned hospital closures and discharges. He knows that the aim of policy is not closure, but the development at a local level of a comprehensive range of well co-ordinated health and social services, matching the range of needs of mentally ill and handicapped people, the elderly and their families. When such local services exist, some hospitals will no longer be needed. The pace of closure is entirely conditioned by the pace of provision of local services. Quality matters more than speed. We say this repeatedly to the health authorities and I hope that the hon. Gentleman recognises that we mean it.

During the past 30 years most mentally ill patients who were well enough to leave hospital have already left and are now in the community. So far, we share the view that not enough resources have followed the patient out of hospital into the community. The 31 planned closures of large hospitals will help to put that right, and the remaining 70 or so traditional hospitals are becoming much smaller and are playing an important part in their own district services. Further discharges are not in themselves an aim of policy. It is for the consultant in charge and his colleagues to decide whether an individual will benefit from discharge.

A similar position applies to the mentally handicapped. The pace of contraction of the large mental handicap hospitals depends on the development of appropriate short, medium and long-stay provision for the residents. We have advised health authorities to aim to accommodate people in small, homely units based in their local communities. None of that should require the establishment of large hospitals, but some might need units with special facilities.

Again, the scale of future NHS residential provision for mentally handicapped people depends on local estimates, particularly of the number of severely and multiply handicapped people or of behaviourally disturbed or mentally ill people. We also need to learn from experience new ways of meeting the needs of such people for medical and nursing care in small NHS and other settings.

However, I am satisfied with—indeed I am pleased to see — the progress being made. For example, the number of mentally handicapped children in NHS hospitals and hospital units fell from over 7,000 20 years ago to barely 490 in 1986. In October 1986 we stated that provision should be made so that no mentally handicapped child receiving long-term care should need to live in a large mental handicap hospital.

The hon. Lady will recall that I asked her a specific question about school meals and milk for mentally handicapped children and those in special schools. I would be grateful if she would reply to my point.

The hon. Gentleman will know that some aspects of those policies are under discussion, but, broadly speaking, our overall policy has been and is to ensure that people receive benefits in cash rather than in kind. That has been the policy for a long time on both sides of the House. As I recall, it was also the policy of the previous Labour Government. However, I shall write to the hon. Gentleman to deal with his point in detail.

The problems of the mentally handicapped are now much better understood in our community. There has been a sea change in services for those people and their families in recent years. I used to be a regular visitor to Monyhull hospital, which was in my ward in Birmingham and which I represented for 11 years. As we made steady progress, one of the porters remarked to me that he could tell the difference because the doctors now had to clean their own cars. It struck me then with great sadness how much we had unwittingly restricted the personal development and happiness of so many thousands of our fellow citizens simply because they had been dubbed "slow" or "in moral danger" decades before in childhood.

The contrast was shown for me up the road outside Collingwood: school in Birmingham for children with special needs when I was chairman of the governors. One day, as I chatted to the then headmaster, Bob Dunn, we were shyly approached by a former pupil. She told us that she was working, and, with great pride, showed us her payslip. The headmaster, with great presence of mind, told her gravely that she was clearly earning more than he was. In another age, in another time, she would have languished all her life in hospital. The alternatives are so much better.

We do have far more difficulty with mental illness. Apart from anything else, the numbers are so much greater. After heart disease, mental illness is the second biggest expense in the Health Service. By 1985–86 the total hospital and community health service cost of mental illness was well over billion, and that does not include, for example, the cost of drugs and care through the family practitioner committees.

I had the figures for mental illness analysed recently and I was surprised to discover the extent to which mental illness is a female problem. In every age group, looking at admissions to hospital for mental illness, women outnumber men. Among men, the commonest diagnoses are schizophrenia and alcohol-related problems, although obviously alcoholism can be an effect of mental illness as well as a cause. I am sure that the hon. Gentleman will welcome the setting up of a ministerial group on alcohol misuse with membership from 11 Departments, chaired by my right hon. Friend the Leader of the House. We hope to make progress on a wide range of services and policies that will help that group of people.

Among women, the major group is the elderly and the commonest diagnosis is not, as I would have expected, dementia, but depression. The archetypal mental patient in Britain is a depressed old lady and much of that clinical depression may be postponable, if not preventable. At least we can aim to minimise its effects. Therefore, it follows that the pattern of services in the community and the way in which we treat our old people may need to shift to reflect those new patterns of need.

I am satisfied that we are making progress and I share the hon. Gentleman's feeling that we shall continue to need our hospitals and improvement in our community care for many years to come. We will need our hospitals for sanctuary, respite, teaching and training, research and ultimately, of course, for long-stay care.

In the past there has been tension about the relative contributions of the different providers of care. Most notably, there was tension between the hospital or institutional provision and provision in or by the community at large. I do not believe that that conflict is necessary or real. The whole spectrum of care provision is complementary. In our 1987 election manifesto we said:
"Elderly, disabled, mentally ill and mentally handicapped people, should be cared for within the community whenever this is right for them.
In the past some people who should have been cared for in other ways have remained in hospitals, sometimes for years. That is changing … This changing pattern has already brought a better life to many thousands of people. It has the potential to do so for many thousands more."
I am sure that the hon. Gentleman will join me in reiterating those words.