Motion made, and Question proposed, That the sitting be now adjourned.—(Mark Lancaster.)
It is good to serve under your chairmanship, Mr Turner. I am pleased to have the chance to discuss home care and home care workers, because it is an incredibly and increasingly important area of service and policy touching nearly every family in the land. As the number of elderly and frail people increases, many of them with some degree of dementia, and as more people stay in their own homes, it is vital that we as a Parliament and the Government take action to ensure that standards of care are what they should be and meet the needs of older people with the dignity and quality of service that they have a right to expect, and that I am sure we all want for ourselves when the time comes.
I appreciate that there are big funding questions. I certainly want social care to be a priority for resources. Under the present austerity regime, social services departments and care providers are struggling to meet the pressures that we discussing. I also favour the full implementation of the Dilnot proposals. However, it is my intention to focus not on finance but on care and care workers and what we can do to address the present shortcomings, which must be evident to Members from all parties.
Let me make it clear at the outset that we should praise the good job that so many care workers and care providers do, often—I shall say more about this—in difficult circumstances. However, there are far too many shortcomings, as described in the recent Care Quality Commission report and the Unison report “Time to care”. We need an across-the-board drive to raise the standards, training, working conditions, terms of employment and professional standing of this most vital group of workers. It is especially important because they are on the front line. They are the first point of care and contact for hundreds of thousands of elderly people and are responsible for helping with their intimate personal needs and medication as well as day-to-day living.
On standards, the Care Quality Commission found a quarter of services to be substandard. Both the Unison report and the survey last autumn by the consumers association Which? found too many instances of rushed and poor care, as well as evidence of good and excellent care. I have been surveying constituents on the issue and have seen the same mixed picture. One daughter in the Which? survey found her mother having her face washed with a flannel with faeces on it and being dressed in the previous day’s soiled clothes. Others spoke of relatives going all day without food or drink, untrained staff using lifting equipment, muddled medication and forgotten alarm pendants. It is clear that standards must be raised to a consistent and higher level.
Training must be an important part of that. We need to listen to people like the worker in the Unison report who said:
“Three half-days’ irrelevant training was given. Then I was on my own. I had never bathed, dressed or cared for anyone before. I had to empty urine bags, colostomy bags etc. with no training. I felt very scared and was left to struggle as best I could.”
The consequences of mistakes involving such vulnerable people do not bear thinking about. We can well understand how workers in that position are being let down by those in charge of home care provision across the country.
I argue, as Unison does, for standardised levels of training and detailed minimum standards on employers to provide practical training to that level, without making the requirements excessively academic, so that we do not exclude people who are good at caring but bad at passing exams. Requirements should include communication, though, especially given the number of people whose first language is not English working as carers. Someone in Oxford told me that her mother was in a care home where just three out of 60 staff had English as their first language.
I also argue for a professional register of accredited carers, just as we have for nurses. People would qualify to get on it and gain the status that it involves, but they could also be struck off if incompetence or negligence warranted it.
The right hon. Gentleman makes an interesting case. How long did it take him this morning, from the moment he got out of bed, to wash, clothe himself, have breakfast and get out the door? Although I appreciate that standards for care workers must be concentrated on, does he not agree that many of them are asked not just to undertake their work on the minimum wage but to complete their tasks in an unfeasibly short time?
Absolutely, and I am coming to that point. I could not get myself completely ready in the limited time that some care workers have; some are allocated 15-minute slots for visits.
When things go wrong, it is vital that staff speak out, yet too often care workers feel vulnerable and not in a position to do so. I note that last month, the Secretary of State for Health said that he was “very sympathetic” to extending to home care workers the duty to whistleblow that the Government are thinking of applying to nurses. I urge the Minister to do so.
It is crucial that inspection is extensive, robust and effective. It is all the more so given the importance of care and the fact that it takes place in people’s homes, away from immediate supervision. There are concerns about that in Oxfordshire right now. Our local paper, the Oxford Mail—I am sure you will remember it well, Mr Turner, from your time in Oxford—has highlighted concerns raised by our local patient voice and county councillors about the adequacy of local CQC inspection arrangements. In November, there were just two inspectors for Oxfordshire, and even now there are only five, who between them are responsible for inspecting 447 health and social care institutions and thousands of home care visits.
There is all-party concern. Conservative councillor Jim Couchman, who chairs the county’s adult services scrutiny committee as well as being a member of the health overview and scrutiny committee, said after meeting the CQC:
“We did get pretty worried by what we saw as an extremely ill-equipped organisation to deal with the responsibility accrued to it…The CQC is not a proper inspection team in any way, shape or form.”
Councillor Couchman has also told me since that apart from the enormity of the task required of such a small staff, the most surprising fact was that recruits did not need any experience or knowledge of the NHS, health care or social services. The CQC seemed more concerned about whether new staff had a background in regulation.
I was also concerned that when asked to talk to the Oxford Mail, the Care Quality Commission declined. When such worries are being voiced, it is all the more important for a body such as the CQC to come forward and answer questions as a basic responsibility of public accountability, as well as to take the chance to build public confidence rather than undermining it, as the CQC ended up doing. Will the Minister look into the position on care quality inspection in Oxfordshire? More generally, will he ensure that the commission has sufficient inspectors across the country with the right experience to do the job?
Feedback from users and their families is another important yardstick by which to lever up care standards. Our county council uses individual visits and client satisfaction surveys to inform contract monitoring. However, a wider public satisfaction rating is needed for the plethora of care agencies. One of the paradoxes of modern life is that, if advice is wanted on the standards of service providers such as restaurants, hotels and garages, or of products such as cars and electrical goods, there is no end of reviews out there to guide people, but for something as important as helping someone to find a good care provider, there seems to be nowhere to look for advice. In theory there is competition for provision, but in reality all the customers are groping around in the dark. That is a good reason not to emulate in mainstream NHS provision the privatisation that has already happened in care services.
Underpinning all that, action is desperately needed on the terms and conditions of care workers. They are doing a demanding job, often on the lowest wages and with minimal security. According to the Unison “Time to care” survey, more than half of home care workers overall and more than 80% in the private sector are not paid for travel time or costs; it has been estimated that between 150,000 and 200,000 home care workers are in effect paid less than the national minimum wage as a result. To make matters worse, more than half of private sector home care workers have a zero-hours contract with no guaranteed pay, and more than half of all home care workers reported that in the past year things have got worse for them on pay, working time and the duties expected of them.
I thank my right hon. Friend for setting out clearly some of the home care issues. Does he agree that zero-hours contracts in particular make it difficult to ensure continuity of care for clients and difficult for a provider to invest in its staff, because they are constantly having to look for alternative work to make up the hours to obtain a decent income to support themselves and their families?
My hon. Friend makes an excellent point, and must be reading my mind, because my next sentence was that zero-hours contracts present real problems for continuity of care, which was the point she made. It is important that vulnerable clients in particular have carers whom they know, trust and have built up a relationship with.
I am grateful to the right hon. Gentleman for initiating the debate and to Unison, with which I have met, for its initiative. I strongly reinforce the collection of points that he has just made. I have had not only users but care workers troubled by their ability to do their job come to see me. In my experience, such workers are troubled by a combination of not having enough time to look after the person they are caring for and no adequate account being taken of travel time, which means that they are in effect paid below the minimum wage to do a job that they cannot carry out sufficiently and that often there is no continuity of care from a particular individual for a vulnerable, normally elderly person. Those are big issues and I hope that the Minister will be sympathetic to all parties saying such things to the Government. All parties together can change what is a fundamentally flawed system.
I am grateful to the right hon. Gentleman for his support. All those comments are vital, and he is right that throughout Parliament and society at large we can insist on raising standards for workers who are doing a demanding, important and professional job on poverty wages, often in pretty exploitative conditions. That has to be changed.
An example to do with continuity was mentioned in the Care Quality Commission report: a client had 13 different home care workers for 35 calls. In such circumstances, clients have to explain time and time again to different care workers what needs to be done, how they like things and so on. Given that the people receiving home care increasingly have substantial health needs, the whole business of zero-hours contracts is a poor and inappropriate employment model. I do not like it anywhere, but it is especially damaging in this sector.
Is my right hon. Friend aware that in my borough of Bexley, a particular model now in use involves a care company that is acting as an umbrella agency? The care workers whom the company sends to vulnerable people are actually self-employed, which means that it is pushing an employment liability on to a vulnerable person and abdicating responsibility. What happens in Bexley is meant to give people greater choice, but it is bogus self-employment. Is the Minister aware of that model? Will he consider looking at it in detail, to see whether it is true self-employment or merely tax planning?
Or, indeed, merely a way of circumventing the national minimum wage. My hon. Friend makes an important point. I will come on to some requests to the Minister for action in that very area.
We touched earlier on the 15-minute slots for care workers, and there are serious concerns about the care that workers are able and allowed to provide when they arrive at someone’s home. The financial pressures on social services providers and on paying clients are leading to increasing use of 15-minute slots. Those may give time for a brief check, but not for caring in any meaningful sense of the word.
We need a thoroughgoing overhaul of the terms and conditions of home care workers. The non-payment of travel time breaks the minimum wage laws, which I understand has been confirmed by Her Majesty’s Revenue and Customs to Unison. Will the Minister meet HMRC so that a priority drive can be put in place to ensure that every home care worker in the country is contacted and helped to secure their entitlements? That would help not only the workers’ basic rights but recruitment and retention in a job that is far too often seen as low-status because it is low paid and has such poor conditions, and that people get out of because they simply cannot afford to carry on working.
Last year, I was approached by a constituent who was working as a home care provider for a company under contract to Oxfordshire county council. The provider was paying him little more than the minimum wage for the exact, restricted time that he spent in each person’s home, with no allowance for travel. After paying travel and other employment costs, he was simply not earning enough to get by, and he found out that he would be better off back on jobseeker’s allowance, which was where he went. I took up the case with social services and the then Secretary of State for Health; both said that it was a matter for the provider. For the providers, however, it is a matter of profit, competition and, for far too many of them, what they can get away with. That is the nub of the problem: in a contracted-out, decentralised system operating to market competition, the buck does not stop with anyone.
I am sure that the public want better safeguards and decent treatment for the vulnerable people being cared for and for the workers who do that vital caring work. That means putting in place a framework of standards and entitlements for clients and their carers, along the lines of the ethical charter for which Unison has argued. That is what I am asking the Government to do. Will the Minister reply to my points on the issues of training to consistent and accredited standards, a professional register, properly enforced standards, the adequacy of inspection, comprehensive enforcement of the minimum wage and promotion of the living wage?
It is thanks to the dedication of many care workers and the good service providers that there are out there that home care is not worse than it is. Far too much of it, however, is not nearly good enough, and some of it is very bad. The people needing care and their families are worried about such matters, and a test of this Government, or of any Government, must be what they do to raise the standards of home care and the working conditions of those who provide it.
I congratulate the right hon. Member for Oxford East (Mr Smith) not only on securing the debate but on covering such fundamentally important ground on matters that clearly need to be addressed. From the litany of issues that need to be dealt with seriously by not only the two parties in government but all parties, it is clear that if we were to construct the circumstances for a catastrophe to happen on our watch, all the ingredients are being prepared in the services being provided to people in their homes.
The right hon. Gentleman described many symptoms, and at present the health system is under extreme pressure. The last Labour Government established the £20 billion efficiency gain, now colloquially known as the Nicholson challenge. All parties know that the pressure for efficiency gain inevitably resulted in an attempt throughout the system to push costs down to the least expensive care models, which means out of hospital, into the home and care by the lowest paid people. In addition, a whole heap of management babble obscures the way in which the trend is being catapulted. The health system depends on a group of workers in people’s private homes, but we should not ignore the fact that many people work in similar conditions in residential homes for people who cannot be catered for in their own home. There is a parallel situation in nursing homes.
With pressure on the system, there will be increasing attempts to ensure that patients are discharged from hospital much earlier than in the past. Part of the management mantra is that the worst place for an elderly person is an acute hospital and that unnecessary admissions should be avoided. That is self-evidently unarguable, but is often asserted. However, at the margin an assessment must be made before making that decision. There is a feeling that older people are being denied admission to hospital because of age discrimination in the system, and that because they are older they should be kept at home when, if they were 20, 30 or 40 years younger with the same condition, they would be admitted to hospital. Many of us know that that pattern exists.
MPs have many examples in their casework, and I am sure I am not unique in this: inadequate care is provided in the home for older people who must endure unacceptably poor standards of care and circumstances. The response is often pontification from the political classes, but the care workers are voiceless. Whenever the “Today” programme runs a story about poor care, which it often does when a shocking story of poor care is revealed or a report by the Care Quality Commission is published, some of our own classes are wheeled on to morning media slots and often denigrate the character of the people who provide care, as though a failing in the carers caused the problem. They say that we must address problems with carers’ characters rather than the unfeasible circumstances in which so many of them must operate.
I intervened on the right hon. Member for Oxford East to ask how long it takes him to get out of bed in the morning and to get ready to go out of the door. All of us in the Chamber are able-bodied and do not need a hoist to get out of bed or to use the toilet. We do not need to be assisted in every way, and we are not on a cocktail of medicines—perhaps some of us are. An hour is probably a reasonable time for most able-bodied people, yet we often hear that care workers must undertake those functions for other people in less than half an hour. That is simply not feasible. People may say that carers cut corners, take risks and do not complete the job, but they are asked to undertake an impossible task.
Many carers are on the minimum wage, and in areas such as mine in west Cornwall and the Isles of Scilly the travel time between visits is often significant. If the agency employing care workers is not prepared to cover properly travel times or costs, it may take the worker below the minimum wage, as my right hon. Friend the Member for Bermondsey and Old Southwark (Simon Hughes) said.
We must address the issues that the right hon. Member for Oxford East has properly listed. All the ingredients are there. As we go forward, the pressure will continue. Bed reviews will be undertaken as the new clinical commissioning groups swing into action in the next month. They will look at how many community beds there are in their area, assess whether they are affordable, and look for new ways of working and new pathways. They will use the usual language to argue that there are better ways of providing the care that is currently provided in community hospitals, that local communities should not be obsessed with bricks and mortar, that they can provide better care in the home, and that people should relax and understand that the number of beds can be reduced even when the population is ageing and the number of people needing care is increasing. Reducing the number of beds will increase the pressure on remaining beds. People will be discharged much earlier to their homes with assurances that adequate care packages are in place when we all know that those care packages are marginal and that the people providing the care will be asked to undertake work that is often unfeasible.
I often resist calls for diminution in the number of community hospital beds in my constituency, and I am sure that other hon. Members do the same. We used to know the number of beds in our local hospitals, but the service that used to be provided is becoming increasingly invisible. The problem is that the service can then be cut, denuded and reduced over time in ways that are very difficult for us all to properly assess, because people will not able to see or understand how it operates. Parts of the service will be shaved off in the same way that local authorities have redefined access to support from moderate to critical, and so on—as I know that many local authorities have done.
I have visited a number of agencies in my constituency. I am really pleased that we have some excellent agencies working in west Cornwall. Many of them are impressive agencies, but of course they are all competing, and there is a risk of a race to the bottom. Local authorities are commissioning on the basis of price, and the fear is that they are not necessarily looking at quality as much as they should be when they make assessments.
I made the point about competition in my remarks. Does the hon. Gentleman agree that a very important dimension is that a lot of clients are paying for care themselves, and they have very inadequate information on which to judge one agency or provider against another?
Absolutely. Minimum standards and agreements across agencies—or if the Government will not establish minimum standards, baseline standards—would give people reassurance. What we understand is happening, as part of achieving the efficiency gain that all parties want, is that not only is there an attempt at constructing a clinical and patient interest argument that patients are better off being discharged to their home, which is better for them, because it is where they want to be—the mantra that is often used; but there is cost-shunting as well. Obviously, if a patient is in hospital, the state is paying for them. There is an increasingly harsh attempt at identifying what continuing care is and is not—in other words, the state continues to pay for that patient in their home—but what ultimately happens is that the sooner the hospitals can get patients out to their home, it is the individual, if they have any assets at all, who meets the bill.
In terms of standards, in my view, we should be encouraging agencies that are providing care to offer at least a living wage for workers—£7.20 per hour and, I think, £8.30 in the London area. Travel time between visits should be part of salaried time. A mileage rate should be set and understood, and everyone should share a mileage rate; in my area, the rate paid to travelling care workers varies between 35p and 40p a mile. There should be a minimum visit time of 45 minutes in very exceptional cases, and at least an hour for most visits, especially if it involves at least two of the following procedures for non-ambulant or semi-ambulant clients: getting out of bed; dressing or undressing; toileting; feeding; washing and mobility support.
An efficient and effective arrival and departure reporting and recording system should be introduced, because there is some dispute between agencies and local authorities on that issue. Registration of care workers is very important, and I hope there will be cross-party support for it. The Select Committee on Health, of which I am a member, has been pushing for it for some time. It would ensure that there is adequate training, proper registration and recognition of the significant job that home care workers do. With that kind of support, I believe that we can give home care workers the proper status and support that they richly deserve.
I begin by congratulating my right hon. Friend the Member for Oxford East (Mr Smith) on securing the debate. There could not be a more important subject on which to have a Westminster Hall debate. I also thank the hon. Member for St Ives (Andrew George), who made a very important contribution. To add more thanks, the recent CQC and Unison reports have been incredibly helpful; for those of us who have been thinking about care for some time, the two reports have crystallised and explained, in a well researched way, the substantial challenge that we face.
If I may make a slightly parochial Merseyside remark, this is an extremely important issue for us, especially in Wirral, where we have an ageing population, which, I must say, we are very glad about. We are glad and proud that our grandparents and parents are living longer, but with that pride comes responsibility. That is why the challenge that we face is very important. I would like to thank my constituents, who have been very good in coming to several public meetings with me on the subject of care. I have asked them to help me think about that issue, because I know that many of them face this challenge. They have willingly given up their time to inform me about their concerns, and I am incredibly grateful.
I have also been lucky in the Wirral because home care staff have met me and given me the benefit of their experience, along with council officers and councillors. I recognise that the problem is shared across all those groups. We are going to fix the problem together, and we are here today to ask the Minister whether he will join us in helping to do that.
On the point she just mentioned, does the hon. Lady agree that one of the pleasing aspects of this issue is the number of active senior citizens in all our constituencies who want, in a voluntary capacity, to involve themselves in the debate to try and lift the standards and ensure that we give the proper care to people in their own homes?
I could not agree more. Only last Friday, I was with Heswall Soroptimists, a very committed group of women who volunteer in our community, and who raised various issues about care. That is only one example of committed groups of citizens who are keen to be involved in finding a solution.
It is important that we make the moral case for change. Too often, people in need of care in their homes are hidden from our society, and people who need support, by their nature, can find significant barriers to their participation in democracy. Therefore, it is extremely important that politicians take the time to speak up for them. I have been meeting regularly with Wirral officers to try and work through some of those issues, and specifically, to discuss whether there is a way that we can improve the quality of care in our borough.
On that note, I flag to the Minister that such conversations are made much more difficult by the funding settlement that local government has received. The fact that local government has taken the biggest cuts from Whitehall has certainly impeded my ability, locally in the Wirral, to get change. I ask the Minister to note that point, and next time that he has conversations with Cabinet Ministers and the Treasury, to remind them of local government’s role in care and of the important challenge that we are trying to meet.
In discussions with Wirral council officers, we have also been trying to consider how to tackle the problem of information that has already been flagged. For people who are trying to procure care, it is difficult to know what quality standards they can expect and what the market looks like. I sympathise greatly with the points made by my right hon. Friend the Member for Oxford East about the role of markets in what is, I would argue, a bit of the economy that does not necessarily lend itself well to markets. I hope that hon. Members will forgive me if I sound like a bit of an economics geek when I say that, in any case, markets do not work well when participants have insufficient information. I believe that if we cannot solve that problem, the current system will never work.
I will move on to talk about two aspects of home care that have repeatedly been shown to be very important to my constituents. As I mentioned, we have had several public meetings in the Wirral to discuss these issues, and we have tried to bring together both those who work in care and those who receive care so that we can see the problems from either side of the coin. Those two aspects are 15-minute appointments and zero-hours contracts. Those two issues typify the insecurity at work and low investment in skills that home care workers face.
First, on 15-minute appointments, it might have been mentioned that the recent Unison report found that 46% of staff felt that they had to rush visits—that is nearly half the workers going into the homes of people who are very important and need help. The result is the feedback that I receive that due care and attention cannot be given to people. I am talking about basic matters of respect, such as addressing the person concerned as they would wish to be addressed.
Let me give an example from my own constituency. A care worker was in a couple’s home to make some food for them, but said that they were able to do that for only one member of the couple—the husband or wife—because that was all that they had been allocated time for. Most people expect to be able to sit down to a meal with their partner. That is a basic thing that we all expect to be able to do in our lives. Fifteen-minute appointments may or may not have been the cause of the problem in that case, but if 15-minute appointments mean that the normal standards that we would all expect to be upheld have to be disregarded, that is not a system that will work well.
I will read out a quote from one of the care workers to whom Unison spoke:
“When the person you go to needs more care or has incontinence you are only allocated 15 minutes for a meal and have to leave them. I haven’t left a client like that and would go over my time (although not paid for it), but it does mean you are running late for other calls.”
I cannot imagine what it must be like for someone to turn up at a person’s home and find, if they are incontinent, that the worst has happened. They are supposed to be there only to make them a sandwich or whatever and they must decide between being late for the next person, which will cause stress, or, frankly, rushing around doing things that they know they will not be paid for, which will cause them stress. At the same time, they are trying to make that individual feel better about what has happened. What skills and talents does someone need to make that situation go well? We should first admire the people who do this job, but also question what in the system is causing such a breakdown.
One aspect of this subject that I have highlighted as a result of listening to my constituents is that too much of the way in which our system works is task-orientated, not person-orientated. Dignity is extremely important. Increasingly, people have recognised that the way in which we treat others in society is ever more important. When we are asking people to do a list of tasks—no more and no less—rather than think about the individual and try to help them with whatever their needs are, we will not fix the problem. Individuals will feel bad about the care that they receive rather than feeling that it is a help to them. Another care worker quoted in the Unison report expressed that very clearly:
“I never seem to have enough time for the human contact and care that these people deserve.”
That is a lesson to us all.
Secondly, on zero-hours contracts, my right hon. Friend the Member for Knowsley (Mr Howarth), my hon. Friend the Member for Liverpool, Wavertree (Luciana Berger) and I have recently commenced a survey that is designed to listen to people across all industries who have experienced being asked to do or have taken on zero-hours contracts. Of course, for people who want a bit of work but do not need it to be regular—students or others—zero-hours contracts may not be such a problem. However, I think we all recognise in this Chamber the problems with that flexibility and insecurity in a world in which people are trying to provide routine, predictability and attention to detail for some quite vulnerable people. I think we would all question the appropriateness of zero-hours contracts.
There are two problems with zero-hours contracts that we need to consider. The first is inconsistent care. My constituents tell me that they would like to know who the person is who will be turning up and they would like visits to be predictable and regular, not least because of respect and dignity issues, such as knowing the little details. Often, people who need care face communication barriers. Understanding in detail how a person communicates is extremely important, so consistency of care could not be more important. How do zero-hours contracts support consistency of care?
The second issue is stress. Insecurity at work causes stress, and in a world in which we are asking people, as I mentioned in my example, to turn up and help vulnerable people, we need them to feel confident and secure and to have enough skills to be able to tackle whatever problems are there. Recent research has shown the impact of stress and insecurity for those working in care on the manner of treatment received by the people for whom they are caring. That is an important message to us all as politicians. What responsibility can we take for creating more security at work for those who care for vulnerable people?
Comments have already been made about the pay levels in the sector. They are clearly low. Low pay plus zero-hours contracts mean that we will have people of relatively low skill. I mean “low skill” in the technical sense; I would argue that people who work in care are extremely skilled and extremely able practically, given what they have to deal with. However, investment in skills will clearly not happen where there is low pay and an insecure labour market.
Having described the problem, I will conclude by describing what I believe might be part of the solution. First, working in home care needs to be seen as an aspirational job. There is no reason why someone should not work in care and aspire to management, to moving up in their career. We need to find pathways through the career chain so that we can make this a genuinely aspirational job. A significant number of our young people are out of work. We need to demonstrate to them that home care work is valued in society and that if they pursue such a career, they will be invested in and respected as members of our society. We need to make that absolutely clear.
I again thank my right hon. Friend the Member for Oxford East for securing the debate. There could not be a more important subject than this. I hope that the Minister will respond positively and explain what we can do to bring some change to the sector.
I, too, thank the right hon. Member for Oxford East (Mr Smith) and congratulate him on bringing this matter to the House for consideration. There will not be one person in the House or outside it who is unaware of the importance of home care workers and what they do. Unfortunately, we can all tell horror stories like those that the right hon. Gentleman told at the start of the debate, but we also have many good stories of care workers who do tremendous work. Where would we be without the good work that they do?
Thanks to medical innovation, people have a longer life expectancy now than they had in the past. As a result, people are trying to live at home just a wee bit longer before they go into a residential or nursing home. A great many people now retire to my constituency of Strangford, because it has the seaside and is also a lovely place to be, and we are very pleased that they are coming to live in our area. However, they are people of a certain generation, and the expectation of people in Northern Ireland is the same as that of people in the rest of the United Kingdom—that they will live that wee bit longer. I believe the Government have been encouraging families to help at home before turning to residential nursing care.
There must be robust regulation of care workers to ensure safety and value for money. In the news, we often hear horror stories of someone taking advantage of the elderly or vulnerable. Hearing such stories concerns and annoys me, but it is not the case in the vast majority of circumstances. There should be regulated training and assessment as well as funding and help, to ensure that we get things right, which is the gist of the debate today.
In the past I have spoken about the difficulties that welfare reform will bring for carers. I shall use the example of my brother, who had a motorbike accident approximately eight and a half years ago that left him with some brain injuries. My parents are well into their 80s—81 and 83, mum and dad—and their ability to cope with my brother and his particular circumstances lessens as every year passes, because the nature of life is that the older we get, the less physically able we are. We are very pleased and blessed to have my brother able to speak and converse with us; the difference is that our Keith will never be able to work again or, as he would love to, ride a motorbike again—that will never happen. He is able to keep his independence due to the carers who come to see him, and they are tremendous. There is perhaps not as much funding as there should be in the NHS for carers; Keith is reliant on his disability living allowance to pay for the help he needs. If that were to change, he would have to be placed in a facility with full-time carers, which would adversely affect his mental health and cost the Government a lot more to provide. That is my honest-to-goodness, personal opinion in the case of someone close to me.
Such situations are replicated across my constituency and in constituencies across the UK; there are many cases. It is essential that home care continues. If people cannot afford to pay for reputable carers, it is more likely that they will look for carers who are less expensive and perhaps less qualified. That is why the Government must regulate more now.
I make a plea for Crossroads Caring for Carers Northern Ireland, which primarily provides domiciliary respite care. It has offered that service for carers in Northern Ireland since 1984, and provides in excess of 200,000 hours of respite care to more than 1,200 families per year. It does tremendous work, as do many others. The service is unique, because it is aimed specifically at the carer. Crossroads is committed to providing a quality, flexible home-care service; its care attendants enable the carer to have a break, by carrying out whatever tasks the carer would normally do. Carers can take a break from caring, in the knowledge that those they care for are receiving quality care from Crossroads. In other words, every bit of quality care will be provided by Crossroads. A break from caring is invaluable in reducing the psychological and emotional stress that many carers face. Crossroads domiciliary respite care helps carers to continue to provide the support they give to a sick, disabled or elderly person.
The care provision is tailored to each caring situation; everyone is unique and the service adjusts to the unique circumstances. Individual care plans are agreed between Crossroads, the carer and the person with care needs. People decide for themselves what help and support they need, and Crossroads responds. Care attendants help with a range of personal care tasks, ranging from bathing and personal hygiene to complex care needs. Through their families, I regularly meet many constituents who have complex care needs. Crossroads adopts a flexible support approach, with care attendants helping with almost any task that is part of everyday living.
Funding for Crossroads is under stress, as I said, so less and less help can be given. That brings us to the thrust of the debate: people are left in situations where they must look to cheaper alternatives, which are not always better. It bears repeating that the Government must address care in the home needs. Too many people are living in dirty homes and not being fed enough. There is only so much that families can do. Although we are trying to save money, care in the community cannot bear the brunt of what the changes will bring. Crossroads Caring has lost the bulk of its funding due to cuts. That will mean more elderly people living in unfit conditions because too much is required of their carers. With respect, the Government do not seem to understand that if they put a little into respite help for carers now, it will mean that carers can continue to care rather than giving up and putting their loved ones into state-sponsored homes, which are more expensive and where issues with carers are more apparent. Saving a penny now will soon mean spending thousands later. I hope when the Minister responds, he will give some indication of the Government’s strategy.
Those advertising care at the moment can do so while providing little training or checks on their staff, as hon. Members have indicated, and that must end. There must be regulation, qualifications and a set standard to which all carers and service providers adhere. When the Government set that in place, we will hear fewer horror stories and more feel-good stories, of which there are thousands and thousands. They are not the stories that make the press; they are about the many carers who go above and beyond their calling to provide care.
As an elected representative—as an MP and a former Assembly Member and councillor—I know of the good work that carers do. They come to me regularly, in their own time, to seek help for those for whom they care. I am always impressed by the fact that carers spend additional time on those for whom they care—above and beyond what is expected. We hear the negative stories, but the good ones always make us feel much better about the good work that carers do in our constituencies.
I am sure that, like me, colleagues feel there must be proper training and monitoring and that it must be put in place in a timely fashion. As each day passes, more people are being cared for at home. We have a duty to ensure first, the regulation of all carers; secondly, the safety of those being cared for; and, thirdly, and most important, peace of mind for the family of the person who needs care. I congratulate the right hon. Member for Oxford East on securing the debate. I look forward to a good answer from the Minister and to his support.
It is a pleasure to serve under your chairmanship, Mr Turner. I congratulate my right hon. Friend the Member for Oxford East (Mr Smith) on securing the debate. It is a pleasure to follow all the speakers, who fully and excellently set out the case for care workers.
When I read the “Time to Care” report, I had an enormous feeling of déjà vu. Before becoming a Member of Parliament, I worked for Unison as a full-time officer. Back in the 1990s, one of my first jobs as a young officer was supporting the Derbyshire county council home helps joint consultative committee. “Home helps” was the name given to home care workers in Derbyshire, of whom there were thousands. The joint consultative committee used to bring together representatives of home care workers from across the county with senior management of social services, including the director of social services, who so understood the important role of home care that he was always prepared to attend meetings to listen to the views of home care representatives. It was an opportunity for them to raise their concerns and the issues that their members faced.
The 1990s was a period of huge change for such workers. The role of home helps was changing immensely: they moved from providing a service that was basically helping older people with cleaning, shopping, meals and even, back then, laying fires, to providing much more intimate personal care and dealing with people with increasingly complex needs. It was also a period of budget cuts, which accounts for the feeling of déjà vu. There was pressure to change services, to make them efficient, obviously, but also to open them to the private market.
I vividly remember Derbyshire home helps raising concerns about a proposed move to a time-recording system. When they arrived at a service user’s house, the first thing they had to do was telephone to tell social services where they were, so that there was much more detailed information on the amount of time they spent with each service user. A concern they raised at the time was that doing so would change their focus, so that rather than their prime focus being on the needs of the service user, their top priority when they arrived was to record their time so that social services could properly cost the service.
I also remember home helps raising concerns about short calls that did not allow them time to care, to listen to what services users wanted or to respond to their priorities.
The hon. Lady makes an excellent point about recording arrival and departure times. Often the system simply fails, not only in rural areas, where mobile coverage is poor, but when using the cared for person’s telephone. Carers often cannot get through and calling becomes a greater obsession than providing the care itself.
The hon. Gentleman is absolutely right. I remember well the representative from the High Peak area constantly making that exact point, which was that there was poor mobile phone coverage. They talked about how much of their time would be spent dealing with the telephone instead of focusing on the person who required their assistance. There were also worries about travel time.
I particularly remember the concerns of people who worked alongside private sector care providers where, they reported, staff training was often inadequate and there was often a high turnover of staff. They also reported that the care providers frequently did not provide personal protective equipment; they talked about the lack of rubber gloves and the like. We often had discussions about which tasks home helps were given time to carry out. They often pointed out that their service users wanted and needed things that might not be what the carers were commissioned to provide.
Unison’s “Time to Care” report and the Care Quality Commission’s “Not Just a Number” inspection programme made me wonder whether we should have listened more closely to the concerns and issues raised by those Derbyshire home helps 20 years ago, particularly when, in describing the current context, the CQC talked about the
“increasing pressure on social care budgets and the rise in the number of people with complex care needs and dementia.”
In describing its key findings—as my right hon. Friend the Member for Oxford East said, a quarter of services fell below the standards expected—the CQC said:
“What is concerning is that our findings come as no surprise to people, their families and carers, care workers and providers themselves.”
The findings really do not come as a surprise, because they are exactly the issues that have been raised over many years.
The CQC highlighted several problems, including service users
“not being kept informed about late arrivals, different care workers from one visit to another, not having their preferences clearly documented, a lack of support for care staff to carry out their work, and failure to address the ongoing issues around travel time.”
Those are responsibilities of not just this Government but the previous Government, but the pressure on social services that are commissioning care services is even greater now, and we need to look again at what is required.
There is great similarity between the findings of the CQC and Unison’s “Time to Care” report. Although the care and welfare of service users is the most important focus, the CQC found that staff felt
“unsupported by their management teams and not…able to deliver care in the right way because they are too rushed, with no travel time and unscheduled visits added to their day.”
It also reported a lack of planning and supervision for staff. Training needs were not identified, staff were not confident in using their equipment, and inductions were not always completed following recognised standards.
As the hon. Member for St Ives (Andrew George) said, the voices of care workers are often not heard in debates such as this one. We ought to address that today. I was pleased to see that Unison’s report included many quotes from individual home care workers. It provided an opportunity for them to have a say and to talk about their experiences. My hon. Friend the Member for Wirral South (Alison McGovern) has already quoted one of the home care workers who contributed to the report, saying they did not have time to spend with their service users and they had to rush between calls.
One of the most important issues is about older people. I imagine that many hon. Members have this experience when they are out canvassing in their communities: they knock on the door of an older person, and perhaps the Member is the only person they have spoken to that day. Their priority is to talk to someone who is willing to listen. That was well recognised by one of the care workers who contributed to the report, who said that
“care is not just about duties but communication and many providers do not allow for this…How can half an hour be enough to get someone up, dressed, meds given and have a chat? People are being failed by a system which does not recognise importance of person-centred care.”
There are many quotes in the “Time to Care” report, which I am sure the Minister has read. I hope that he listens to the voices of home care workers and the issues that they raise.
It is vital that, like the director of social services in Derbyshire back in the 1990s, we listen to the voice of home care workers, because they meet service users every day. Most of them are incredibly committed to providing a good-quality service and ensuring that people receive the support that they need. It is also vital that we do not simply listen to them, but act. Will the Minister meet home care workers and their representatives to discuss the findings of Unison’s “Time to Care” and the CQC report? Will he set out today how he intends to respond to the findings of those reports?
It is a pleasure to serve under your chairmanship, Mr Turner, and to follow my hon. Friend the Member for Nottingham South (Lilian Greenwood) and all other hon. Members who have spoken.
I congratulate my right hon. Friend the Member for Oxford East (Mr Smith) on securing today’s debate. Home care workers often work in isolated environments, and the people who receive care are isolated. Too often, they do not have a voice, and one of our jobs as Members of Parliament is to provide a voice for the voiceless. My right hon. Friend has helped us to do that today.
The issue is extremely important. More than 800,000 people provide home care in the UK. Some 80% of them are women, and their median age is about 40. They provide vital, intimate and personal services to more than 1 million of the most vulnerable people in society. If any other policy area had that scale of figures, this debate would be on the Floor of the House, with many other hon. Members present. It is good to have hon. Members here in this debate, but the issue that requires addressing is a huge one.
The help that home care workers provide is crucial for older and disabled people, because it helps them do what they want, which is to stay living independently in their own homes. It is crucial for families, who often have to go out to work and cannot provide support and care for their elderly relatives. Also, they might not live nearby, as I know well myself. Home care help is crucial also for the public finances and taxpayers, because if we can keep more people living healthily and independently at home and not going into hospital, taxpayers will receive better value for money.
Like other hon. Members who have spoken today, I have been concerned about the issue for a long time. Last May, I held a domiciliary care summit in Parliament with the United Kingdom Homecare Association, with 50 providers coming along. I have work-shadowed home care workers in my constituency, including Amanda White. Going out on an early-morning shift with her was an eye-opening experience. I also speak to many older and disabled people and care workers in my constituency and across the country. Many of the points that I have heard have been repeated by right hon. and hon. Members today.
There are many examples of excellent, decent and respectful care. The home care workers to whom I have spoken, including Amanda, love their job. They feel that they are doing something important for vulnerable people, helping them to live the kinds of lives that they want. However, the overwhelming picture is of a vicious downward spiral, with ever-increasing demand and ever-decreasing budgets, poorly paid, motivated and trained staff, and poor-quality care. Just to summarise, I will go through five issues that many hon. Members have raised today.
The first issue is low pay. Many people do not get even the minimum wage at the end of the week, because they are not paid travel times. Unison’s survey, “Time to care”, which hon. Members have mentioned, found that half of those who responded said that they did not get paid travel time, rising to more than 80% in the private sector. King’s college London has found that between 150,000 and 220,000 people working in the social care sector get paid less than the minimum wage. I will ask the Minister some questions about that towards the end.
The second issue concerns shorter and shorter visits for people with higher and higher levels of need. It is important to remember that as budgets are squeezed, councils raise their eligibility criteria, so people who need care and support at home have greater needs but get shorter and shorter visits. According to the UK Homecare Association, three quarters of visits are for 30 minutes or less, and one in 10 visits are for only 15 minutes. As several hon. Members have said, that is completely inadequate to get someone up, washed, dressed and fed, particularly if they have dementia. Anyone who knows someone or has a family member with dementia will know that they often struggle in the morning, which is a really disorientating time.
One thing that carers provide to those on whom they call is a wee bit of a chat in the morning—someone to speak to—because many people have no one at all to speak to. When they come in, they light the fire and do all the things that the hon. Lady has mentioned, but communication between carers and those they visit is important. Does she think that that should be given more time?
Care and communication is vital for people with all sorts of frailties and conditions, but particularly for those with dementia, as carers try to keep their memories and brains going. Those people often feel lost in a fog, and having some kind of contact is vital to keeping them going, so it is important.
We have heard about the problems of call cramming, with carers being rushed, getting late to one client and leaving early for the next. Older people are worried when they are left waiting on their own, and staff are frustrated that they have to rush in and out.
The third issue that has been raised is zero-hours contracts. As hon. Members have said, such contracts are very bad for workers, because they find it difficult to budget and plan their lives. Zero-hours contracts make it hard to attract people to the sector. They are also terrible for the users—older and disabled people who do not get continuity of care. I cannot imagine someone coming round to get me out of my bed and take me to the shower. I would be naked and they would be washing me, but I would not know who they were, because they would often be different people each time. We would not put up with that for ourselves, and we should not expect it for older people either.
The fourth issue is the lack of training, which is a real problem in dementia care. It is only since having known people with dementia that I have fully understood why they are seen to get aggressive: they do not, but they are frustrated because they cannot remember things. Carers need detailed training for that.
The fifth issue is the vicious downward spiral or vicious circle that leads to poor care for users of services and real problems for staff. The last UK Homecare Association report states that vacancy rates are at 21%, so we are simply repeating the problems.
In my remaining time, I want to make three comments about why that is all happening and what we need to do. Clearly, demand has increased in recent years. However, as my hon. Friend the Member for Wirral South (Alison McGovern) said, when local councils’ budgets are being cut by a third, when adult social care is 40% of their budget on average and their biggest discretionary spend, and when the money that the Government say they have transferred from the NHS has not been ring-fenced, it is inevitable that care budgets are being cut. Figures from the Department for Communities and Local Government—the Government’s own figures—show that more than £1.3 billion has been cut from older people’s social care budgets since the coalition came to power.
There are a few deeper things going on. First, the caring profession is mostly delivered by women and is low-skilled. Such professions have always been neglected in the past, so that is a concern. Secondly, the problem is invisible: it concerns isolated staff and isolated, frail older people who do not have a voice. In talking about the care crisis, I always tell people that I have received five letters about the care crisis in my constituency and 99 about saving forests. I am passionate about forests, but getting only five letters on the care crisis shows that this is an issue of isolation and we should stand up about it.
Like the hon. Lady, I have shadowed care workers in my constituency. One point that often comes across is that when I ask those who pontificate from on high—criticising poor care standards and implying that it relates to the character of the people providing the service—whether they would be prepared to do this job, no one wants to do it, even at twice the salary.
I completely agree. That is why Unison’s report, “Time to Care”, which has given people a voice, is important.
The third fundamental issue is that our NHS and care system have not kept pace with changing demographics—people living longer—and changing needs and expectations. Families cannot always cope with caring for elderly relatives, and older people want to stay in their homes for longer. In the past, it was not the business of the NHS and social care to think about the home; its business was always about sending people to institutions.
What should be done? I want to raise four matters with the Minister. First, I know that the Low Pay Commission has looked at the minimum wage. Will he confirm, however, that as my right hon. Friend the Member for Oxford East said, Her Majesty’s Revenue and Customs has ruled that it is not legal to pay for travel time? If that is the case, what is being done about that? What action has been taken? In any other area, there would be legal action to enforce the minimum wage, so what is being done?
Secondly, I know that the Minister wants a shift to commissioning for outcomes, rather than by the minute. That is the Government’s policy, but how will he make that work in action? What are his levers over local councils? Thirdly, it is time to have a national strategy for improving training for home care workers. What are the Government’s plans?
Finally, although the announcement on the Dilnot cap is a step forward, Dilnot has always said, as the Minister will know, that proper funding is needed in the current system, which this Government have not produced. I know that he will be in intense conversations with the Treasury over the future budget. If, following the Budget, the Government decide to pull over more money from the NHS to social care, will he ring-fence that money this time?
It is a pleasure to serve under your chairmanship, Mr Turner.
I congratulate the right hon. Member for Oxford East (Mr Smith) on securing this incredibly important debate. As was pointed out by the shadow Minister, the hon. Member for Leicester West (Liz Kendall), the subject is too often neglected. It is literally hidden behind closed doors, and it does not get the attention it deserves. I also thank my hon. Friend the Member for St Ives (Andrew George), and the hon. Members for Wirral South (Alison McGovern), for Strangford (Jim Shannon)—he drew attention to the brilliant work done by Crossroads in many parts of the country—and for Nottingham South (Lilian Greenwood), who spoke from direct personal experience.
I totally agree with the shadow Minister that the health and care system has not kept pace with the demands and challenges of an ageing society, and that we need a fundamental re-engineering of how we deliver care. I have a passionate belief in the need to shift towards an integrated care model, in which we shape services around the needs of the individual, rather than those of the institution, which is a shift that must happen.
Before I go into details, let me say that I applaud Unison for having undertaken the report that several hon. Members have mentioned. When its staff wrote to me about the report, I asked officials to meet them, and they will meet soon. I, too, asked to meet them, and I will discuss their concerns with them next month. I recently met some care workers, with another hon. Member, to hear directly from them, and I want to experience myself what goes on—often behind closed doors.
The right hon. Member for Oxford East mentioned whistleblowers, and I have a lot of sympathy with the points he made. Last January, the Government extended the Government-funded whistleblowing helpline to the whole of the care sector, so that any care worker can find out how to pursue their concerns. Of course, as employees, care workers have employment law protection, and we should encourage them all to use their rights.
The Government want to do all we can to ensure that standards of care remain as high as possible, and indeed improve. That is the challenge we all face. People who receive home care and their families should be able to expect the highest quality of care every time. I am aware of the many examples of poor care. The right hon. Gentleman and other hon. Members drew our attention to some pretty shocking case studies and to the fact that someone can have up to 13 different care workers over a relatively short space of time. As the hon. Member for Leicester West said, it is completely unacceptable that a person has to receive quite intimate care from someone whom they have never met before. Moreover, the idea of a zero-hours contract is, in most circumstances, completely incompatible with a model of high quality care, in which the individual really gets to know their care worker.
The CQC report “Not just a number” highlighted some serious concerns, which we must take action to address. The responsibility for bringing about improvement rests with all the key players, including the providers, the councils and the regulator. The Government too must take their share of the responsibility here. The trick is to erase the bad, keep the good and improve services across the board.
The care and support White Paper sets out our intentions to improve the standard of social care. We will do that primarily by investing in people—by focusing attention on the staff who provide care in the first place. I want to join the right hon. Gentleman and other hon. Members in paying tribute to care workers, the vast majority of whom do really excellent work, often in difficult circumstances. They work under real pressures because of the way in which care is commissioned over very short spaces of time. We are seeing a race to the bottom, and we must move away from that. It puts care workers under impossible pressure and it does not provide good quality care.
Another matter I feel strongly about, and to which I referred in my response to the Winterbourne View scandal, is that there must be much more effective corporate accountability. Some companies are making very good money out of home care, so accountability must go with that profit making. It is unacceptable that home care providers sometimes allow negligent care to take place under their watch, and they must be held to account for it. Poor care, private or public, should be condemned wherever it exists. We must not have the idea that poor care exists only in the private sector. It was intolerable that hundreds of people died in Mid-Staffordshire hospital, an NHS hospital, as a result of poor care, and it is equally unacceptable when it happens under the watch of a private provider.
It is impossible to speak about improving standards without also talking about human capital. Care workers who feel valued and encouraged will perform better; it is as simple as that. The more attention the Government pay to the skills, training and personal development of the work force, the better are our chances of improving standards. After all, it is the care workers, not us in Parliament, who ultimately provide the care. We must increase the capacity and the capability of the social care work force, give people better information about care providers and improve the performance of the regulator, the Care Quality Commission. All those things will make social care a more attractive place for people to work and, most importantly, improve the quality of services.
We will shortly introduce new minimum standards to improve training for care staff to make sure that all employees have the foundations for excellence. My focus must be on training and standards, and ensuring that they apply across the board. I am dubious about the idea of creating a new regulator or of using the Nursing and Midwifery Council, which has not had a great record, to regulate some 1.5 million people. The money that is available should perhaps go to the front-line workers, rather than on creating new bureaucratic structures. I will give way to the hon. Lady, and ask her to be very quick if she does not mind.
I will be speedy. I have listened carefully to what the Minister has said about the causes of the problem. He does not seem to have mentioned funding pressures on local government. Will he respond to that point, because it is a massive constraint on improvements in the sector?
I will directly address that point. The analysis of the independent King’s Fund said that provided councils apply the money that the Government have allocated to care and undertake proper efficiency savings, which the previous Labour Government recognised had to happen across health and care, they should be able to continue to provide the level of service that exists at present. We need to think more fundamentally about a much more integrated approach between health and care. We can save resources and improve care if we bring the systems much more closely together.
It was, I think, the hon. Member for Wirral South who made the point about looking at care as an aspirational role.
I totally agree with her. If a worker can aspire to something better—perhaps a progression in their career—they will commit themselves very fully to the role. The idea of a vocational progression towards nursing, even if, at the end of the day, a degree is involved, should be opened up much more than it is at present. I completely agree with her on the points that she makes.
I share the concerns that hon. Members have raised about pay. There have been reports that some home care workers may be working for less than the minimum wage, which is an absolutely disgraceful situation for a vast number of reasons, not least because an illegally low wage will never produce excellent results and it is an exploitation of the worker that we must not tolerate. It is the responsibility of all employers, including home care providers, to pay staff at least the national minimum wage. The Government are working closely with the Low Pay Commission and local authorities to address that issue. I can assure all hon. Members that we will not accept anything less than 100% compliance with the regulations.
When I was a Minister in the Department for Business, Innovation and Skills, I wanted to change the rules to make it easier to name and shame employers who fail to pay the minimum wage. We must regard that as completely unacceptable practice, and any employer who indulges in it should be exposed; it is utterly intolerable.
I am conscious that time is tight and I want to address the remaining points.
The hon. Member for Erith and Thamesmead (Teresa Pearce), who is no longer in her seat, raised concerns about potentially bogus arrangements in her constituency in Bexley. I think that she is writing to me on that matter, and I will be happy to look into it.
Care providers are also responsible for ensuring that their services meet the requirements in regulations and essential standards. The regulator, the Care Quality Commission, has powers that it can use to make sure that that happens. The CQC has our full support to use those powers as it sees fit to drive improvements in services. It is worth taking a moment to talk about the CQC report, which we have been discussing this morning. Between April and July 2012, the CQC inspected 250 registered home care providers as part of a themed programme to highlight respecting and involving people who use services and safeguarding them from abuse and neglect. To ensure that everything was examined thoroughly, it involved the people who use the services as well as the people who provide them. It looked at how staff are supported and how standards are maintained. Overall, the CQC found that 74% of the services that it inspected met the standards, and about a quarter did not. That is unacceptable and we must all focus our attention on those services.
The right hon. Gentleman referred to concerns about CQC’s capabilities in Oxfordshire, and I am aware of local media attention on that. My officials have raised those concerns with CQC and they were assured that it is on track to achieve its goal of inspecting 100% of adult social care locations across Oxfordshire by 31 March, that its Oxfordshire compliance team now consists of 10 full-time inspectors and that, after a period of recruitment, CQC has had no vacancies in the area since last December. If concerns continue, I urge the right hon. Gentleman to contact me and I will be happy to look into them further.
The importance of commissioning must be stressed. Commissioning over short periods of time—that race to the bottom—is unacceptable. We must commission on the basis of quality, as the hon. Member for Leicester West said. Finally, let me thank the right hon. Gentleman for securing such an important subject for debate.