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Adult Social Care

Volume 687: debated on Thursday 7 December 2006

rose to call attention to the funding of local authority adult social services and the consequences for the rising numbers of elderly people; and to move for Papers.

The noble Lord said: My Lords, I am grateful for the opportunity to review the funding of local authority social services today, especially in the company of so many noble Lords with great experience in these matters. I declare an interest as chairman of the Local Government Association, although I speak for myself. I shall address three questions. First, is there clarity and consensus about demographic change? Secondly, what kind of care services do we need for the decade ahead? Thirdly, what is the funding requirement to respond to demographic change and change in service demand?

It has been said that you can judge a society by the way it treats and cares for its elderly people. That was never more so than it is today. I was pleased to see that the Treasury’s Comprehensive Spending Review 2007 set out just five factors of change and that one of them was rightly the challenge of demographic and social change. Rising to the challenge of demographic change will certainly be one of the “key tests” in judging CSR 2007.

The over-85s require the most urgent attention and the most intensive care. According to the Government’s actuaries, in 2005 there were 1.2 million over-85s and by 2050 there will be 4 million. For the first time, there are more people in England over 60 than under 16. In the Comprehensive Spending Review challenges report last month, the Chancellor focused only on the next 10 years, reporting a forecast 38 per cent increase in the number of over-85s. His report also drew attention to what he called the “baby boomers”—the increased birth rate in and after the Second World War—which, coupled with increasing life expectancy, now brings a dramatic increase in the number of over-65s. There is clear recognition of dramatic demographic change but, I am afraid, a failure to act on it.

In considering a changing service, we need to respond not only to the demographic change in numbers. Help the Aged, Age Concern, the King’s Fund, numerous charities and local authorities are also reporting a sharp increase in mental, learning and physical disability in old age. We must respond to this, too. At the same time, local authority adult social care budgets are also responsible for the 16-to-65 age group. In this group, we see that medical advances, coupled with better health and social care, mean that children with the most severe learning and physical disabilities are often living into middle age. Indeed, the director of social services in my own county of Kent reports that this financial demand is now even greater than the escalating demand from changing demography. Those vulnerable young people require and deserve intensive, high-quality care.

In 1991, the Government introduced a Bill on community care that allowed elderly people to receive care in their own homes for the first time. That radical reform brought new independence to the elderly and has been, and must be, built on so that independence is the central principle of a changing service. Last week, the Commission for Social Care Inspection reported improvements in social care by local authorities. It is clear that community health and social care services must be designed around the needs and wishes of elderly people. Social care services must be personalised, offer choice, focus on early intervention and prevention, bring a higher quality of life for elderly people, deliver care with kindness and compassion, and give time. They must also value and care for the many carers who do invaluable work. At the same time, we need greater innovation and stronger partnerships between social care and the health service and stronger working with, and a stronger role for, the voluntary sector.

The Wanless commission pointed to the need for a funding increase of some £20 billion for care of the elderly over the next 25 years, an increase of almost £l billion a year, yet we have had no response from the Government. However, the situation for elderly people and the facts from the Government, local authorities and many charities and voluntary groups are entirely clear. The Treasury forecast that in the next decade the number of people aged over 85 would increase by 3.8 per cent a year. The Local Government Association’s autumn statement showed a 6 per cent increase in the number of weeks of care commissioned by local authorities last year alone, but, to pay for that increase, half the social service authorities had an increase in government grant of 2 per cent or less this year. While the NHS has had a 90 per cent increase in real-terms funding over the past decade, local government services, including social care, have had an increase of just 14 per cent.

A year ago, social service directors reported that they started this year with a black hole from 2005-06, when they spent 13 per cent—£1.8 billion—more on adult social care than the Government estimated for funding. On top of that, there are numerous other factors, including cost pressures, the reduction in grant under the Supporting People programme and the new and additional costs from direct payments, to which a recent Audit Commission report drew attention. As a result of the new demand, the absence of any new funding or action from the Government, and because council tax payers cannot pay more, half the social service authorities in the country are reporting that they are raising eligibility criteria and so rationing care for the elderly. In a civilised society, that is unacceptable.

When we consider funding, the relationship between local authorities and the health service is the central issue. On the one hand, local authorities have been working in close partnership with the health authorities. A number of social care departments, working with their health authorities, set themselves a target of reducing hospital admissions for people over 75 by 20 per cent. The majority of those 10 authorities achieved that target, but through additional cost to the local authority. However, it brought financial benefit to the health authority and real benefit to elderly people. That is encouraging, but, on the other hand, due to the current cost pressures within the NHS, many local authorities are reporting cost shunting by the health service. In my own local authority, the East Kent Hospitals NHS Trust closed 180 beds this year, which has resulted in earlier discharges and the need for higher and more intensive levels of social care. It also brought reductions in primary care services, which the health service would not wish for. However, cuts are being made in respect of district nursing, community matrons, community physiotherapists and the NHS equipment provided to residential homes.

I am pleased to say that this issue is recognised across the board, not least in my own party. Just last month, my colleague in another place the right honourable David Cameron identified,

“the artificial and damaging barrier between the NHS and social care services”.

Organisations that break down that barrier do so against the odds. To give an example from my local authority, in the case of NHS continuing care, it is estimated that 24 per cent of those in nursing homes in Kent have care needs that should be the responsibility of the NHS. We urge the Government to develop a test of eligibility with clear criteria that are understood by all so that we can resolve that issue.

The White Paper on health, published last month, calls for,

“a shift in the centre of gravity of spending. We want our hospitals to excel at the services only they can provide, while more services and support are brought closer to where people need it most”.

It is right that services and support should be brought to community social care and community health care, but where are the action and funding to support that?

None of these issues is easy, but we urgently need solutions. It is clear that local authorities and private and voluntary providers of care services for the elderly must rise to the challenges of changing need and increasing demand. However, it is also vital that we have a resolution to the immediate funding crisis in the provision of care services for the elderly and for vulnerable adults. We also need a clear statement from the Chancellor about his intentions for CSR07 and how funding will be provided to enable us to rise to the demographic and social challenges of the next decade that are so important for any civilised society. I beg to move for Papers.

My Lords, I thank the noble Lord, Lord Bruce-Lockhart, for introducing this important debate. He is uniquely well placed to do so. Last night, with two colleagues, I hosted a party to celebrate the 100 years that we had spent in social care. I hasten to add that it was 100 years between us, not each, although sometimes it feels as though I have been doing it for 100 years. I reflected on some of the terminology we use, how it has changed over the years and especially how we refer to people who access the services provided by local authorities. They went from being called the “applicant”, to the “client”, to the “care recipient”, to the “user” and now the “customer”. The changes in terminology reflect the changes in the way that services are provided. We should not forget that “social care” itself is a relatively new term. We used to call the services provided by local authorities in people’s homes, predominantly to older people, “domiciliary care” or “care in the community”.

I was one of the advisers to the Griffiths review of community care, which was published in 1988. It was one of the most significant documents in the development of this type of care, and, as far as I recall, the term “social care” was not used at all. It has come to be used as a sort of catch-all to identify any care which is not healthcare and primarily the care which is the responsibility of the local authority.

The Griffiths review was extremely significant, some noble Lords will remember, for two main reasons. First, it was very strong on the principle that care should be organised as near as possible to the care recipient and his or her family, and that meant by the local authority. That seems perfectly normal to us now, but at the time, when local authorities were so unpopular and so underrated by the then Government, it was pretty well a revolutionary idea. I remind your Lordships that the report was virtually suppressed for more than a year before the Government finally and reluctantly took Sir Roy Griffiths’s advice.

The second reason the Griffiths report was so significant, at least from my point of view, is that it was the first time that the contribution of family carers to the provision of what we now call social care was truly acknowledged. All these years on, I am still convinced that Sir Roy Griffiths was right. Overall, the record of local authorities in delivering or overseeing the delivery of social care is a fine one, as the latest statistics show. They have not only proved their value and commitment to supporting the care recipients but they have also been pioneers in the recognition and support of carers, aided and encouraged of course by the pioneering work of organisations such as Carers UK and by three separate Acts of Parliament.

Although the number of carers has remained static since records began in 1985, the number of carers providing substantial care—more than 20 hours per week—has increased from 1.5 million in 1990 to 1.9 million in 2001, the latest year for which we have proper statistics. The value of carers’ support has increased from £34 billion to £57 billion.

Carers UK’s helpline increasingly hears from carers whose breaks packages are being cut, where day centres are being closed and domiciliary care packages are being cut back. Local authorities are telling carers that they are short of funds and many are not reassessing carers—in direct breach of the law.

The consequences for carers are dire. That way of working is also very short-sighted. If insufficient care is provided, people are likely to give up paid work at a time when they most need to build up pensions and work towards retirement. As a society we simply cannot tolerate that. We must therefore ensure that services for carers are provided in a way that enables them to combine paid work with caring. That means providing support for carers before a crisis point is reached.

We must be mindful of resource problems of local authorities, as the noble Lord reminded us, but the current withdrawal of early intervention and preventive services is very short-sighted. To intervene earlier and give care and support is not only cheaper at the time, but the carers also are likely to keep caring longer. That is why the White Paper Our Health, Our Care, Our Say, which focuses on supporting local communities to make a strategic shift towards prevention, is so welcome. The key initiatives, including the partnerships for older people projects, popularly known as POPPs—I understand that several more have been announced today—are very important. It is particularly important to help carers. I am glad that today’s announcement of another 10 projects emphasises the needs of carers.

If services are to be provided satisfactorily for carers, the carers must be, both in rhetoric and reality, equal partners. I am very glad that so much progress has been made towards including carers in that regard, including extending and updating the 1999 strategy for carers. All these initiatives must be carefully monitored at local and national level.

In the limited time I have left to speak, I want to mention two more things. The first is the third sector provision and co-operation with local authorities. Can the Minister tell the House about the announcements made yesterday, in the action plan for third sector involvement in public services, about skills and systems for commissioning from the third sector? How will they be followed through? I do not need to remind your Lordships that third sector providers are hugely important in providing effective and user-focused services. However, local authority commissioners are still too likely to commission, as they have always done, without regard for the skills and experience of the third sector.

Finally, although the staff ratings of local authorities are improving, there is still not enough joined-up working across health and social care. Can the Minister remind us about the progress that is being made on the care services improvement partnership and the other initiatives with social services announced in the autumn?

My Lords, I declare an interest as an employee of Age Concern England. I thank the noble Lord, Lord Bruce-Lockhart, for giving the House the opportunity to focus on the Cinderella part of health and social care. The noble Baroness, Lady Pitkeathley, is right: in the past we did not talk about social care very much; these days it is unusual to talk about social care on its own. We have a very welcome opportunity to do that today.

When dramatic changes occur in healthcare, and particularly when buildings are closed, there is public outcry, but when small but significant changes happen in social care, very rarely is any notice taken of it at all. The turmoil and fragmentation of social care of the past few years has been profoundly significant. I want to pick up on that issue today.

Five years ago an organisation called SPAIN, the Social Policy Ageing Information Network, published a paper on the underfunding of social care and its consequences for older people. In July 2005, it returned to the subject and looked at what had happened over a period when there had been well above inflation central government funding of social care and a raft of initiatives such as fair access to care services, the national charging framework and the Community Care (Delayed Discharges etc.) Act 2003. This work was added to by the King’s Fund report, produced by Sir Derek Wanless in early 2006, about the future of adult services. The headline is that that basic underfunding of social care, which runs to about £1 billion, remains.

Any analysis of expenditure is complicated by how funding streams have changed. Some responsibilities, such as long-term care, have passed from the NHS to social services, while the Supporting People initiative has been used to meet some lower-level support needs which were previously met by social services. During that time social services have faced the dual challenge of increased targets from central government—helping more older people to live independently, the provision of community equipment and the pressure to close care homes and shift care closer to home—and, as the noble Lord, Lord Bruce-Lockhart, so graphically put it, those demographic changes that they have had to deal with as well. With an overspend of £1 billion, in the past two years social services have had to make significant increases in the funding of children’s services and services for adults with learning disabilities. Those have followed the implementation of major legislation. Nobody is suggesting that that legislation was not necessary, but the impact of it on an already overstretched budget cannot be underestimated.

Within spending on older people there are clear trends. According to the Laing & Buisson survey of 2005, the number of households receiving domiciliary care has declined by 21 per cent, even though the number of hours of domiciliary care that local authorities provide or purchase has increased by 20 per cent. Despite the existence of four bands for assessment for fair access to care services, it is almost unheard of for any local authority to fund anything other than critical or substantial needs.

The trends are quite apparent. Despite the laudable aims of many of the Government’s policy statements in the past few years—the Green Paper Independence, Well-being and Choice, the White Paper Our Health, Our Care, Our Say, the rhetoric of support for early intervention and prevention—spending is in practice going towards the most dependent and frail. That is a shame when the noble Baroness’s own department has produced evidence, such as the economic case for preventive services for older people, which demonstrates clearly that such intervention is not wasteful. In fact it can add greatly not only to the lives of older people, but down the line it can also make savings in expenditure both for social care and the NHS. I must say that when the bigger part of the equation of health and social care, the NHS, is implementing drastic cuts in many boroughs, especially in London, it is easy to see that the first things to go are preventive services—what older people refer to as that bit of help, all the bits and pieces that help them to live their lives well, whatever conditions they may have.

I should like to hear more detail about third sector involvement. I welcome it, but it is not without its drawbacks. The development of social enterprise certainly encourages innovation, but it also downshifts risk from the statutory to the voluntary sector. I wonder whether we are not asking the impossible of small and medium-sized voluntary organisations to manage risks and deficits when the statutory sector, with its size and purchasing power, has not been able to manage the social care market. It is unclear how they will do that.

I welcome innovations such as individual budgets, but I wonder how others will manage a social care workforce when local authorities have been unable to do so. The Government have been full of initiatives for the care of older people—such as the New Deal for Communities and healthy living centres. The problem is that they have been short term; there have been too many of them; and they have been too disjointed and not joined up to healthcare. We believe that, rather than beefed-up overview and scrutiny committees, local authorities need the role and the time to ensure that some of those initiatives can be taken forward strategically and with an evidence base. We would like to support them to do that.

My Lords, I very much welcome this debate, as it gives me an opportunity to expand on an all too brief reference to social care that I made in my maiden speech a couple of weeks ago. It also enables me to say something about independent living for disabled people, which is the subject of the Bill tabled by the noble Lord, Lord Ashley, which returns to the House on 15 December. I very much regret that I will be unable to be present to support his Bill.

The Disability Rights Commission speaks of adult social care, especially for disabled people, as being in crisis. In a way, that is true, in that social services are largely geared to crisis management. The noble Lord, Lord Bruce-Lockhart, spoke of the crisis. To a large extent, only those whose needs are judged to be critical or substantial receive service. Most often, it is the needs of children, which hit the headlines, that are prioritised. There is nothing wrong with meeting the needs of children, but adults have needs which are just as pressing, especially in a society in which more and more of us can look forward to a life of old age and infirmity.

What should really constitute the blot on our social conscience is that adult social care is not widely seen as being in crisis. More and more people are eking out an existence in a condition of social isolation, deprivation and neglect, which is set to get worse unless something is done about it. There is not much evidence that anyone proposes to do anything very much about it. That is what I may call a chronic crisis: one that persists from year to year below the radar of social concern; below the level that attracts the “shock, horror” headlines—which is what it seems to take to promote action.

I feel increasingly like Sir Mike Jackson when I observe the disconnect that seems to exist between official diagnoses and professions of intent, which seem to inhabit some kind of bubble removed from reality, and what is happening on the ground. Let us take the White Paper, Our Health, Our Care, Our Say, published in January 2006. It placed great emphasis on prevention and providing greater choice and better access to community health and social care services for users. Launching the White Paper, Patricia Hewitt said:

“We focused a huge amount of effort and resources into reforming the NHS and social care through extra capacity in hospitals, more facilities and supporting more older people than ever before to live independently.

Today's White Paper moves us on to the next stage of our improvement and signals a major change in how health and social care will work together in the future”.

The Local Government Association reports that demand for social care is rising by 6 per cent every year. In the next three years alone, there will be more than 400,000 more older people, many of whom will require social care, but there will be no extra resources to deliver it.

In reality, the number of older people supported by social services has been shrinking from 528,500 in 1992 to 354,500 in 2005. Last month the LGA stated that, without additional funding, by 2009-10 up to 370,000 older people currently receiving free, low-level care could have it withdrawn completely. I am not quite sure how those two statistics, taken from different sources, stack up against each other, but what is clear is that there are likely to be major cuts in provision.

Since April 2003, every local council in England uses the national framework known as Fair Access to Care Services, according to which people's needs are to be assessed as critical, substantial, moderate or low. It was aimed to create greater consistency across the country in deciding whether people have services. However, since the ruling in the Gloucestershire judgment, which allowed local authorities to take resources into account when allocating services, FACS has failed in reducing the postcode lottery of service provision.

In March 2006, the finance committee of the Association of Directors of Social Services outlined the severe financial problems that many local authorities were facing and warned that only those people who fall into critical or substantial categories of need, as set out in the Fair Access to Care system, will receive services. Seventy per cent of local authorities have tightened their eligibility criteria. In the coming year, eight in 10 councils are set further to tighten their eligibility criteria.

That has a number of untoward consequences. One is that anyone not in the critical or substantial category has little chance of getting vital equipment that they need to function effectively in the community. If you have a mobility difficulty, you will be able to get a wheelchair, but those with a visual impairment will be lucky if they can get a white stick. It needs to be recognised that people with sight difficulties may be dependent on communication aids that are just as expensive as a wheelchair, such as a closed-circuit television or a computer.

In that connection, it is worth remarking that there are many inefficiencies in the equipment service. Major economies of scale could be achieved with a system of national purchasing or commissioning for local delivery, such as the RNID has recently achieved from the hearing aid service. The review of the equipment service recently set up by the Prime Minister is thus very welcome and it is to be hoped that it will prove to be a vehicle for getting rid of many of those inefficiencies.

Secondly, the system is largely geared to managing crisis rather than supporting people to live independently, with dignity and a good quality of life in the community. Thirdly, it is putting people at risk. The Commission for Social Care Inspection’s recent report, Time to Care, found instances where people’s safety and well-being have been compromised by inadequate support. According to the Audit Commission, in 1999, there were 190,000 A&E attendances as a result of falls by people with a visual impairment, which cost hospitals £270 million. Nearly half of those were as a direct result of visual impairment, at a cost of £130 million.

Fourthly, leaving people to fend for themselves until they reach crisis point is no doubt meant as a means of rationing resources but, in fact, it not only fails to meet their needs but is extremely wasteful. Much unnecessary bureaucracy is involved in multiple assessments. It would be a good deal more cost-effective if people were given the right kind of help—the kind of help that they want and the kind of help that they really need.

These points are well illustrated by a case cited by Sense, which works on behalf of deafblind people. It concerns an elderly deafblind lady, who was identified by her social services department as deaf and provided with an induction loop. However, the instructions were in small print that she could not read. She was also identified as blind, and a white cane was delivered, but she could not receive training to enable her to get around using it because the instructor could not communicate with her. She was then identified as socially isolated and referred to a day centre, where she could not communicate because of the noisy environment and the lack of communications skills of staff and other users of the centre. Finally, she was provided with home-care workers five days a week but, again, they could not communicate with her. The notable thing about the services offered to this lady is that they cost a considerable amount of money but gave exceptionally poor value. A service that would meet her needs more effectively, such as regular access to a trained one-to-one worker, would almost certainly be less expensive, and it would without doubt be more cost-effective.

What needs to happen? The noble Lord, Lord Bruce-Lockhart, has rightly reminded us that the way in which we treat the most vulnerable members of our society should be seen as a yardstick by which the moral health of that society should be judged. National standards and frameworks exist for many different groups, but not for people with specific disabilities. I declare an interest as chairman of the RNIB, which worked with Guide Dogs and the Association of Directors of Social Services to develop a new national service framework for blind and partially sighted people, called Progress in Sight. It would be a great help if standards such as these could be given official, even statutory, recognition by government, and I should be very interested to hear from the Minister whether she would be prepared to consider this.

Secondly, we need to give the Disabled Persons (Independent Living) Bill of the noble Lord, Lord Ashley, a fair wind as the best prospect for moving forward. This would place a duty on local authorities and NHS bodies to co-operate with each other and with key partners, such as Jobcentre Plus, to promote independent living and improve outcomes for disabled people. The DRC is calling on the Government to renew investment in independent living for disabled people of all ages to improve their life chances. One person in government recognises the need for such investment. At the Labour Party conference in September, the Chancellor said that the state of services to disabled and older people was one of this country’s greatest social policy failings. It is greatly to be regretted then that nothing was said in the Chancellor’s Pre-Budget Statement yesterday about making available the resources needed to remedy this situation.

My Lords, I thank my noble friend Lord Bruce-Lockhart for bringing this debate to us on a matter that is particularly interesting to me as, for most of this year, I have been one of the co-chairmen of the all-party groups that conducted a joint inquiry involving primary care and public health and social care. We took oral and written evidence from more than 35 groups, including the Association of Directors of Social Services, local government authorities, the British Association of Social Workers, and Sir Derek Wanless himself on the White Paper, Our Health, Our Care, Our Say. I understand that a meeting is planned with Ministers in the New Year, so what I am saying today will be influenced to a certain extent by it. Our publication will not be influenced by it, because we have already reached our conclusions, but we will have an opportunity to discuss it.

The conclusions are valuable and worth repeating here. First, the groups agree with the evidence presented by Sir Derek Wanless and others that current levels of funding are insufficient to meet present and predicted demographic pressures, in particular the growing numbers of the very old with high levels of disability. Secondly, the groups agree that a reconfiguration of existing provision and resources will be necessary to achieve the increase in preventive health and social care services envisaged in the White Paper. Thirdly, the groups note that the level of charges for domiciliary social care is very unpopular with service users and acts as a deterrent to using such services for those with income above the entitlement to free provision. This often leads to the earlier use of more expensive institutional care.

The groups believe that decisions must be taken. We strongly support the case for significantly increasing investment in prevention and community support services, and the evidence submitted to us suggests that this is what most people want. The groups believe that a range of measures will be needed, including advocacy, brokerage and other participation, choice and control strategies, to ensure a stronger voice for people using services, particularly those with complex needs requiring a range of services from different sources.

The groups acknowledge that both the NHS and social care depend heavily on the huge amounts of support provided by caring families and friends, without which the statutory services would be overwhelmed, and consider current investment in carer support to be inadequate. The groups recognise that in developing a health and social care strategy for the long term, the Government should fully engage patients and clients to change the culture from one of dependency. This will require changing the role of health professionals so that they accept the responsibility to provide health literacy, support self-care and self-management, and actively involve patients in treatment decisions.

The groups also note that it will be important to embrace a fully joined-up approach by primary care trusts and social care agencies and to acknowledge that PCTs’ commissioning decisions will be influenced by GPs’ plans under practice-based commissioning. Any resultant shift in spending should be informed by the needs of the population, and by evidence of the effectiveness and efficiency of preventive actions.

The groups recognise that most people of working age and older people with physical, sensory, intellectual and mental health problems require support from both the NHS and social care, and need more flexible and joined-up responses and help to negotiate an ever more complex system. I know from my experience a long time ago as a chairman of social services that there has always been this urge for the NHS to push as much cost as it can out of the health service and on to the social services. The social services are equally keen that as much as possible is funded by the NHS. It is time that that changed so that they work together to get the best value for money rather than worrying about which budget it is coming out of.

The all-party groups consider that closer co-ordination and integration of NHS, social care and wider local authority services will require better aligned priorities and more investment in infrastructure mechanisms and retraining, but that they should deliver increased service coverage and better value for money. The new nursing roles need to be clearly connected. There is a need for primary care health teams to be further developed or, as in some parts of the country, if necessary, reinstated.

I could make many more points. The report is to be published and, therefore, this will be available to all. It was quite an education for us to hear from people who work directly in these services all the time. However, we do not even need to hear that evidence. We could think just of our neighbours, friends, family or anyone we know. Everyone is aware of the important point made by the noble Baroness, Lady Barker; namely, it is the little bit of help that is very important in the long term.

My Lords, this is a fascinating debate, but I have to point out that if all speakers from here on use their full time, the time for the reply of my noble friend Lady Andrews will be cut by five minutes. I urge noble Lords to stop short, if possible, and, at any rate, not to overrun.

My Lords, I thank the noble Lord, Lord Bruce-Lockhart, for introducing this timely and relevant debate. I declare an interest as the chair of Age Concern Surrey. I want to talk particularly about the results of a survey that we undertook on the well-being of older men in Surrey. Surrey is similar to Kent and I recognise the general situation explained by the noble Lord, Lord Bruce-Lockhart. Our population is about 1 million, which, by 2020, is due to rise to 1.16 million. At present, 16 per cent of that population are aged over 65, which will increase within the next two decades to 21 per cent. As the noble Lord suggested, a disproportionate part of that change will be in the over-85 age group.

We also face the same problems concerning social services. Surrey has a relatively healthy and wealthy population. Therefore, funding allocations to the National Health Service and to local government are low. Equally, we have a very articulate and demanding population. It is very difficult to fund what is supposed to be a demand-led health service with the funding allocations that are made to that service. Therefore, we face, as do many other PCTs in the south-east, considerable overspend beyond what is allocated. Currently, the economies being made are cutting back on acute care. Noble Lords have already talked about the overlap between social services and the NHS. The earlier bed-blocking problem has been solved, in some senses, by social services picking up the tab. However, it is increasingly difficult for them to do that. In particular, local social service low-level care has been more or less totally withdrawn. The only care provided is for those who require extremely high levels of care.

There are huge problems. Age Concern Surrey has been running services to provide low-level and more personal care. It is difficult enough to find people to provide those services, but CSCI’s increased demands for training and for carers to have NVQ Level 2 have made it impossible for us to meet the overhead costs associated with running the services, so we have had to pull out.

The survey that I mentioned looked at lone older men. Although the number of widowers is likely to fall, the number of those who are divorced is increasing rapidly. As a result, about one in three of the population aged over 65 is single. Increasingly, that will include older men. There has been very little research into the involvement of older men in the community. Disproportionately, women have traditionally been the partners who form and maintain social networks, and acquire knowledge of support systems, such as the NHS and social services. The services are geared to this larger, more visible and more vocal population of older women. Men are less willing to ask for or accept help and less aware of what is available. The lack of social support networks means that many of them, without people realising, are extremely depressed by being left on their own.

What are the key conclusions? First, as has been mentioned already, retaining independence is extremely important. We need to be able to offer low-level care— domestic cleaning, shopping, washing and so forth—in such a way that individuals retain control over their own lives. Getting in early is also extremely important.

Secondly, social networks are vital. We need to involve older men in their 60s and 70s in social networks before they become unable to travel easily. They can themselves build networks for older people, and being involved in volunteering in this way can help a great deal. Transport is a key consideration, particularly for those who have to give up driving. It is very important that there is more sensitivity with regard to transport. Someone who was surveyed said:

“Dial a Ride will only take you where they want to go, not where I want to go”.

Thirdly, there needs to be sensitivity in offering help. Elderly gentlemen have to be coaxed to seek help and are easily discouraged from seeking further help. Information and advice services are easily available and in a user-friendly form, but there was a very strong plea for “no automatic telephone answering”. People did not want to be passed on from one bureau to another or to have to ring up one agency after another. One-stop shop help is extremely important. It is also important to be sensitive with the older generation when providing, for example, bathing or personal hygiene services. There are obvious sensitivities about all helpers being female and it is important to try to provide male helpers in such circumstances.

It was an interesting survey and I have touched on only some of the main conclusions to emerge from it. It is quite clear that the demand for help and services for this group will increase, not diminish, and the development of social networks is vital. This House provides a very good social network and, in many senses, those of us who are in the age group who will be looking to these services gain so much from it.

My Lords, I am grateful to the noble Lord, Lord Bruce-Lockhart, for initiating the debate because it enables me to share with the Minister a problem that has been growling in my belly for the past two years. I declare an interest as a trustee of a home for the care of old people. I do not expect the Minister to reply to the specifics of what I have to say but I think it illustrates a more general problem.

The home was created 100 years ago for the care of old, poor people. The people who come to us are aged mainly between 85 and 90. They are not the kind of people who can be looked after for five hours a day in their home. The home has provided a valuable service to the community for a century.

Representatives of the Care Commission visited the home two years ago—and here is the problem—looked round and said, “Thou shalt do this and that”, including, for example, increasing our staffing. This visit added £150,000 a year to our costs but the local authority has not been able to increase its payments to us. As a result, we lose £5,000 a year for every one of the 30 beds we provide for the needy, poorer people in our community. One public body demands—and if one does not respond one can be closed—and yet the other public body is unable to meet the bill.

Although the Government do not require single-room accommodation from bodies such as ours which have been providing care for such a long time, the Care Commission makes it absolutely clear that this is what it expects. However good our care may be, we can never get a better rating than “adequate” because we are not providing single-room accommodation. We would love to refurbish and reconstruct but, at the rates the local authority can afford to pay, that will not be possible unless we move from caring particularly for the poor towards looking after those who can afford to pay at rates of £200 or £300 a week more than we need if we are to care for the poor.

The local authority has its own financial problems and it is perfectly entitled, under Section 26 of the 1948 Act, to shop around and find rooms where it can, here and there, at marginal cost, in private sector nursing homes. But you cannot run a home on marginal cost when catering for the poor. You can do that only for a few beds.

My point is that we are all driven to short-termism. I do not see how the needs of poor 85 to 90 year-olds will be met in the long term if places such as ours cannot continue specifically concentrating on care for the poor, rather than moving over more towards a different market. I ask the Minister to look at this as an illustration of an issue that will not go away and will get worse. How can the Government reconcile having a public commission with the power to require while not providing the means of meeting those requirements? It just does not add up.

My Lords, I begin by congratulating my noble friend Lord Bruce-Lockhart on securing this enormously important debate. He spoke with his customary eloquence and authority, and we have had other good contributions. This serious issue is now impacting on every local authority in the country, and, in turn, not just on the elderly or disabled but on every user of local services. Before I begin my comments I must declare an interest as leader of Essex County Council. It is from this experience and in this capacity that I have first-hand knowledge of the seriousness of these problems. I will turn to the position within my own authority a little later.

It is not an exaggeration to say that the problem of adult social care is now the single largest challenge facing local government today. Ever-growing numbers of elderly people with cases of ever greater complexity, combined with a government grant that has failed to match that spent on key services, means that services for the elderly are teetering on the brink. The present situation is unsustainable. Knock-on effects are being felt.

It is clear that despite significant cost savings made by local government—even the Government recognise that efficiency savings in local government have been better than in their own services—all services are suffering, and resources are being diverted away from other services to fund the spending on elderly care. That problem is not confined to any one geographical area; nor is it dependent on the political party in control. It is faced by every local authority in the country.

One needs only to look at the letter published today in the Guardian to see the extent of the concern: 40 leaders of some of the largest local authorities in the country say that the present situation is not working. I hope and trust that the Government will take a moment to listen and, with any luck, will conclude that something is indeed going wrong. What we do not need from the Government are comments such as those we have seen in recent weeks dismissing the scale, size and seriousness of the problem. We were disappointed by that approach. It helps no one.

The reality is stark. Over two-thirds of local authorities provide services only to those at substantial or critical risk. Many authorities are having to consider whether eligibility thresholds will have to rise. To date, the vast majority of authorities have held off from raising those thresholds, but the position cannot last much longer. If this process of rationalising care were happening in the NHS there would be a public outcry, but, as the noble Baroness, Lady Barker, said, these tend to be Cinderella services and do not get the publicity they need.

This problem has arguably been long in gestation but it is now very much facing us in the open. Each strand has come together to put these services on the brink. Chief among them, as several noble Lords have said, is the growing number of over-85s requiring some kind of support. We welcome the advances in healthcare that have made ever-growing numbers of people live longer, but there is an ever-growing dependency on social care services. Side by side with the growing numbers is the complexity of diagnosed cases. Complexity of cases inevitably leads to much more expensive care packages. This is further compounded by the NHS moving towards short-term interventions. We have heard a lot about preventive work today. I agree that when the preventive work is cut back, the long term suffers.

The root cause of these problems stems from the financing of these services, and we must do something about that. In aggregate, councils with social services responsibilities set 2005-06 budgets 13 per cent above the notional requirement calculated by the Government. I cannot help but think that the Chancellor missed an opportunity yesterday in the Pre-Budget Report when he took £3 billion in taxation. As much as we all support extra spending on schools—I have spent a lot of my time in local government supporting education—we could have had some recognition of the support our elderly people need. It is about time that some money was diverted to that area.

As I said, I am leader of Essex County Council and I face these problems daily. We provide 25,000 care packages in Essex; adult social care currently accounts for 43 per cent of the county council’s net revenue budget. We are a big local authority, and our net budget is something like £1.2 billion. A tremendous amount of money is going on adult social care. Over the past decade, spending has risen by an average of 9.3 per cent a year. I repeat: this is unsustainable. We had a 2.7 per cent grant increase last year, 2.7 per cent this year and we will get the same amount next year. Local authorities are unable to maintain services with such an increase in grant settlement. Other services are being cut back dramatically to finance adult social care. In my county, the 85-plus population is growing at twice the rate that it does in other areas. We are a coastal county and, in common with other such places, a lot of people have moved there.

I know that the Minister cares about these things. She cannot deliver the money but the Chancellor can. I ask her to persuade her colleagues so that local government can get extra respite to finance dealing with some of these problems.

My Lords, I add my congratulations to the noble Lord, Lord Bruce-Lockhart, on initiating this very important debate. I greatly appreciate the focus on older people.

As the noble Lord, Lord Hanningfield, mentioned, today’s letter in the Guardian has reinforced the message that there is a real crisis in the funding of social care. Only those needing the most intensive care in the community are receiving it, so the lower levels of care mentioned by the noble Baronesses, Lady Barker and Lady Sharp, are inevitably not being received. However, these can make all the difference to the quality of life and physical and mental health of many frail older people in the community, avoiding higher costs of residential care later.

We know that the fees paid by local authorities to residential care homes are too low. The message in today’s Guardian reinforced that. Many care homes cannot deliver the required standard of care for that level of fee so the self-funders, as my noble friend Lord Dearing has said, end up paying extra to meet the costs. The 2004 OFT study found that 33 per cent of local authority-funded residents had a third party making up the difference. The actual amount being paid in top-ups by families and the voluntary sector is not known, but we know that such people are paying more for the same level of care than local authority-funded residents. We are talking about a cross-subsidy to the state. The amount varies across the country. In the south-east, where costs are highest, additional costs can come to more than £150 a week. The OFT research showed that one care home in five charges self-funders more than local authority-funded residents for similar accommodation and care. This is an iniquitous form of taxation being levied on a vulnerable group of people. When a care home is sold to another owner, or the local authority’s contract with that home ends, there are often substantial new costs. If the person cannot pay, they will probably have to leave. Even when an elderly person has sold their home, they do not know how long the capital will last. They are faced with huge worries and extreme ill health often results.

If the Government are serious about their dignity agenda, they must take on board the fact that this chaotic, confusing and inequitable situation is profoundly undignified for many older people. Age Concern estimates that it would cost the Government £230 million a year to address these basic inequities, and doing so must be a necessary first step before radical, longer-term reform is undertaken. The need for it has been recognised by the Secretary of State, who mentioned the acute necessity of funding reform in her speech to the ADSS last October. We need a wide public debate about this.

For a long time now, the Government have declared their commitment to devolving functions to a more local level. If this is to succeed, a much more fundamental problem needs to be resolved. For as long as I can remember, local government has understandably called for more and more central funding to solve its problems, but, at the same time, it bemoans the fact that the Government control more of their work. It is a kind of logjam. Perhaps the direct arrangements which are in place in some cases in Scotland could offer an idea of one way forward, but, in an age when dealing with almost every local function and problem requires astronomical sums of money, this problem must be sorted out in the longer term. We need to forge a new, workable and more appropriate compact between central and local government if our progress in solving these problems is to be real and long-term. For the sake of our elderly population and other vulnerable groups, this is crucial.

My Lords, despite what my noble friend Lord Bassam said earlier, the position now is that if all remaining speakers take their full time, the Minister’s reply will be cut short by six minutes. I ask noble Lords to be mindful of that.

My Lords, I, too, thank the noble Lord, Lord Bruce-Lockhart, for bringing this incredibly important debate to the House. I declare an interest as a provider of social and personal care. During the past few days, I have spoken to other providers and service users.

Social care has changed dramatically during the past few years. We expect to deliver more of our care packages at home. The number of people with mental health problems, Alzheimer’s disease and dementia is on the increase. People who in the past might have been cared for in a care home are now expected to be managed at home. We as providers have found that packages have become shorter. Less time is available for care to be provided, yet the demands on that time have increased. We hope that the Government will ensure that, when care packages are delivered within the confines of the home, proper funding is available for proper care to be given. Care workers are now expected to perform roles which were previously carried out by nurses. If adequate training is not put in place, service users will receive a poor quality of care while demands increase. I therefore urge the Minister to take this matter away for consideration. If we are going to support people within our communities, it is highly important that we give them the quality of care that they deserve.

I have a few questions for the Minister. First, we have an ageing population, which is rapidly increasing. A lot of emphasis is put on increasing budgets for the NHS, but we still see very little movement from the Government on—or even a wish to look at—social service funding and the funding of care for the elderly and those suffering from disability, dementia, Alzheimer’s and all the other illnesses that come on rapidly with age.

Secondly, if care workers are increasingly expected to carry out more nurse-based care, perhaps the Minister could look at how we fund the training. At the moment the burden rests wholly on the providers. It is hit and miss whether we get the consistency in training that all carers and care workers need if they are to carry out the care properly and provide the quality of care that care packages need.

Thirdly, there is a huge demand on respite care, but we seem to overlook that area all the time. The families who live with service users, who put huge demands on them, need to be able to feel that they have adequate facility for respite care. But on the whole, on the basis of talking to families and other providers, that seems to be another area that is completely overlooked by the Government.

Finally, I urge that we as a society do not airbrush out those vulnerable people who cannot speak up for themselves. At the moment the debate is heavily focused on our funding of the NHS. That is right, but we must not airbrush out those people who cannot stand up and vocalise their concerns.

My Lords, I congratulate the noble Lord, Lord Bruce-Lockhart, on a timely debate and on illuminating it with a speech of authority and knowledge. I declare an interest as a trustee of a residential home for women with learning disabilities in Hampshire and as an honorary vice-president of MCCH Society Ltd, which provides social care for those with a disability in Kent, in the south-east. I am also the parent of someone with learning disabilities and, accordingly, most of my remarks today will be on those aspects of the debate. Because of those circumstances I am more aware than most of the crisis—I do not think that that is too emotive a word—which affects such homes today, as well as the providers of sheltered housing and day centres.

My own council, Hampshire, has an excellent record as a caring and competent authority in these matters. However, with the doubtful distinction of catering for one of the largest populations of over-60s in the UK, it also finds itself saddled with the second lowest social care grant. How can that be? Perhaps the Minister can tell the House on what basis those grants are made. With the population of over-60s with learning disabilities forecast to rise by 36 per cent in the next 20 years, the future for anyone in that category looks bleak indeed.

Councils are trying to cope as best they can. As Mencap pointed out, eligibility criteria are being hastily revised and the LGA has estimated that 80 per cent of local authorities are planning to tighten existing arrangements, with 70 per cent providing only for those judged to have critical or substantial need. It ought to go without saying that any such cuts should not be unilateral but should involve councillors, officers and the people affected, but it seems that in some instances that has shamefully not been the case.

At times of stress such as this, the lack of joined-up governance tends to become more obvious and more damaging to the innocent. As a result of thinking in recent years it has become accepted that residential homes for those with learning difficulties should never have more than 10 occupants and ideally nearer five. Whenever possible, sheltered accommodation should be provided for those at least nominally able to lead an independent life. All providers subscribe to that utopian objective, but how do we get there and, more importantly, how do we get there at a time of considerable financial restraint and no spare cash?

I give an example of the current dilemma. The home with which I am associated has 16 ladies in it, of varying ages, living in what is by any standards a comfortable home standing in its own grounds in a village where it is very much part of the community. These ladies have for the most part lived contentedly together for many years. But, of course, the home is the wrong size according to current received thinking, a fact which we, the trustees, freely acknowledge and intend to put right at the earliest opportunity. I should add that we are a non-profit-making charity.

Being the wrong size means that we get no referrals from social services to fill any vacancies which may occur because they are aware of the formula which CSCI, the social care inspectorate, is charged with implementing. Without the referrals our income is reduced until, finally, we go bust. Sixteen ladies then have to be removed from what has until now been their home, perhaps parted from each other and then distributed to any place that can be found within the system, no doubt at considerable extra cost to the wretched council, which is already trying to deal with reduced funding. All for want of—as they used to say—in this case just a smidgen of common sense on everyone’s part. I know that we are now said to live in a throwaway society, but surely this is taking that concept a step too far.

More could surely be done to involve the voluntary sector in working with the elderly and with those with learning difficulties. Many well meaning helpers are nowadays put off from giving a hand by bureaucracy of various kinds, whether it involves the checking of personal records or the complexity of regulations. That is certainly an urgent and realisable option. Most important of all, these conditions now cry out for a return to the concept of partnership and a pooling of resources.

The statutory service providers must be required by government to work together for the common good. That should not just be a pious hope. The NHS should lead in commissioning on mental health matters, and social services should lead in matters relating to learning disability. That this can be done and positive benefits achieved is exemplified in a new development in Bexley where 22 beds, provided by MCCH for senior citizens suffering from dementia, are next to a Kent community housing trust facility for 120 elderly people. That sort of initiative is the way forward in the face of increasing demands and fewer resources. Use of land, joint building programmes and imaginative and innovative solutions to problems are what the statutory providers should be constantly looking for, not as exceptional, once-in-a-blue-moon experiments, but as normal operational routines.

Attention tends to be focused on the problems and failures of the NHS. We have debated that today. I believe that this afternoon we should turn a sympathetic spotlight on the old, the infirm and those with learning difficulties. They arguably deserve even more of our sympathy and support. Whether they get it in the difficult years that lie ahead is a measure of the integrity of this country.

My Lords, I am grateful for the opportunity to support my noble friend Lord Bruce-Lockhart. As the debate has shown, this is a discussion about the inadequacy of resources to meet the needs of contemporary adult social care. I shall talk about older people’s care but I recognise that adult social care has a wider scope, as the noble Viscount, Lord Tenby, reminded us.

I begin by declaring two interests. First, for the past 18 years until recently I was chairman of the charity that runs Holbeach Hospital. I remain a trustee of a project which is an exemplar of community action, which since its closure by the health authority has doubled capacity with nine doctor beds, outpatient facilities purchased by the PCT and 37 high and higher dependency care home beds. There is more to say on this but time is short. Noble Lords will appreciate that I have seen how funding problems in the health service and social services can impact on providers. How I identify with the comments of the noble Lord, Lord Dearing. Secondly, I am married to a Lincolnshire county councillor of long standing, so from time to time I am subject to intense briefing.

We have heard of changing demographics. In Lincolnshire the population aged over 65 is growing at between 4.5 to 5 per cent per annum. This increase alone is costing £6 million per year just to maintain the status quo. To improve services to desired levels would take £11 million per annum. Some of this growth is coming from people retiring to live in the county. They are welcome; they strengthen our communities, but in the main they are not rich, and most of them quite rightly will need support and care in their older age.

Care services are also vulnerable to wage cost inflation. They are labour-intensive, often one-to-one, and more often than not are provided by lower waged staff who have rightly benefited from higher than inflation increases in the national minimum wage. We create costs too by the bureaucracy that is part of the care culture of our time. From CRB clearances to inspections, those costs take resources away from front-line provision. Even a short inspection can cost a local authority upwards of £300,000. That is enough to provide 25,000 home care hours, or full-time residential care for 20 people a year.

Financial pressures usually lead to short-term cost savings, which are usually very inefficient, including skilled-staff redundancy, reorganisation and reconstructions. All of it is taken from providing care. Underfunding can lead to a withdrawal of service in different ways, and we have heard examples of those. We know of the post that is not filled in too much of a hurry, the cover that is not found for short or long-term absentees, and the overt or covert failure to encourage take-up. Worst of all, it encourages voices that say, “Don’t shout about it too much; they will all want it”. No, my Lords, we must shout about it. It is the mark of a civilised society that it cares for its older citizens in a proper way.

My Lords, I thank the noble Lord, Lord Bruce-Lockhart, for bringing the debate forward today and for giving us the opportunity to discuss these issues in what has been a remarkable set of speeches. They have been remarkable for the breadth of experience that lies behind them, and for the consensus on the scale and size of the problem and its root causes. I shall use my time to concentrate on the situation that is faced by local authorities. As other noble Lords have spoken so eloquently about the plight of individuals in need, there is a risk that my remarks might sound rather technical, but I assure noble Lords that in fact all my sympathies lie with those who are not receiving the care that they should.

Local authorities have been facing a stringent financial situation for some years now. I know that the Minister will argue that the 40 per cent increase in funding to local government from central government over the past 10 years has been generous. I know that the Local Government Association will argue that because most of that money has been ring-fenced for school spending, the actual increase available to local councils has been closer to 14 per cent. It says something that we cannot reach consensus on the starting point for the debate.

There is no doubt that in the past decade councils have faced a growing demand for their services right across the piece. For example, the number of people aged 85 and over has increased by 6 per cent a year. Their needs become more complex; 25 per cent of them will develop dementia and will require a high level of care. We have heard a lot about that, particularly from the noble Lord, Lord Dearing, with his experience. As NHS budgets are squeezed, almost half of local councils are reporting a reduction in PCT support for joint projects. An LGA survey carried out in June shows that 70 per cent of local councils have been adversely affected by actions such as bed reductions and community hospital closures.

It is not a one-way street. Local authority cuts, especially to carers, can often result in pressures on the NHS. At a time when we have never needed co-operation between the NHS and local authorities more, the danger is that they will retrench into positions that simply protect their own budgets, rather than thinking about value for money and service to the people who need it. Central government has placed new burdens on local councils of new legislation and inspection and target regimes.

Local authorities have absorbed those costs and pressures, just as they have had to absorb costs that have increased ahead of inflation in other areas such as waste disposal, road maintenance and energy. We know that unit costs in privately run children’s homes have increased by 45 per cent, costs of social care contracts have increased as the impacts of minimum wage compliance have been felt and the demands of CSCI have increased costs, too. As the noble Baroness, Lady Greengross, and the noble Lord, Lord Dearing, put it so elegantly, even so, given the pressures on local authorities to pay more, they are still not paying enough to manage care homes properly. The difference is being picked up by the voluntary sector and by the families.

Councils are currently spending on social services some £l.8 billion above the amount allocated to them by central government. That money can be met in one of only two ways: either by increasing the council tax or by making cuts in other services. The difficulty for local authority leaders—and I know from experience what this is like—is that social services, after education, has by far the largest pot of money. One can make huge cuts in other areas of service delivery, but they make only a small difference compared with the social services budget. The noble Lord, Lord Hanningfield, mentioned that 43 per cent of the Essex budget is spent on social services, so there is very little scope for local authorities. They cannot keep increasing council tax, nor can they keep cutting other services to deal with demands in social services.

Changes to the way in which government grant is assessed can have a significant effect on individual councils, even where the overall effect is neutral. For example, Luton council tells me that it lost £5.9 million through the operation of the Government’s damping mechanism. Reductions in funding through the Supporting People programme have been reported by Luton as £170,000 and by Somerset as some £2 million. In Bristol the figure is some £3 million.

According to the Commission for Social Care Inspection, increased demand has already led to,

“a gradual reduction in the numbers of older people receiving state funded home care”,


“the tight targeting of statutory support towards those with critical levels of need”.

Wanless made similar comments and said,

“there is evidence of significant unmet need”.

Speaker after speaker in today’s debate has referred to this erosion of low-level care, which makes all the difference to the quality of people’s lives and ultimately to their ability to stay in their own homes for longer. The contribution of the noble Lord, Lord Low, was especially interesting, as he emphasised how changes in eligibility criteria, year on year, can affect particular groups in a special way—he mentioned the visually impaired.

If one believes everything that one reads in local newspapers, one would think that this is all because local councils are simply inefficient. There is no evidence to suggest that. Local government has a strong record on financial management and service improvement, as was judged by the plethora of inspecting bodies that the Government have thrown at them in recent years. The Audit Commission performance assessment shows that 68 per cent of councils achieve 3 or 4 stars—out-performing the NHS by a long way. The Commission for Social Care Inspection only last week announced that local authorities have improved for the fourth year running. There are now no zero-rated authorities and 78 per cent are in the 2 and 3-star categories. The noble Baroness, Lady Pitkeathley, paid tribute to the role of local authorities over the years in the delivery of social care.

Local government has achieved its Gershon efficiency target of 2.5 per cent savings per annum—a year ahead of target and faster than central government departments. I have no doubt that local government has been and will continue to be capable of rising to challenges, but it cannot keep doing that unless there is a complete change in the strategic framework to one that genuinely reflects the needs of people and, more importantly, how it should be funded.

On current trends, by 2009-10 local authorities will no longer be able to provide support and care, other than to those in critical need. We currently provide home care to 370,000 people. That figure is low by international comparisons and we should not contemplate allowing it to drop further. Demand for help from those with learning disabilities is increasing. Somerset has identified the need for 35 new places by 2010. That may not sound like very many, but the cost to that authority will be more than £1 million a year. The total population in England is expected to rise by 11 per cent over the next 30 years, with the largest growth in the over-85 age group. Stockport council has told me that it provides support to one in two people aged 85 and over in its area.

We need to maintain a committed workforce to achieve our aims. The objective of managing costs cannot be entirely at the expense of a high-quality workforce. The noble Baroness, Lady Verma, made that point very well. Recruitment and retention is already a major issue in social care, and vacancy rates are high.

The 2007 Comprehensive Spending Review provides a real opportunity to consider how we should meet the needs of the elderly and those with disabilities. It should not be a matter of how little care we can possibly get away with; we should be using as a benchmark a level of care to which we ourselves would aspire when the time comes.

The Government now have to make a serious choice about matching their vision for social care with the means available to fund it. The burden cannot be surreptitiously pushed on to council tax payers, as it has been in recent years. On these Benches, we hope that when the Lyons review eventually comes out, it will have something to say on this matter.

The noble Baroness, Lady Greengross, had it absolutely right when she said that central and local relationships are at the heart of this issue. Both local and central government have a vision of improved public services which offer a better quality of life for citizens. Both can play their part but there must be a mature debate and agreement on how we move forward. The annual game of claim and counterclaim between both sides, while people see their local services cut, helps no one.

My Lords, I, too, congratulate my noble friend Lord Bruce-Lockhart on obtaining this debate and on proposing it so cogently. I declare an interest both as a chairman of an acute hospital and as a member of a London local authority.

The noble Lord’s excellent speech has been followed by those from other very well informed speakers, from whom there has been an unusual degree of unanimity. They have all demonstrated the problems of lack of resources or lack of continuity between various authorities.

The debate has demonstrated the difference between rhetoric and practical application. I want to touch a little on the National Health Service. I know that it was the subject of the previous debate but it is relevant to what we are talking about here. There have been policies for at least six years to reduce the amount of time that people spend in hospital and to provide both medical and social care in the community so that people have a choice in the way that care is provided, and by whom, and so that they have freedom to fund their requirements in their own way. But that has been in the complete absence of a coherent policy for funding the major “turn” in the structures of care. There are aspirations, of course, but these are continually thwarted by crises in budgets and funding. The policy needs both local authorities and the National Health Service, in the form of the primary care trusts, to work together to provide the funding and expertise. However, because of increasing cost-pressures and deficits within the health service, in particular, there is a black hole in the amount of money available to support it.

My noble friend Lord Bruce-Lockhart touched on the subject of that black hole, and other noble Lords mentioned it too. It is amounting to about £1.8 billion this year. Seven out of 10 local authorities have been hit by reductions in funding not only from central funds but also in the form of funding that they were expecting from primary care trusts. That is hampering the implementation of the policy of greatly extending local authorities’ responsibility to work closely with the National Health Service to bring down the number of people in expensive hospital beds.

It is no longer the position that even patients—even if they have had intensive medical treatment——cannot return to their homes provided that there is a well considered and planned discharge programme, with proper and adequate professional care involving the services of both the primary care trust and the local authority.

The implementation of this policy is starting to bring about a reduction in the number of beds in hospitals, albeit that the practicality of social care in the community is not one that is widely or well modelled across the country. This is a major change in the structuring of care, needing all the right professionals in place and sufficient of them—this has been touched on by other speakers—to manage a full range of care, from intensive long-term care to a more short-term involvement.

As yet there is not a system that is universally available, nor are the requirements, or costs fully understood. What is clear is the need for a close working relationship between local authorities and the health service so that there is a seamless responsibility between them. The absence of reliable funding to enable this to be planned and implemented widely is reducing the choice that should be available to patients on discharge.

Many noble Lords have touched today on the care of the elderly, and the respectful approach to their care has been high on everyone’s agenda since, particularly, the publication of the National Service Framework for Older People in 2001. I am chairman of the national service framework in my hospital.

More than 65 per cent of patients in hospital at any one time are over the age of 70. At any one time, 1.5 million of the most vulnerable people in society rely on social workers and support staff for help. An estimated 1.23 million people who received help and support from social services in 2004-05 were living at home and were over 65 years of age. That is a significant proportion of the population. If they need and qualify for help, there is a vast amount of work for both the local authorities and the health service to undertake. It is essential that those who require help with day-to-day living are left with choice and flexibility in how that care is provided, and a reassurance that they can rely on it. But that, as my noble friend has said, will depend on the budgets available to sustain it.

In an era when more and more funding seems to bring blacker and blacker holes, we have to face up to the fact that social care in the community and looking after people in their own homes, which is now their overwhelming preference, is not a cheaper option than residential or institutional care. While it is much more desirable, it is in many cases more expensive because it is individualised and personal. This is a road on which we are embarked, and which rightly will continue. The NHS is reducing the amount of nursing accommodation in favour of more home care, and that home care is being transferred to the local authorities. The number of residential homes provided by local authorities is being reduced in favour of home care, supported housing and extra-care sheltered accommodation. People who can, are encouraged to make their own arrangements and are helped by the still limited scheme of direct payments, which enables them to buy their own care.

There are failings, which have been amply demonstrated by the noble Lord, Lord Dearing, and the noble Viscount, Lord Tenby, in describing what is plain to us now. There is a divergence and dichotomy in the bureaucracy over how care homes should be and the practicalities. More are shutting now because of bureaucracy than because of the practicalities of ensuring that people can stay living in the homes where they wish to do so.

The noble Baroness, Lady Verma, also gave a very clear indication of what happens for packages at home. We need to give people in their homes the care that they need, which is not cheap. We also need to be sure that there is respite care. Many noble Lords touched on the benefit of carers and the amount of time that they provide for free in looking after people in their homes. They need to have respite care from time to time.

There is so much change but, when in dire straits with funding, both the National Heath Service and local authorities resort to waiting lists or tightening of eligibility: rationing care, as we have heard. Many people who need their services do not necessarily get them, nor do they get what they want when they want it.

Finally, I was talking to a social worker just the other day who was about to discharge an elderly patient from hospital to supported care at home. I asked her what that meant, and she said “Oh, she will be visited four times a day”. I asked whether that included the night-time. “Oh no,” she said. Somebody was being discharged home to be looked after and fed occasionally during the day, with nobody there at night. I did not ask if there was a carer there at night, but I am not sure it would have mattered. That was the package she was going to get.

As all noble Lords have said, choice and independence lie at the heart of what we all profess to believe. We are not delivering them. My noble friend Lord Bruce-Lockhart has today introduced an extremely important subject. All speakers have demonstrated the black holes which need to be filled if the Government’s policy of social care in the community, looking after those who need it, is going to mean something.

My Lords, I join all noble Lords who have congratulated the noble Lord, Lord Bruce-Lockhart, on such a timely and excellent debate. Not only does he bring his own authority and experience, but he has enabled noble Lords around the House to talk with great authority from experience of local authorities, bringing a wealth of insight and illumination to some of the situations on the ground.

In many respects, I am happy to join the consensus he raised, bringing others in your Lordships’ House with him, about the scale and seriousness of the challenge and the reasons for and dimensions of the pressures of demographic change. I take issue with him and some other noble Lords, however, on his allegations of the absence of funding, failure and the idea that the Government somehow lack a sense of urgency. I shall try to address those.

It is a pleasure to be at the Dispatch Box. Speaking for the Department for Communities and Local Government gives me an opportunity to represent the Government speaking with a single voice on social care, work and pensions, which many people want to hear. I hope that that is a good start to a debate which affects each of us and covers the whole range of what government is for. Those who depend on social care need to know that. In the light of the pressures identified by noble Lords, they also need to know, as the noble Baroness, Lady Scott, said, that there is a mature debate: we are looking at the same pressures in the same ways, using the same language. The most important thing is the fact that we have been working closely—nobody knows this better than the noble Lord—with the Local Government Association and the Association of Directors of Social Services in a working group since the beginning of 2006, which has informed the debate. We welcome that collaboration and are committed to working throughout the CSR 2007 process—the opportunity that the noble Baroness, Lady Scott, indicated—to ensure that they are engaged in all stages of the process. That way, we can identify in specific ways the pressures which have been identified this afternoon, as well as considering how they can best be mitigated. From what noble Lords say, we are approaching diagnosis of and strategy for problems in exactly the same way.

The LGA is engaged in CSR work schemes across government. It is too early to predict the outcome of the process; we know that the next spending review will be tight, so it is important to be clear and frank about that. That partnership means a lot to us. For example, local authorities have benefited from the grant settlements we have been able to provide for councils this year and the next, with an extra £800 million above existing spending plans.

The pressures have been extraordinarily well described in a variety of ways in the contributions made by the noble Lord, Lord Low, the noble Lord, Lord Dearing, who spoke about care homes, and by the noble Baroness, Lady Sharp, who drew attention to a group that is often overlooked because it is relatively invisible and new to our conscience. The noble Viscount, Lord Tenby, drew attention to the increasing number of young adults with complex disabilities and the fact that they are living longer, which puts great pressure on the system. As the noble Baroness, Lady Verma, said, we have a responsibility to provide services that are not merely appropriate but of the quality that we would want for ourselves and our relations.

There is no difference between us. We know the pressures that local authorities are under. The Secretary of State for Health recently told the ADSS that she recognised that this is a tough time for directors of social services and that many of them feel that the Government are asking them to do more when they are running to stand still. Yet every example that noble Lords offered this House is an example of real experience. I could offer some excellent examples, as we all could. Nevertheless, we are talking about the way the vulnerable in our society need the social services that we offer. We are aware of the scale of the challenge. I shall not go over the statistics because they have been well described and they are bound to increase, given an ageing population.

The consensus extends to the Wanless report. I shall say a word about timescales. We are dealing with the challenge of three timescales: the immediate, the sort of things we have been talking about this afternoon; the interim, in relation to CSR 2007; and the strategic framework referred to by the noble Baronesses, Lady Scott and Lady Hanham. That needs to be a robust strategic framework with an understanding of future needs, and that is what we asked Derek Wanless to produce. We have not yet addressed it because we are working with him on the interim and the long-term, but we will. The good news is that the challenge of providing for an ageing population is relatively predictable as we move towards more stable financial frameworks with multi-year settlements and local and central government working together.

The noble Lord, Lord Low, suggested that the Chancellor has not recognised that there is a problem. Yesterday, in the Pre-Budget Report, the Chancellor referred to the sharp rise in the number of old people that is expected in coming years. Sir Derek Wanless and the Joseph Rowntree Foundation are feeding in to the assessment that is going into CSR 2007. We want to offer progressive universalism, but we also want independence, dignity, well-being, personal control and affordability in the future system. We have also flagged up some new ways of working. They are set out in Our health, our care, our say, in the National Framework for Older People and in Improving the Life Chances of Disabled People and the messages are the same.

I have to respond to the challenge that the Government have not acted by giving some statistics and dealing with some statements that were made. The investment that we have brought forward has seen a total government grant for revenue spending for local authorities of £65.8 billion, which is an increase of 39 per cent above the rate of inflation. Over each of the past 10 years, we have had a grant increase above the rate of inflation. Last week, I was able to confirm the increased investment in local services that we announced as part of the first stable and truly predictable settlement for local government. That settlement was closely informed by what local authorities said they wanted. However, I have to take issue, in the nicest possible way, I hope, with the statement that somehow the increase outside spending on education has been only 14 per cent. There are several problems with that figure. It is simply not possible to compare like with like because government funding for education was not hypothecated in 1997 but now is. It is extremely difficult to disentangle funding streams. Secondly, the 14 per cent figure excludes specific grants, which are grants given to local authorities for specific purposes. In the case of social care, that provides a distorted picture because £14.6 billion has been given in specific grants for social services since 1999-2000. So it is not right to say that the increase in local government funding, excluding education and specific grants, has been 14 per cent in real terms since 1997.

We are now consulting on formula funding. On top of the fact that, as I said in the Statement last week, we have funded for these new burdens separately, local authorities will benefit from government grants of £1.6 billion for specific initiatives in adult social services in 2007-08. That will aid budgets, as most are not ring-fenced and therefore decisions can be made. They go alongside, as the previous debate in the House rehearsed, massive spending in the National Health Service. It is significant additional provision, which has attempted, by best evidence and working in partnership, to meet and identify the pressures within the system. It has led, for example, to the fact that, since 1999, local authorities have doubled the number of intermediate care beds, which helps people avoid hospitalisation. I do not put these arguments to diminish anything that has been said about situations in local authorities or those in the personal examples, but it is only fair that we recognise the evidence and the effort that has gone into funding, which is a major challenge in this country.

The other main argument made this afternoon—that there is real pressure on local authorities just to fund substantial and critical care—is well documented. We know that local authorities have to make difficult choices. CSCI has recently reported that the majority of councils are setting the threshold for care-managed services as substantial. That does not mean that the system is about to collapse. It does not mean that it is in chaos. Half of councils are still supporting the threshold of moderate means.

People are receiving the essential low-level services which make the difference between keeping them in the community in safety and not in hospital—for example, the kind of situation when a person has an unnecessary fall. I absolutely agree with every noble Lord who has commended local authorities on how they have responded and on the massive improvements in the system. We have to see the changes in the context that CSCI has also said that social care services for adults have improved for the fourth successive year. What a credit that is to local authorities. Three-quarters of councils have two or more stars and have exceeded their efficiency targets. However, the argument has been that however much extra funding there is, however many efficiencies are made and however efficient local authorities are being, that is still not enough and there is a great deal more to be done.

It has been suggested that somehow health and social services are not only not joined up but are in opposition. Nothing could be further from the truth. The delayed discharges Bill was able to bring people into the community, releasing health service beds for people who were in more critical need of them. We have seen a 5 per cent shift of resources from secondary to primary care, but the Secretary of State for Health has also acknowledged that in some places social services are having to pick up the pieces as the NHS withdraws and vice versa. It is not good enough. We are not going to defend that. Social care and healthcare are both sides of the same coin. We do not want this to be a game of pass the parcel. That is why I want to talk about how we are addressing and going forward with local authority partnerships.

A great deal has been said about care homes. The noble Baroness, Lady Greengross, and the noble Lords, Lord Low and Lord Dearing, spoke about this issue. These are very specific and special situations. I cannot answer the specific instances, but we should look at the range and choice in the quality of services that we want to offer with care homes.

I turn to the argument about prevention and independence. At the heart of everything we have been trying to do—noble Lords have recognised this—is this move towards prevention and keeping people out of care-managed services and providing appropriate support. We know that the NSF for Older People set a target of improving the quality of life of older people by ensuring that 30 per cent of people receiving social services did so from home. That target has been met two years ahead of schedule.

Many of those services and prevention have been mediated through our 6 million carers. I am surprised that it is only a hundred years for which my noble friend has been working for the Carers’ Association. She has done a magnificent job. She and the noble Baroness, Lady Verma, will want to know that the department is already working hard with carers’ organisations to update the 1999 document so as, for the first time, to put a real priority on carers—for example, to develop guidance on best practice in the provision of emergency respite care. It is crucial for them to be able to predict when they can get away. We are very serious about ensuring that people have the respite that they need.

On the commissioning argument raised by the noble Baroness, Lady Barker, and my noble friend Lady Pitkeathley, yes: in the third sector review, we are looking hard at how we can introduce more stability to the voluntary and community sector, precisely so that, through our three-year grant-funding programme, it can provide a much more predictable and stronger role.

Independence and choice? Yes. There are developments such as extra-care housing. We now have 3,000 extra-care units providing 24-hour support. The point about independence and how we will deliver services better is that we need to know more about how to deliver it. That is the purpose of the partnerships for older people project—how to pilot it so that we get the best not just for the elderly but for people such as those about whom the noble Viscount, Lord Tenby, and the noble Lord, Lord Low, were talking: people who need consistency of care. They need the person beside them in the community daily, when they want them, whether it is night or day, rather than a procession of different carers and options. That is the purpose of the project, and that is the model for independence that we are trying to work through.

That leads me to the great pressures, to which we must respond, for joint commissioning. When you have an individual budget and model for a person, you must have joint commissioning to bring the services together. We have seen an explosion of partnership arrangements: £3.25 billion of core resources have been used in recent years. The shape of the future is independent budgets for people.

I turn to the wider strategy. There is a changing landscape. Perhaps the greatest change will come from the new settlement between central and local government and the community that will be introduced via the White Paper on local government. I could not agree more with what the noble Baroness, Lady Scott, said about the implications of moving from centralised targets to local objectives. The White Paper will help everything that we have discussed in specific ways. It provides the framework for more visible leadership on health and well-being in cross-cutting issues. There will be a lead member on local authorities who must play a leading role in health and well-being partnerships. Local authorities and the NHS must work towards a coherent set of priorities and targets, rather than pulling in different directions. It will strengthen the commitment of other partners by placing a duty on the health service to co-operate with local authorities through LAAs, which will be statutory. Those strategic frameworks will make the difference. Of course, that will come alongside the Lyons review and the long-term funding horizons.

A great deal is happening in this area. I am conscious that I have not referred to all noble Lords who spoke, let alone answered their many questions—for example, the cases raised by the noble Lord, Lord Hanningfield, in Essex, the noble Lord, Lord Taylor, in Lincolnshire, and the noble Baroness, Lady Gardner of Parkes, who introduced the perspective of the all-party group. It has been an extremely well informed debate, and I look forward to reading it.

In conclusion, I believe we have delivered much of what we could have been expected to deliver in the funding and organisation of social care for adults in this country. We have also placed a new emphasis on dignity for older people, on the need to develop advocacy and independence and on the need to enable them to make the proper choices for themselves, whether that is residential care, extra-care housing, intermediate care, or care in the community on which they can rely.

The debate has been absolutely excellent. I hope that it has reassured noble Lords that our partnership with local government is strong and frank and that it is not only for the short term but will certainly see us through the Wanless processes as we meet those unprecedented challenges. I have no difficulty in saying in response to the letter in the Guardian today that we will work with local government to find a viable and lasting solution.

My Lords, I am grateful to the Minister for her reply. I very much agree with what she said. It has been a privilege for me to be part of a debate that has had so many valuable, experienced and heartfelt contributions. I beg leave to withdraw the Motion for Papers.

Motion for Papers, by leave, withdrawn.