Second Reading (Continued)
My Lords, I was a little uncomplimentary about this Bill in the Queen’s Speech debate on 26 November. The more I discover about it, the less I like it, as Members of this House will know from the letter that my noble friend Lord Lipsey and I circulated and from my Motion on the Order Paper. I shall be blunt. This is a seriously flawed Bill that has been inadequately discussed and scrutinised, and it takes us down an unaffordable path. It has been put together in a great rush in the search for clear blue water to place between Labour and the Conservatives. In my view, the Bill is not a step towards the wider reform of adult social care that we need and that the Department of Health has been seeking over the past two years or so; it is a political gimmick that the Government are trying to ram through Parliament before an election without proper scrutiny of what it will result in.
Let me be clear at the outset about my position on free personal care at home. I have a track record in this area, having spent six years as a director of social services, helping elderly people to stay in their own homes as long as possible. I am proud of that record. Like many people in this House, I would favour free personal care at home for more people if it were affordable. However, at present it is not. Even when the public finances were in a better state than now, the Government turned their back on tax-funded free personal care: in 1999, with the report of the Royal Commission on Long-Term Care of the Elderly; again in 2006, when Sir Derek Wanless produced his report; and most recently in July 2009, when the Government published their own Green Paper which “ruled out” free care paid by the taxpayer. Page 18 of that Green Paper is the reference.
Cometh the electoral hour, cometh the man. When the public finances face what the Institute of Fiscal Studies has described as “two Parliaments of pain”, the Prime Minister decides to tell the world that we can afford more free personal care at home, a few months after he signed a foreword to a Green Paper with seven other Cabinet Ministers acknowledging that we cannot afford to pay for free personal care. He ruled out that option.
I remain in the position I have been in for some time: that it is unaffordable at present. I am really pleased to see that the Liberal Democrats have acknowledged that it is not affordable at this time. The Conservatives remain a little inscrutable on the subject—they seem to have a preference for insurance—but they have not made rash promises that may be very difficult to deliver. I am grateful to the right reverend Prelate for what he said about not promising what you cannot deliver. I think that promising elderly and vulnerable people and their families something which is not affordable or deliverable any time soon is a rather cruel deception, and I certainly do not want any part of it.
I turn now to the affordability and costs of the Bill. The Government say that it will cost £670 million a year, with £250 million being funded by local authorities—to which I will come later. In an admittedly incomplete survey of 132 local authorities by the Association of Directors of Adult Social Services, the Government figures are shown to be significantly understated. ADASS states that the annual bill will be at least £1 billion—some 50 per cent more than the Government’s estimate. The final cost could be even higher.
The difference is because the Government have seriously underestimated how much care per week many of the people with critical care needs will require. It will not be over just six hours a week at an average cost of about £100 a week, it will be many more hours with costs ranging from £200 to more than £400 a week. The case that my noble friend cited in introducing the Bill sounded to me like it would require a lot more than six hours a week to keep that person in their own home. The Government's cost figures take no account of increased demand year on year, and little account of rising service provider costs. Their impact assessment states that there will be a 1.5 per cent annual increase in service volume from demography, and a 2 per cent annual increase in price for wage increases. In a Written Answer to me, the Government declined to accept that there will be any increase in demand, or that providers could put up their prices by more than 2 per cent a year.
Although this is not directly comparable to the Scottish situation, the Government's stance flies absolutely in the face of the evidence from that social experiment, if I may put it that way. In Scotland, when home care became free, the costs doubled in four years between 2003-04 and 2007-08. The number of people claiming went up by 36 per cent in the same period. In the last of those four years, cost increases by providers were about 15 per cent in a single year. The Government's proposal will create a perverse incentive to have free home care rather than means-tested residential care, so why they regard it as unlikely that there will be increased demand totally eludes me. It is also worth noting that in Scotland, a debate has begun on the affordability of free care.
I turn briefly to the uncomfortable position in which the Bill places local government. In a written reply to me of 27 January, the Government stated that gross current expenditure on adult social services in the past three years went up by 1 per cent, 0 per cent and 3 per cent in real terms. That compared with a nearly 15 per cent real- terms increase in NHS expenditure for the same period. My understanding is that from this less than generous position, local authorities must now find a further 4 per cent efficiency savings and their share of the £670 million. If it turns out that the Government’s estimate of £670 million is wrong, it looks to many people in local government—they are understandably concerned about this—that they will have to pick up an even larger tab at a time when many of them will also be losing income from the many people who pay charges now. This is an uncomfortable position for all members of ADASS and the local authorities they work in. Parliament is entitled to press the Government much harder on their costing figures and assumptions. My noble friend the Minister rather brushed this aside, relying heavily on the PSSRU. We should listen more carefully to the guys and gals who will be running this system in local authorities up and down this land.
These are all matters where we might reasonably have expected to discuss in Committee some of the technical issues in more detail after the Government had completed their consultations on the content of the regulations and guidance and had given some indication of their response. Likewise, some of us have concerns—the noble Baroness, Lady Gardner of Parkes, referred to this—about the administration of the scheme and its added complexity. I do not have time to go into all these issues today, but the volume of assessment problems for local government and front-line staff could be quite considerable in this exercise. As I understand the Government’s intention, this is all to be completed, over the summer holidays, by 1 October—and yet the Government want us to be in Committee on 22 February, before they have completed their consultations and responded to the concerns expressed.
Given that none of the new arrangements is in the Bill but are left to regulations and guidance, this seems to me to be—I do not use the term lightly—an abuse of parliamentary procedures for the proper scrutiny of legislation, especially in light of the limited scrutiny in the Commons. Simply passing to us some draft regulations—which the Government say will not be the finished business—to look at, without hearing how the Government are going to respond to the points made to them by many expert people in their consultations, is not sufficient. That is why I have tabled a Motion on the timing of the Bill going into Committee. I shall speak to that Motion at the appropriate time but I hope the Government will think again and give ground in this area. I am grateful for the support for this of the right reverend Prelate the Bishop of Norwich.
The Bill will complicate an already complicated assessment system, which is itself under review following criticism from CSCI in 2008. The Government’s impact assessment at paragraph 5.21 admits that the “wealthiest older people” are the main beneficiary group. If we want to do more for carers, as I am sure many noble Lords do, there are better ways of doing so much more cheaply than by spending £670 million a year. The costs of implementing the Government’s proposals under the Bill look to be over £1 billion a year—the Government have not disproved that estimate—and will continue to go up faster than the Government’s estimates. The Bill is unaffordable given the current state of the public finances. We owe it to a younger, taxpaying, working population not to impose an unaffordable financial burden on them as our population ages. There is an inter-generational social justice issue around this area of activity and I urge the Government to get back to their Green Paper, work with the stakeholders and the other parties and try to secure much more consensus on the funding and service reforms needed for adult social care, rather than wasting more time on this Bill.
My Lords, I agree with every word the noble Lord, Lord Warner, has said—not surprisingly, since we have been working non-stop on this for several weeks now—and with his remarks about the right reverend Prelate the Bishop of Norwich, who hit the nail on the head. Not every piece of legislation that goes through this House is perfect but some pieces of legislation stand out because, by common consent, they prove disastrous. I am thinking of the Local Government Act 1988, which introduced the poll tax, and of the Dangerous Dogs Act. I could go on, but that would bring me into the term of office of the Government of which I have hitherto been a loyal supporter. However, as someone who has worked in and around these Houses for 38 years, I believe that this Bill will prove to be a contender for the worst of the lot.
Bad legislation has certain characteristics. When first proposed, it sounds great. Behind it usually rests an overtly political purpose. It usually has the dogmatic backing of the Prime Minister of the day. It is usually subject to insufficient consideration in Government and rushed through Parliament. We legislate in haste; we repent at leisure. All these are characteristics of the Bill before us today. There was no policy process. Or rather, there was but it was usurped by the Prime Minister’s rabbit-from-a-hat trick at the Labour Party conference, which I was unfortunate enough to witness. There was no government consideration or any ministerial collective consideration worth the word. As the Government were consulting on the Green Paper on the subject—a very good Green paper produced by the Secretary of State, Mr Burnham—the Prime Minister announced as the Government’s firm policy one which directly contradicted that Green Paper. Then, after a few days during which Whitehall reeled in unparalleled confusion, this Bill was cobbled together with costings which have disintegrated under scrutiny and regulations which leave all the vital decisions to be taken without parliamentary scrutiny, not even the affirmative resolution procedure in the two Houses of Parliament. After Second Reading, the Bill was rushed through the Commons in a single day of perfunctory debate and now the Government want to rush it through the Lords.
That brings me to the role of your Lordships’ House. We are rightly wary of challenging the will of the elected House but we are charged with a duty to ensure that legislation is well scrutinised and as fit for purpose as it can be made. This is particularly the case when a general election is pending and the temptations facing elected politicians are so very great. Our role is not necessarily to say no, but to give space for pause and reflection. If ever there was an area where cross-party consensus was desirable, it is long-term care. There is a parallel here with pensions, which for years were bedevilled by party conflict but have now fortunately been resolved in the wake of the Adair Turner commission. If people are to plan for their future, they need to know where they stand—not for today, not for tomorrow, but for decades to come. If some of the most vulnerable people in society are to be protected, there has to be clarity and consistency—not for today, not for tomorrow, but for decades ahead.
I am sure I share a part of the blame for this, but progress towards such a consensus has been slow, dating back to the division in the royal commission, chaired by the noble Lord, Lord Sutherland, on which I and my noble friend Lord Joffe sat. Milestones along the way included the Wanless report in 2006 and, notably—I have said how much I support it—the Green Paper published by the Government. Hope was there; a route map to a consensus solution was there; but the Prime Minister chose at his party conference to tear it up.
Everybody who knows anything about long-term care knows that it needs more money. The 2 per cent real increase in budgets being provided by the Government is not enough to cope with the ageing of the population, let alone to provide the better services that older people deserve—that goes just as much, if not more, for disabled people. If the Bill provided a decent sum of money—perhaps not £670 million—to improve care services, no one would cheer more loudly than me and its other critics. However, we are not getting more care; we are getting free care. As the Government’s own impact assessment for the Bill shows, that will benefit the wealthiest among older people and not the less wealthy.
I shall say a word in supplement to what my noble friend Lord Warner said about Scotland, which has adopted an experiment in free personal care, including free personal care at home. I am aware that whenever I refer to this the noble Lord, Lord Sutherland of Houndwood, whom I greatly respect, rebukes me for getting it wrong, so, rather than quote myself, I shall quote two independent researchers, Margaret and Jim Cuthbert, members of the Public Interest Research Network at the University of Strathclyde, writing in Public Finance magazine. They confirm the figure given by my noble friend Lord Warner, showing that the cost in Scotland has doubled. They note a further fact about Scotland: that it is the cost of care at home that has gone through the roof, not the cost of care in residential homes. Taking account of the danger that, because of the Bill, people will choose to come out of residential homes and stay in their own homes, they expect that the cost in England will rise from £580 million in the first full year to £1.73 billion five years later. The cost will have trebled and it may treble again. There is no easy way to stop that cost exploding, this at a time of the most difficult fiscal retrenchment.
The researchers refer to the unintended consequences in Scotland; namely, that those who get a little help with lighting the fire or getting groceries have had their services squeezed to pay for free care. Expenditure of this kind has fallen 24 per cent in the past two years despite the rising elderly population. I could go on. It is a fiasco for Scotland, which the Prime Minister’s Government now want to repeat for England.
Can we please call a truce on saying that the Bill will be paid for through efficiency savings? Local government and central government have eye-watering efficiency savings to make already. If Ministers think that, every time they dream up a new policy which they think could win some support, they can wave a magic wand called “efficiency savings” and the money will come flowing into the Exchequer, and the money tree will blossom in the Department of Health, they are talking complete rubbish. This Bill, if we allow it to go through in its present form, will mean increases in taxation or cuts in services or both, and that at a time when we are already going to get increases in taxes or cuts in services or both to deal with the nation’s fiscal crisis. I ask the Government, if they have a shred of honesty left about them any more, to come clean about the cuts that will follow from this Bill and not pretend that, somehow or other, the money that Gordon Brown wants will drop from this tree in the Department of Health.
Some noble Lords may say, “Yes, it is costly, but there is a price for fairness; these people need fair treatment”, and, of course, I agree with that. I shall therefore outline for noble Lords the fairness encapsulated in the Bill. Councils will have to spend far more on care, so they will have to intensify what they are already doing: cutting back, as they have in Scotland, on the little bit of care that people need to stay fit and healthy in their own homes in favour of concentrating resources on those with the greatest care needs. Is that fair?
Let us look at the people the Government are helping. There comes a time when people with the greatest care needs such as those with advanced dementia and so on reach a point where care at home is no longer an option, certainly not an affordable one when 24-hour care is required, and they need to go into a care home. On that day—and for many it is the saddest day of their lives—they will find that not only do they have to leave their home, they have to dig into their pockets to pay the full cost of the care they are moving into. Is that fair? What of families who find themselves torn between the desire to do the right thing by mum and the fact that if they do—by letting her go into a care home when she needs to—their inheritance is going to be blown away? Is that fair? What of local councils that want to respect the rights of people to remain in their homes wherever possible, but know that if they can get them to go into a care home, their care will be paid for by themselves as individuals and not by the council? Is that fair? What of the hard-pressed taxpayer who will have to pay for all this? Is that fair, when the money will go largely to benefit better-off old people in the last years of their lives? There may be arguments for this Bill, although I find it difficult to discern them, but fairness does not seem to me to be among them.
I referred earlier to the fact that I have spent 38 years in and around the Houses of Parliament. For two of those years I had the great privilege of working as a lowly adviser to James Callaghan, whom many noble Lords will remember in this House, at No. 10. Many of your Lordships will also remember the winter of discontent, even if many outside this place have forgotten it, and the Government’s appalling poll ratings with an election coming near. The Government were facing a vote of no-confidence in the Commons. We advisers cobbled together a scheme whereby we could win that vote with the support of the Ulster Unionists—at a price. It was £80 million to provide a gas pipeline under the Irish Sea. Rather pleased with ourselves, we put it to Jim. His response—he put it bluntly so I will paraphrase—was that he was not going to do something contrary to the national interest in order to try to get his party out of a hole. I know what would have happened to any aide who had dared to suggest to Jim Callaghan that he should adopt the policy encapsulated in the Bill before the House today as his election loss leader.
My Lords, I thank the Minister for explaining the Bill. Having recently heard the Secretary of State for Health, Andy Burnham, speak to Cross-Bench Peers about this Bill, I have no doubt of his genuine wish to see this legislation help those most in need of care. He told us that the care his own mother had received was far from ideal.
My husband was ill for many years as the result of strokes, Parkinson’s disease, diabetes and, eventually, a cancerous tumour. I can assure your Lordships that care at home is very expensive and has to be well organised, reliable and tailor-made for the individual. My husband’s wish, like that of many people, was to live at home. At the end of his life, we had a traumatic time when the out-of-hours doctors over the weekend let us down. Also, we could not set up a drip to give him antibiotics as he had a problem with swallowing. He died in the A&E department of a local hospital which could not retrieve his medical records as it was a Sunday. By that time, pneumonia had taken hold. Community care for people with long-term conditions has a long way to go to make it better and safe across the country, as it is now.
With our personal experiences, it is not surprising that Andy Burnham and I feel that the present system should be made much better, but I have several queries relating to the Bill before us today. First, what will reablement consist of and how will it be given to a person in their own home? If a person is suffering from Parkinson’s disease, for example, they may need physiotherapy, speech therapy and occupational therapy. They will also need their drugs monitored. If their home is in a rural location, it will be very expensive in terms of the time of those professionals travelling from place to place. There can be long waiting lists for speech therapists, for example; how will the social services obtain the necessary staff? Reliable assessments can be difficult when people are elderly, frail and disabled. They can have good days and bad days.
I have had personal experience with the North Yorkshire wheelchair service. Equipment can be vital for disabled people, yet communication in that area is appalling. When I tried to make contact last week, the only people in the office were a secretary and a volunteer. Pressure sores, which can be very serious, are estimated to cost the country several billion pounds a year, yet the wheelchair service, which supplies wheelchair cushions for prevention of pressure, is known as a Cinderella service. If the Government could make it efficient and quick, with staff who knew what each individual patient needed, much aggro and waste could be saved. This is one reason why I have my doubts whether the aspirations of the Bill will be distributed fairly across the country. All existing services should be made better first, or it will still be a postcode lottery.
Secondly, the Bill seems to be concerned only with very severely affected people. Does the Minister not realise that sometimes a little help can make the difference of enabling people to stay in their own home? There needs to be far more flexibility. What will happen if only the severely affected people are helped? This will be unfair and impractical.
Thirdly, who will do the assessments? Will there be a right of appeal? All Bills of this nature should have a clear definition so that it is transparent who will benefit from free personal care, otherwise there will be much dissatisfaction and an even greater postcode lottery. Parkinson’s is a long-term condition, and many people would benefit from preventive measures such as therapy services, aids and equipment, long before they develop critical levels of need. They would like to see this type of support extended to all who need it. They are also concerned that the process described in the consultation document on regulations and guidance is overbureaucratic, requiring people to undergo a period of intensive support before their assessment, followed by an assessment of their needs and then a separate assessment of their personal care needs. A three-stage process would be prone to waiting lists and confusion. It is essential that the process is as streamlined as possible. How long is the estimated time of the whole process before a decision is made for each individual once they have been assessed?
The Parkinson’s Disease Society recently published the results of its largest ever survey of its members and found that one in four needed personal care services, but one in five was not receiving it. Also, their needs included home helps, house adaptations, equipment and medical expertise. It is evident that social care is drastically underfunded, and more help in the home is welcome, but the concern is about where the new money is coming from. I have heard that it may be coming from research—but which research?
We desperately need more medical research in many fields—to mention just one, high-risk neuroblastoma, an aggressive cancer in young children. It is a devastating condition for the whole family as it is rare and difficult to diagnose. Much more research is vital at this very moment. One does not want to see the Personal Care at Home Bill taking much-needed research money. Somehow the money must be found without robbing Peter to pay Paul.
There is no doubt that more specialist nurses and therapists will be needed if assessments are to be correct. As many of these conditions are neurologically based, the UK desperately needs more neurologists. I was told recently that the UK ranks alongside Albania in the percentage of neurologists to patients. We need more support for the centres of excellence dealing with these patients, who are often difficult to diagnose and need their drugs monitoring by experts. They also need personal care at home.
The Bill may be short but the implications are huge. It needs careful consideration and cannot be done on the cheap, otherwise many mistakes will be made and there will be many disappointed people.
My Lords, I welcome the Bill. For too long we have neglected the care particularly of elderly people but also of the disabled of all ages. This is a great step towards the introduction of a national care service. It guarantees free personal care at home for the most seriously disadvantaged. We are promised a White Paper on the broader issues in the next few weeks.
I am sure that the Bill is also welcomed by carers. I have been a carer myself. I know that personal care at home is what most of the long-term ill want. Few want to go into a care home. In my own family, I had to promise my mother when she was ill in hospital that she would not be sent to a care home; she wanted to go back to her own home as soon as she possibly could. The same was true of my husband, who was in need of personal care in his last years. In his case, I approached the local authority because I felt that I needed assistance. Someone came to see me. I pointed out to her that we had at that time a scheme entitled care in the community and there was an obligation to assist people in my situation. “Yes,” she said, “but it is within available resources. Our resources here are limited, so we’d be obliged if you would do the best you can for yourself”. I was willing to pay but they did not have people to do the work, so I did help myself. A neighbour recommended a local woman who had caring experience. I saw her and arranged to pay her. She came every day, and together we looked after my husband until he became too ill and had to go into hospital, where sadly he died a few days later. I tell this story because I think local authorities must have the requisite resources to provide the services envisaged in the Bill—not just money, but also people.
There is also a need for better interaction between the services available and information for families. This is important for people who, perhaps later in life, find that they are faced with having to care for a partner or a relative. I recall being phoned by an old friend whose wife’s condition had worsened. He was really quite desperate: “I don’t know what to do”, he said. I was able to give him some advice, which he took, and I am glad that in those circumstances the local authority has been very helpful, and assistance is being provided to an ageing woman who has a spinal disease and is immobile, and is also blind.
With this Bill, which I have said before is a first step, the Government are ultimately offering us a national service which will be able to ensure that people requiring care can receive it in their homes, plus help for them to be as independent as possible. Savings will be made because fewer people will require residential care.
Care homes are desperately expensive. They are not always of as high a standard as many would like; there have been reports to that effect in recent years. Insurance schemes are currently being advertised so that people of modest incomes can afford such care should they ever need it. Many are worried that this may mean selling their homes. Local authorities only pay for residential care in cases of absolute poverty, and then at the lowest level they can find. The Government believe that arranging for people to receive care in their own homes will be very much cheaper, as well as being much better for the vulnerable people concerned.
Of course, there has been some opposition to the Bill—we have heard some of it this afternoon—mainly on grounds of possible cost. However, we should be prepared to accept the obligation involved in the care of disadvantaged and vulnerable people. This is a first step towards a new national scheme, and it is directed at the care of those most in need. Issues about eligibility have been raised, notably by the Local Government Association. No doubt this is a matter that could be further explored; the LGA believes that the number of reassessments is likely to increase, as people who have been provided with care by unpaid family carers will come back into the care system for free. The eligibility system, it says, will increase the work of social care staff, as decisions will have to be taken as to who is and is not eligible for free personal care. No doubt the Minister will respond to that in her reply.
These comments from the LGA highlight how much we rely on family carers providing all the work involved for nothing. I cannot help feeling that this is a bit of an imposition. We know what a drain this can be on family resources. It is not surprising that carers’ organisations fully support the Bill, but there is far too much reliance throughout the system on what families are able to do.
I recall that when I was in hospital following an operation some years ago, the floor manager came to see me to tell me that I was going out the next day. When I protested that I was a widow living on my own, and would be unable to cope if I left hospital so soon, her immediate reaction was, “Haven’t you any relatives?” I responded that none lived near. She asked me who lived nearest, and I said the nearest lived in Wiltshire—I live in London. She told me she could let me have another day and I could phone my relatives in Wiltshire and get them to collect me. I was able to do that, but many older people live entirely on their own with no relatives able to assist.
We should not base our care services on the assumption that relatives can always be available to provide help. This is increasingly less likely. Family members no longer live close together. The Government’s Bill recognises that, and attempts to deal with it. It is a first step towards providing social care, and I fully support what the Government are endeavouring to do in this much neglected area.
I oppose the amendment: it will simply delay the Bill. We know what many organisations think, because they have already told us. Many of the objections, as we know, seem to be about cost. I believe that we should simply get on with the proposals outlined in the Bill; and I welcome the Bill.
My Lords, I declare an interest as president of the Local Government Association—I here express support for amendments to the Bill that the LGA will be promoting but which time does not permit me to address now—as chair of the All-Party Parliamentary Group on Housing and Care for Older People and chair of the Hanover Housing Association, the country's largest provider of extra- care housing for older people. At this stage of the Bill, I must confine my remarks to my specialist subject of housing.
The Personal Care at Home Bill is predicated on the home being suitable for high-level care to be delivered there. Regrettably, the design and/or construction of many homes makes them quite unsuitable for those with the highest care needs. If you need help with washing, toileting, dressing and so forth, you are likely to need a home that is highly accessible. There must be no steps to the front door that become hazardous in icy weather and which are impossible for anyone with a Zimmer frame let alone a wheelchair, and no inadequate heating systems, poor insulation or huge fuel bills that can all render a property too cold or damp for a frailer occupier. Personal care at home is not a realistic proposition in a house with no downstairs bathroom where the recipient of care has to crawl or be carried upstairs.
If the design or condition of the property makes it impossible for someone with care needs to stay there, a move to residential care can become an expensive and usually unpopular necessity, so entirely commendable efforts to support personal care at home must start with an assessment of whether the home in question rules that out as a practical proposition. Of course, the ideal may well be a move to a well designed, light, bright, fully accessible and adaptable, highly energy-efficient apartment with care available if and when it is needed. Such places are far more common on the European mainland, as I saw in the summer when visiting Sweden, Switzerland, the Netherlands, Denmark and Germany as chair of the governmental Housing our Ageing Population Panel for Innovation—HAPPI for short.
We have some excellent examples in the UK, including high-quality extra-care apartments where personal care is on tap as required, and a few retirement villages that can also supply a range of health, fitness and social facilities. I am grateful to the noble Baroness, Lady Gardner, for speaking eloquently on the value of building excellent retirement housing for sale or rent thereby helping younger families by freeing up underoccupied housing.
However, for the great majority of older people it will be by adapting their existing accommodation that personal care at home becomes feasible—such as adding a downstairs bathroom, putting in handrails and easy-to-turn taps, better heating, emergency call systems to summon help, stairlifts and so on. Because we know that the cost of adaptations in these cases can be repaid by savings to the NHS budget, switching more resources from health is well worth while.
Andy Burnham, the Secretary of State for Health, talks rightly of joined-up thinking and integration of providers and provision of health and care, but the third leg to the stool, housing, must also be addressed. Of the £670 million rather loosely estimated as needed to fund the Bill’s measures, I note that £130 million is to be set aside for reablement, which is excellent work in helping people, including some of those leaving hospitals and residential care establishments, to live at home. I am told that the pot of funding incorporates something for home adaptations, including installing assistive technology with sensors to monitor those, for example, with early dementia. But I note that the calculation of £130 million is based on each of 130,000 recipients getting £1,000, equating to 30 hours of specialist home care.
On the face of it, that leaves no room for any spending on the home itself and without any such spending there will be considerable difficulty in implementing the Bill. My plea, therefore, is for the third leg of the stool—housing as well as health and social care—to receive recognition in the Bill, with proper assessment of the suitability of the home as well as of the individual and with funding for home adaptations, perhaps switched from the health budget, where these are necessary. After all, it cannot be too much to expect the Bill to address housing concerns when it has the word “home” in its title.
My Lords, I was a member of the Royal Commission on Long-Term Care for the Elderly, which reported in 1999, and with my noble friend Lord Lipsey, co-authored the minority report of that commission in which we opposed the case made by the majority for free personal care for all, financed from taxation. The opposition came from us despite our high regard for the chairman of the commission, the noble Lord, Lord Sutherland, and other members of the commission.
While we were naturally attracted by the concept of free personal care for all who needed it, the rationale of our opposition was that, having regard to the constraints on government expenditure, all available funds should be spent on improving the quality and range of care of those who could not afford to pay for it rather than to provide free care for those who could afford it. I emphasise to the noble Baroness, Lady Campbell, that this opposition to the Bill has nothing to do with opposing free personal home care, but everything to do with the equitable allocation of available resources for all those who need such care.
After the commission reported, the Government agreed with our minority approach and in a statement to the House on 2 July 2002, my noble friend Lord Hunt of Kings Heath, then Parliamentary Under-Secretary at the Department of Health, said in rejecting the recommendation of the majority of the commission on this view:
“We chose a different course because we believed that if we instituted free personal care, we should not produce a single extra service as a result but would benefit many better-off people”.—[Official Report, 2/7/02; col. 123.]
That has been the policy of the Government for the past 10 years and it is difficult to understand why at this stage government policy is being changed.
When in July last year the Government published for consultation their Green Paper Shaping the Future of Care Together, which was to be followed this year, after consultation, by a White Paper, it seemed that a carefully considered and appropriate process was being followed by the Government to determine future strategy and funding for such care, which in practice covers a wide-ranging, complex and interlocking set of issues. Against that background, the Bill before the House, which piecemeal addresses the single issue of funding free personal care at home for those who can afford to pay for it, cannot seriously be addressed without taking account of the funding for other interrelated parts of social care.
The Green Paper considered in great detail the various funding options for social care, and until a government decision is made on which option is to be followed, it is irrational to decide on additional funding for extending free personal care. Indeed, if the funding option for care finally chosen by the Government is insurance, which is one of the three recommended options in the Green Paper, there will be no purpose whatever in having put in place the legislation proposed by the Bill, which seeks to make it free.
The failure of the Bill to be set in the context of a holistic policy of social care will create inconsistency in an area where none exists at the moment, leading to a number of perverse incentives. Presently, people who can afford to pay for care are obliged to do so both for care at home and in care homes. Making home care free will create an incentive to demand such care even where it may not be in the best interests of the individual.
Malcolm Johnson, Visiting Professor of Gerontology and End-of-Life Care at the University of Bath and Emeritus Professor of Health and Social Care at Bristol University, has worked on these issues for 35 years. His research concludes that for old and often sick people towards the end of their lives, going into a care home is often not the worst option. He points out that the majority of such people—some two-thirds—are women living alone. Their social networks will have been eroded, including by the death of contemporaries. They are unlikely to have family members living close enough or willing to visit daily. They may be blind, have lost their hearing, be incontinent singly or doubly, or have lost mobility. Frequently they will suffer from two or more of those disabilities.
Public services typically offer these people little more than six hours of care a week, and nothing at weekends. For such people life is isolated, consisting of large chunks of time sitting around, perhaps in physical and often in mental discomfort, waiting for carers who may or may not turn up on time. One could reasonably conclude from this research that it would be in the interests of some elderly people to be provided with free care in care homes rather than free care at their homes. This issue needs to be considered as part of a coherent care policy.
Other perverse incentives arise from the Government’s funding proposals. I will not dwell on the injection of significant additional funding by the Government at a time when their own funding is under such pressure, as so incisively analysed by the noble Lords, Lord Warner and Lord Lipsey. Rather I shall focus on the proposal partially to refund the cost by relying on efficiency savings from local authorities. Many cash-strapped local authorities will be unlikely to find these savings and will resort to perverse incentives such as diverting those with the highest need into means-tested residential care, increasing charges for non-personal care, or limiting free care to those with the most severe needs, thereby denying access to individuals with moderate or in some cases substantial care needs.
Previous experience also suggests that some of these local authorities will seek to make cost savings by decreasing the fees they pay to independent care providers, which provide 80 per cent of care homes for patients. This in turn will impact adversely on their lower-paid workforces, where there is already an annual staff turnover of 24 per cent. This will adversely affect the quality of care that the elderly folk in these homes receive.
For these and all the reasons raised by noble Lords who have already spoken, in particular in the eloquent address by the right reverend Prelate the Bishop of Norwich, it would damage the Government’s reputation for responsible legislation to proceed with a Bill on an issue that they put out for consultation before the conclusion of that consultation process and which fails to take account of their own overall policy on social care—yet to be determined. I urge the Government not to proceed with this Bill.
My Lords, I come at this Bill as a doctor who has for some 30 years worked in the community as a specialist with older people. I feel passionately about the serious inequities between the provision of health and social care and the seriously unjust system we have at the moment, so you would probably think that I would like this Bill. I am also quite supportive of the policy objective to allow more people to remain in their own home for as long as possible and to support them with adequate personal care there—although I take to heart the point of the noble Lord, Lord Best, about the appropriateness of the home circumstances.
I collaborated in a good deal of research with the government-funded Personal Social Services Research Unit—the PSSRU—over many years. More than 20 years ago we demonstrated that the policy objectives of this Bill were feasible even for the most heavily dependent, if—I stress “if”— the appropriate personal case management was applied flexibly to each case and if there were real choices available. This is a good moment to pay tribute to the fantastic evaluative research that PSSRU does. However, it has always been careful to point out that fidelity to a successful model is important in getting the right outcome. This Bill is based on no such evaluative project. As the noble Baroness, Lady Gardner of Parkes, and the noble Lord, Lord Lispey, said, it is a piece of electioneering, presented at party conference as something that would rally support. Most older people’s organisations naturally support this Bill; after all, who in their right mind would turn down more money to enable the most dependent to stay in their own home?
Yet this is a horrible Bill. It is socially divisive, bureaucratically retrograde, provides financial incentives to choose one sort of care when another might be preferable, moves money from the most financially disadvantaged to the wealthier sections of society and will be a nightmare to implement. Instead of using this opportunity to develop an innovative state/public and personal partnership approach to the business of personal care, the Government have stepped in during the process of their evaluation of the Green Paper and rejected the development of a realistic and practical formula in the interests of headline popularity. As I say, they have not even finished the consultation on the Green Paper which carefully outlined a whole range of options around which we could build a political consensus.
In the small print of the modelling exercise paper on the costs of this Bill, PSSRU has itself hedged it round with some caveats. The modelling exercise depends on choosing exactly the right levels of assessment of activities of daily living, which I will come on to. I expect that any of your Lordships will have looked at the proposed scheme of assessment which will determine who gets the jackpot and who does not. It looks just like the Poor Law scheme of 1834 to determine the deserving and undeserving poor. In this case we will have a magic lift-off point. If you have four prescribed activities of daily living down then you are eligible; if you have only three activities of daily living down, sorry, but you will not be. As the noble Baroness, Lady Campbell, pointed out, this sort of deficit assessment is a truly divisive and horrible tool.
Apparently there will be a nationally agreed assessment tool, although who knows who will administer it? I suspect it will be the same workforce which does the current fact assessments. Can anyone remember what happened in the last attempt to devise a nationally agreed joint single assessment tool between the NHS and local authorities? It was a nightmare, taking three years to agree and then implement. Does no one remember the eligibility criteria for NHS continuing care? I used to see all the appeals against the final judgments of the tribunals on the contested cases in the north-east London area. Most of the cases were so arbitrarily unfair, particularly against people with dementia, that it made one weep. This Bill will have exactly the same effect.
Let us turn to these activities of daily living. The PSSRU modelling is all based around these assessments. First you have to go through the fair access to care assessment, as now, and then you are subject to the reablement services if possible. I do not know what they are, but I have a pretty good idea. This will be a tool for delay and procrastination, of course, but it has a rationale. Then the ADLs will be assessed. This is crucial. I will mention them all, as they are listed; it is not so much what they contain as what they leave out that is important. The ADLs are eating and drinking, toileting, washing/bathing, dressing, oral care, skin and hair care, plus another, which is the prompting and supervision of a person who is unable to make the decision for themselves about the ADLs on the list. The list excludes cleaning, housework, shopping, laundry, transport, sitting services and so on.
I am detailing these because, although it is true that the number of ADLs that people are unable to do correlates well at population level with demand for care services, they are not good at individual level. A body of research, largely from the United States, has shown how inappropriate these eligibility criteria can be for many people with dementia. For example, a patient with profound Lewy body-type dementia can suffer from serious behavioural disturbance, aggressive and deluded outbursts and wandering and can need 24-hour supervision from relatives who are effectively imprisoned in their home and yet they might not be disabled to the point of having more than one or two activities of daily living points on this scale. What happens in a case like this? It has to be interpreted by very sophisticated, well trained assessors, who are willing to use their common sense and to fudge in order to get people into the criteria. Just as hundreds of appeals are upheld every year against mean-minded assessments of night and day rate attendance allowance, this assessment will also generate hundreds of appeals, because the system will be a bureaucratic nightmare and a profound letdown for many who may assume that they will be eligible.
The financial incentive to stay put and not go into residential care will, I believe, be a serious and insuperable difficulty. Families will understand very quickly how to maximise their future inheritance. While it is usually right for people to stay at home, it is sometimes right, as we heard from many contributors today, for people to enter residential care, especially when dementia is advanced. There should be as little distinction as possible in financial burden for relatives between care at home and residential care. Without that, decisions are skewed away from choice made on clinical and social grounds to those made on financial grounds. This Bill fails on these criteria.
Finally, I turn to matters of social equity. My objections are not simply on the large financial costs. Heavens, I have been quite a psychopath in my time about winkling out of social services and healthcare more than my patients’ fair share of the budget, so I have no guilt if I winkle out of the Government more than a fair share for this very needy cause. However, I believe that the Bill undermines the mechanisms by which we can reach a consensus on meeting a grave and growing social issue. We must find some fair middle way of funding care that is neither old-fashioned means-testing nor frankly unaffordable universal coverage. We are in a big enough mess with the NHS, which inevitably will have to be addressed at some point. Providing public funds, irrespective of assets and income, for all those living at home will transfer wealth to better-off members of society and their heirs at the expense of those most in need. Already we are aware that many people who receive attendance allowance simply do not need it. Such a proposal as the one in the Bill is extraordinary when the Government are groping towards a welfare system that promotes social equity.
We need a partnership between public and private sectors. That was made clear by Wanless and by extensive research by Julian Le Grand and others and it was ably outlined today by the noble Lords, Lord Lipsey, Lord Warner and Lord Joffe. Elderly people increasingly want the dignity of choosing for themselves the type of care that they receive by buying it rather than by having assessed care packages. That is the brilliance of the Government’s approach to personal care funding, whereby people can buy their own. Already a third of elderly people pay for their own care and it is estimated that this will rise to more than a half over the next 20 years. However, not a single penny of this extra state funding would go to improving standards of care for elderly people. The Bill will transfer vast sums of money out of the public purse to those who are currently deemed to be able to afford their own care. Since very little of the preserved assets will be spent by disabled elderly people themselves, the state will secure for elderly people’s heirs a better inheritance for the future. Is that the objective? I think not.
It is very hard to hope that this Bill will fall, because undoubtedly some older people with profound difficulties will be helped in the short term. However, I think that the funding will rapidly come to an end, as the Bill is not practical. I fear that this sticking-plaster solution will act as a deterrent to the creation of a more comprehensive solution to our profound problem. A Bill with this title is needed, but this is not it. If the noble Lord, Lord Warner, presses his amendment this evening, I shall support him.
My Lords, I declare an interest as vice-president of Carers UK. I want to give a carers’ perspective on this Bill, but let me be clear about what I mean when I use the word “carer”, as there is an increasing tendency to conflate it to mean both the families, including the neighbours and other informal carers who provide care free of charge, with what I would properly term “care workers”, or those people who are paid to provide care. I will talk about the informal sector.
This Bill will, for the first time, provide for people who have savings or an asset such as a house to be entitled to free care from the state. As Carers UK has been campaigning for that for many years, naturally I support it. It will help families to meet the costs of care, which can be very high and which contribute to the poverty faced by disabled people and carers. A survey of 1,700 carers in December 2008 found that 66 per cent were spending their own income or savings to pay for care. It also found that 74 per cent of carers were struggling to pay essential utility bills and that, because of the costs of care, 52 per cent were even cutting back on food.
Carers UK research has always found that carers want to care for their elderly and disabled relatives at home whenever possible. They also want to ensure that the person for whom they care gets the best possible care, which usually means looking after them at home, as that is what both parties want. This Bill will support those wishes. However, realising the desire for people to receive care in their own home should not be based on the assumption that families will provide the levels of care, which may be inappropriate given their circumstances or detrimental to their health or well-being. We need clarity about the expectations placed on carers, as the noble Baroness, Lady Gardner, reminded us.
One in five carers is currently giving up paid employment in order to care, so removing one element of the cost that they face will help families to manage their finances and remove some of the stress of caring. Carers, of course, have strong views about charging for care. They want an element of care to be free of charge. As I said, Carers UK has been campaigning for this since the introduction of community care in 1993. Early research in 1995 found that, as a result of councils increasing charges, one in four carers and their families were experiencing hardship and that around one in seven were cancelling services. In the 1995 research, three-quarters of carers surveyed thought that a guaranteed package of services should be free irrespective of income. I am pleased to say that that research was carried out for us by the noble Lord, Lord Warner, who said that,
“by the year 2000, all carers providing over 35 hours per week should have access to a respite care programme which provides regular weekly and some weekend breaks together with an annual holiday”.
He costed this at £1.4 billion per year and said that,
“public expenditure of this kind looks a good bargain compared with the alternative of letting carers collapse and taking those they care for into residential accommodation at a cost to the public purse that would put 20p on income tax”.
He suggested that guaranteed care should be free of charge to carers. The report was very influential and widely circulated at the time. We were very grateful to the noble Lord, Lord Warner.
As we know, criticisms have been made of this Bill. The debate in the House of Commons suggested that families would give up caring in order to receive free care. The evidence published by the Joseph Rowntree Foundation two years ago, after the implementation of the model in Scotland, found very little evidence of this. Most families continued to provide personal care because this is what they preferred to do. The modelling provided by the Government mirrors that.
We consistently underestimate the willingness of families to provide care and overestimate their desire to get out of the caring situation, however hard that situation may be. Carers are the absolute antithesis of what people are wont to call “broken Britain”, and politicians would do well to remember that.
To give noble Lords a case-study, Alan has cared for his wife for many years since she had a stroke. He is now in his late 60s. They have applied for continuing care, but have been turned down, and they have spent down their savings to pay for care. The wife is severely disabled—she needs to be moved several times in bed, and regularly stops breathing and needs to be resuscitated. She needs help with all forms of personal care. Alan says, “if I had got free personal care years ago, it would have made such a difference to my life. I am sick of poor quality care and having to pay for it as well”.
The Government have said that this Bill is a stepping stone towards the longer term goal of a national care service and I certainly welcome that vision. This Bill is by no means a solution to the problems that we face with social care—I am the first to admit that—but it is a step along the way. The view that I have taken for years about changes to the social care system is that change should be incremental, not revolutionary, and should come—salami-like—in small, sometimes very small, slices. That was the case with all the legislation for carers. The first carers Act in 1995 was not what I or carers wanted, but it was step along the way. It could be used as a launching pad to argue for other, greater rights for carers, and that has proved to be the case.
I know that the White Paper on social care is expected soon. It will be important that the Government look in that at the wider picture, and not just at alleviating stress at the heaviest end of need. For example, would support put in earlier mean that fewer carers would break down and that families would thereby be enabled to go on caring for longer? Would reablement and more independence for older people make it easier for their families to continue in paid work? People giving up paid work to care for a relative is a cost to the economy and to business which we can ill afford at the moment. Can the Minister assure me that the White Paper will look at the wider economic impact for families, rather than merely at expenditure with regard to residential and NHS costs?
There is no doubt that carers have concerns about the Bill. The evidence from some councils is that they are poorly assessing disabled and older people by assuming that families will provide care. This is against the current legislation, but it is also short-sighted, since it can lead to families struggling without appropriate help, as I have already said. Most carers want to continue to provide care and will continue to do so. However, they do not wish to be taken for granted and they do want their needs and support to be taken into account when looking at what services will be provided to the person being cared for.
Can the Minister assure me that the Government will ensure that guidance on this Bill clearly states that local authorities should not assume carers’ willingness and ability to care, but that they should check with them that they are able to do this? Will the Government stress in their guidance that the sustainability of the caring role must be carefully considered in assessment? If the carer is at risk of breakdown because insufficient support is provided, this will result in enormous costs for several people rather than limited costs for a few. I also seek assurances from the Government that if this Bill becomes law its operation will be regularly reviewed.
Finally, I remind your Lordships that all the significant charities and third sector organisations supporting carers and older people have issued statements in support of this Bill. They said:
“Care charges for those with critical needs are often a crippling cost to families already struggling with the financial impacts of illness or disability. This Bill would mark an historic end to means-testing and charging for some of the most vulnerable people in our society to provide for their most basic care needs. The older and disabled people, families and carers we represent have long called for an end to charging for care services—and”,
“would not forget if this opportunity was missed to end unfair charges for those most in need.”
There is no doubt, they go on, that,
“the care and support system is in need of a complete overhaul, and this Bill does not come close to solving the inequalities, inconsistencies and profound funding challenges”,
which we face.
“However the principles set out in this Bill are a vital first step in reforming social care”.
I hope your Lordships will remember that.
My Lords, I confess to a number of interests. I am president of Alzheimer Scotland and of Scottish Care, and I do some work with the English Community Care Association.
That being said, some of us have waited 10 long years. We looked for a response from the Government to the royal commission report on The Funding of Long-Term Care for the Elderly, and response had we little. Indeed, it was so little that a rump of Members, after five years, sent a reminder to the Government. The message of the reminder was, generously I thought, “Well, you don’t like what we recommended—have you an alternative?” They had, after a fashion, but I characterise it as follows: it promoted a postcode lottery; there were thousands of complaints to the health ombudsman, who in key cases ruled against the Government; resulting compensation payments ran into hundreds of millions of pounds; there was much articulated discontent; and for many real, often silent, suffering and puzzlement because they could not understand and work with a far too complex and unfair system. There was, I would suggest, no recognisable policy, but just a series of unfortunate happenings.
As a result, one has reduced hopes and expectations. Some of us had hoped, hearing that a Bill was coming, that we might at least have half a loaf; better than no loaf at all, as the old saying is. Perhaps the Wanless report offered more than that, but it was turned aside. However, now we have a Bill, admittedly a short piece—indeed, one might say, a modest piece, something of a morsel, perhaps even a crumb. Unfortunately, no longer a crumb from a rich man’s table, but I shall return to that. What about this morsel? Is it to be rejected, to be postponed until it is stale, and in its staleness nibbled into extinction by the mice rumoured to be invading the Back Benches of this House? What are we to make of this morsel, this crumb, this “legislative opusculum”, as one of my friends put it? In terms of evaluation, I am among those who welcome this morsel, but noble Lords must understand I am a hungry man. I digest the crumbs with alacrity, and I do not want to leave them to go stale for the mice to nibble into extinction.
I hasten to add that the most important feature of this Bill is not on the face of it. I hope that the Minister will speak plainly and put things on the record on the critical element, which is the context and promise the Bill offers of a new direction of travel towards a national care service. I know there are many problems with setting that up—there were problems in setting up the health service—but are they problems to be faced, or to be recounted and the Bill withdrawn prematurely?
I remind the House what a national care service minimally involves. It involves a single point of entry to a system of assessment of need, not to a bureaucracy or clutch of different funds which you might raid if you have expert advice but not if you have not. It involves a single point of entry. When the royal commission sat, this was one of the biggest cries that we heard from those whom we met in large numbers throughout the country. I know that there are dangers—my noble friend Lady Murphy has pointed these out very fairly—but it needs a single set of criteria of eligibility, pointing towards a degree of equity and fairness. Without a single framework, we will be back to a postcode lottery and divisions that we should be fleeing from. Such a service needs a single point of commissioning. I came to realise that this is what all the talk about personalisation of the service means. The person in need of support—the carer—or the person needing care needs to talk to an individual about what is to be commissioned and what the needs are.
Behind this, it needs a single budget—a budget that will reflect that need. That budget will need to be portable so that you can, if necessary, move around the country. This point was made very well by the noble Baroness, Lady Campbell of Surbiton. The provisions made will then follow you, and you will not enter again the morass of renegotiating on five or six different fronts. It is important to treat the needs of older people equitably, with no artificial distinctions set by the way in which we administer the money and care. There are three different sources of funding for care for older people: the health service, local authorities and the Department for Work and Pensions. Are these flowing in the same direction? I have not seen the evidence, but I have seen plenty of contrary evidence. The Government have been unwilling to tackle a single budget. It is too difficult. There has been sucking of teeth up and down Whitehall as the Government say “How could they suggest such a thing?”. I will listen with great interest to what the Minister has to say about what many of us are currently saying to her about the shape of a national care service and its preconditions.
There are plenty of counterarguments; we have heard them all and some are very good. I pay tribute to the noble Lord, Lord Best, who is unduly modest. The sort of schemes being outlined by, for example, the noble Baroness, Lady Gardner of Parkes, are of the type that he was instrumental in putting together when running the Rowntree trust. A very large sum of money—over £20 million, I understand—was invested in creating a care village, effectively, where one could do exactly the sort of thing that the noble Baroness, Lady Gardner, rightly holds up as a good example. The noble Lord knows what he is talking about. What he says about housing is very important; I am completely with him on all of that.
We have heard much about the bad legislative and governmental process. I am no more than a spectator to personal grief within the Labour Party on this. What grief and agony transports between individuals there is a matter for consenting adults in private, rather than in public. Of course the Bill comes from a bad legislative process. Of course it is inadequate. However, it is not the first Bill of which that has been said and doubtless it will not be the last. It must be improved massively—of course it must—but it will not be improved by being put on the back burner. I say to the right reverend Prelate the Bishop of Norwich, who suggested that waiting and considering are important: of course they are. However, we do not all have the biological constitution of Methuselah. We have waited a long time already. Perhaps we would like to see some action that might lead to a policy. There are those who say of such a wait that the amendment that might be tabled is not a wrecking amendment. They have said it in an email that I received, as, no doubt, did the Minister. If I were a cynical man, I would say, “Pull the other one”, but I am not so I will not comment.
Those who argue against the Bill rightly raise questions of affordability. This is not affordable; there is much that we are doing that is not affordable. It is suggested that in Scotland we are talking about affordability again. We have never stopped talking about affordability. It has been a constant discussion and so it should be. However, if we are talking about what is and is not affordable, why do we seem always to start here? We can whip up a headline about the cost of long-term care of the elderly. I give a few alternatives because affordability is often assumed to be within the constraints of these three sources: the National Health Service, local authorities and the Department for Work and Pensions. This country’s financial position transcends that. We should look more broadly at priorities across government, not within artificially constrained government departments.
On affordability, national identity cards are not at the top of my list. These were initially budgeted at perhaps £1 billion to £3 billion but the LSE came up with an estimate of £18 billion. These things are very elastic. There is our current foreign policy and the associated defence costs. I do not suggest that we stop having decent defence, but it is a matter for discussion. Malcolm Rifkind makes that point in the Times today, stating his own conclusion. These are major issues. Are we overextending ourselves or are we not? This should be talked about when we discuss affordability and priorities. The bureaucratic costs, including consultancy in the current health service structures, are massive. Rewards and payment for general practice have escalated without any obvious benefit. I speak as someone who looks for a general practitioner sometimes in vain. The cost of merit increments for consultants is massive for the health service; is it something that we can continue to operate with? I am sorry to any consultants who happen to be present, but it is an issue of affordability. We are talking about priorities. Dare I even add public sector pensions, which doubtless many of us in this Chamber benefit from? Finally, I add to my short list—noble Lords will have their own—an elected House of Lords, which will cost more money but seems to be pushed up various groups’ list of priorities.
Cost is now a matter of priorities across government. That is the one thing that we are learning from the huge financial constraints that we find ourselves under. We cannot opt out and say, “Just a little bit here or a little bit there”. We have to look again. I am in no doubt that the outlook for the next few years is very sombre. It will be a time of real cuts, but we are looking for a national care service and a means of dealing with all the problems that have been paraded around the House today about how we are not serving the needs of the elderly well—and we are not. If we are looking for a solution to that, I suggest that we incorporate the costs of providing for the needs of the elderly in a single budget, covering the health service, the Department for Work and Pensions and local authorities. Then we sit down and ask where the cuts will fall.
At the moment, folk see the rather tall poppy of care of the elderly threatening to grow again and want quickly to slash it and cut it down. It should be incorporated with other matters and then a decision taken. In my view we cannot afford the health service that we have, but when the cuts come—as I believe they will—they should not start with the elderly before looking at the rest. There should be a rounded discussion. I am not asking for false and unsustainable prioritisation of the needs of the elderly; I am asking for them simply to be taken into the same pot. However the decision is made, and by whatever form of deliberation, fairness, equity and rationality should lead the discussion.
I did not want to talk about Scotland but I have been goaded, or prompted, into it. I am sorry; I have to do this for just a couple of minutes. I sometimes think that I hear the following, adapted from Animal Farm: Scotland bad in the area of care for the elderly, England good. Perhaps that is occasionally permissible and, sometimes, I regret to say, justifiable in Wembley or Twickenham, but is it fair to give that impression of what is happening in Scotland? There is not a sense of national catastrophe, as there has been in the hysterical language that we have heard. The myth is that Scotland is a spendthrift country which has become more profligate since devolution. The fact is that at the time of devolution—and, indeed, 10 years ago in 1999—Scotland spent 16 per cent more per head on public expenditure. In 2009, Scotland still spent 16 per cent more. There has been no escalation as a result of that policy of devolution. Scotland operates within a cash-limited budget. English public expenditure has increased by exactly the same amount—16 per cent. It is true that it starts from a different baseline, but it is more or less true that there has been the same increase for Wales and Northern Ireland. The rate of increased spending is no different in Scotland. The idea of profligacy is not correct.
The reason that Scotland spends more is of course due to the Barnett formula, which, as we have learnt this afternoon, was introduced by a Labour Government who possibly were advised by the noble Lord, Lord Lipsey. If you want to tackle the larger expenditure on the public sector, look at the Barnett formula. I am open to that as a suggestion—indeed, I make it. It would be a very odd policy to say to Scotland, “We’ve got this formula; it’s a bit funny but we are not willing to change it. You get all this extra cash, but you may not spend it on social care for the elderly. You can spend it on anything else that you like”. Scotland lives within cash limits, just as everyone else does. That means that it has to take decisions not to do things that we are going to do down here.
I shall give a good example. Last year, we improved what I can only call the raising of the school leaving age in England. It was suggested that that will cost £750 million in the first year of operation. I bet that that is an underestimate. While it may be something that England can afford, Scotland cannot, because it is spending its money in other ways. There are other aspects of expenditure in Scotland that I could examine, but I shall not because I have used up my time.
This Bill points forward. It is weak, it is inadequate, and it has been presented at the wrong time—it should have been put through 10 years ago—but it is the best crumb that I have, and I am going to live with it. I commend it to noble Lords.
My Lords, like the disability organisations with the main interest in this Bill, I welcome its intention to support severely disabled people to remain living in their own homes and the fact that it highlights the urgent need for a national care service that is fair and sustainable to be established. But, like other noble Lords, I have serious concerns about the perverse incentives contained in the Bill. These have been sufficiently rehearsed and I shall not repeat them. I will, however, cover much the same ground as that referred to by the noble Lord, Lord Best, in his excellent speech. I hope noble Lords will agree that it is worth re-emphasising.
The Bill focuses our attention on providing better help for people with high support needs to be able to remain in their own homes. I greatly welcome that. However, what is notable is the absence of any reference to the adaptation of the home in which the person with high care needs is to be supported in order to live. In my view, any new arrangements to meet the cost of personal care at home must also integrate a system for fast, effective provision of home adaptations. That, at the moment, is sorely lacking in many parts of the country. My noble friend Lady Andrews did a great deal to rectify this situation during her time at the Department for Communities and Local Government with the excellent strategy report, Lifetime Homes, Lifetime Neighbourhoods. That work needs to be built on and fully integrated into the health and social care support available for disabled and older people.
As Care & Repair England points out in its latest report, Time to Adapt, the issue which makes the greatest contribution to enabling independent living for disabled and elderly people for as long as possible, and reducing the cost of their care, is housing adaptations. Not surprisingly, making sure that someone can, for instance, get to and use a bathroom, to wash and go to the loo, is often pivotal in enabling people with high care needs to remain living at home. That is the purpose of the Bill.
Adaptations impact directly on the cost of care because they enable the disabled person to do as much as possible for themselves and they make the giving of personal care much easier for paid staff and unpaid carers. It is in the interest of the best use of public finances, let alone in the interest of the dignity of the individual, that adaptations are fully integrated into the proposed system of free personal care.
The research undertaken by the University of Bristol for the Office for Disability Issues in 2007, entitled Better Outcomes, Lower Costs, set out the evidence for this. It showed that timely adaptations and appropriate equipment can produce direct savings to the public purse in terms of the amount of home care required, hospital admissions and delays in discharge. Adaptations also directly lessen ill health among care givers; for instance, by reducing the numbers of strained backs from lifting. That report also showed how better outcomes for the individual can be achieved with the same level of expenditure. For example, if for the same amount of money a disabled person can have frequent visits by a carer to help them to use the loo and wash, or can have an automatic loo and level access shower to use whenever they please, the latter will, for the vast majority of people, be far preferable. In short, if free personal care is to be provided for those with the highest needs, then, in order to make best use of public funds and to ensure that the care at home is of the best possible standard for the individual, housing adaptations have to be an integral part of the assessment and provision that is made.
The Government propose that this Bill is,
“the first step towards setting up a new National Care Service—a simple, fair and affordable care system for everyone”.
This is laudable and in keeping with one of the most broadly welcomed proposals in the social care Green Paper—that of clearly defined, universal entitlement. If the Bill is the first step towards a national care service and a move away from the uncertainty of variable local provision, then steps also need to be taken to create an integrated, health and social care linked national adaptations service. The need for such a service was argued by Sue Adams of Care & Repair England at a recent meeting of the All-Party Group on Housing and Care for Older People, and I am indebted to her for her help.
Currently, disabled and older people face a bewildering array of possible local systems when they need help with urgent home adaptations. While there is indeed a national legislative framework in place defining eligibility for help with adaptations through disabled facilities grants, the degree of flexibility for local housing authorities in the implementation of the framework results in highly variable local delivery. As the Audit Commission noted at the same all-party meeting, while there have been improvements in the provision of assistance with small items of equipment and minor adaptations, larger disabled facilities grant-funded adaptations systems are, in a significant number of authorities, simply not fit for purpose.
Many disabled people have to wait years for adaptations help. The result is not only extra costs to health and social care, but suffering for individuals. Older and disabled people face the undignified situations of living, sleeping and eating in a single room with a commode in the corner and being strip washed in the kitchen. Carers are put at risk by having to carry people upstairs and lift them in and out of bed, when, for a few thousand pounds for a stair lift or hoist, their lives would be transformed.
Changes to the disabled facilities grant system, announced in 2008 and phased in over 2008-10, offered local authorities even greater local flexibility. While this will result in improvements in some areas—the Foundations report, Adapting for a Lifetime, cites a number of positive examples—in other areas, DFG help will decline. The ending of the legal obligation to match government funding for DFG has already resulted in some local authorities reducing their DFG budgets. More are expected to do so in the next financial year, despite the very welcome increase in national grant. The adaptation help that a disabled person can expect will become determined by where they live. This is totally contrary to the aims of increasingly universal provision of personal care at home that this Bill heralds.
While home adaptation is not currently in the Bill as drafted, the Bill could still provide the incentive for reform to remedy the current incoherent pattern of provision—a reform that is urgently needed. I hope that my noble friend the Minister will acknowledge the necessity that, in shaping the future of personal social care, the central role of home adaptations must be integrated into any new systems.
My Lords, I am not sure whether this is a modest or an immodest Bill, but it certainly has much to be modest about. Free personal care at home for those in greatest need sounds like a marvellous idea. As others have said, who could possibly be against that? Yet the moment that you begin to look at what is proposed, it immediately becomes clear that it is not quite what it seems. The more you look at it, the more it becomes clear that it has some quite untoward consequences, which have not been thought through. Although the idea of free personal care at home is initially attractive, I fear that, as enshrined in this Bill, it is overwhelmed by the arguments that have been deployed by the noble Baroness, Lady Murphy, and the noble Lords, Lord Warner, Lord Lipsey, Lord Joffe, and others. It is hard to say anything fresh at this stage of the debate, but perhaps my remarks will come as a handy summary for the Minister before she winds up.
For a start, it is not really free personal care at home for all those who might need it. The Bill introduces a right to free care at home for only a proportion of those whose needs are assessed as critical, because they require help with four or more activities of daily living. Thus, only a small proportion of those who need social care will benefit from the provisions in the Bill. The Bill also provides an entitlement to 30 hours of intensive reablement support over six weeks. What is the relationship of that entitlement to the general right to free care at home introduced by the Bill? For those whose needs are severe enough to put them in line for the free help offered under the Bill, that is hardly intensive. They would certainly need more support, and for longer. The kind of people we are talking of here probably need round-the-clock help; what is offered would barely scratch the surface. What is the position of those who receive reablement support but do not qualify for free personal care after the six weeks are over? Those are just some of the questions about which there needs to be a lot more clarity.
The additional cost of the measure is set to be substantial. On the Government’s reckoning it is £670 million a year, with £420 million to come from NHS budgets and £250 million from local authority efficiency savings. However, as we have heard, ADASS has estimated that double that will be required from local authorities. What will be the effect on NHS and local authority budgets, which may already be helping people to stay in their homes for longer? What will be the effect of funding free personal care at home, for those with the highest need, on services provided to those with moderate or even substantial needs? One possibility is that they could incur the double whammy of having their attendance allowance—even their disability living allowance, if aged under 65—taken away to fund social care generally under the reforms presaged in the Green Paper, and having the level of social care support they receive degraded at the same time. In practice, the money will have to be found, in whole or in part, through service cuts or, possibly, charges. That could further fuel the pressure for an ever more restrictive process of fair access to care services.
What about the practicalities of implementation? The impact assessment accompanying the Bill estimates that at least 70,000 people who currently do not receive formal social care services will be eligible for free personal care from October. The Royal College of Nursing argues that if the changes are to be successful, substantial and immediate investment in community nursing will be necessary—on top of the Government’s estimates that I have already referred to. I suppose that it would say that, but there are worries all the same that, with only nine months until the measures comes into force, there may simply not be sufficient numbers of properly trained social care and nursing staff to deliver the commitment to free personal care in the Bill. The college’s worries on that score would seem to have some force.
The complexity of the assessment process is also a major concern. Once the existing fair access to care services rationing process is combined with the new personalisation arrangements and the personal care at home criteria have been added, the assessment process will consist of six interlocking stages of Byzantine complexity. That is all too likely to lead to confusion among practitioners, and service users will be baffled and alienated by the experience of Kafkaesque bureaucracy. Extremely careful guidance and excellent staff training will be necessary if chaos is to be avoided. The draft guidance issued so far is not reassuring, displaying as it does far too little clarity and precision regarding the assessment process, its multiple stages and the relationship between them.
There also stand to be some very untoward consequences, as we have heard from other speakers in the debate. The impact assessment makes it clear that the wealthiest old people will be the main beneficiaries. Because care in a residential home can be charged for according to the ability to pay, the requirement to provide care at home free will also give local authorities a perverse incentive to pressurise better-off people into going into care homes, where they will contribute to the cost. That could have the effect of forcing people into care homes even when that is not the best thing for them.
Finally, the process is seriously flawed. The Government were in the middle of a consultation on the Green Paper that discussed, inter alia, a national care service, partnership between the state and individuals in paying for the costs of care, and a system of insurance to enable individuals to insure against their care costs. The announcement of free personal care at home for those in greatest need in the middle of that consultation cuts right across it. Indeed, it clashes directly with the Green Paper, since all the options canvassed in it ruled out free care at the expense of the taxpayer. The Government say that this is just a stepping stone or building block on the way to a national care service, but the measures in the Bill are not a subset of the vision set out in the Green Paper. That is really the answer to speakers such as the noble Baroness, Lady Turner of Camden, and others who have welcomed the Bill as a down-payment on implementing a comprehensive and more wide-ranging strategy for social care.
The Government have stated that the policy of free care at home will need to be reviewed after 18 months. We need to be reassured, therefore, that this potentially temporary measure will not adversely impact on the plans for longer-term reform that all parties recognise is needed, and which may help many more social care users, and that those who will benefit from the free care at home provided in the Bill will not lose out following the 18-month review. That may prove a very difficult line to tread.
Only a small proportion of those who need social care will benefit from this Bill. The wealthy will benefit most; funding it will be difficult; and raiding the pots that the Government have fingered will have unpredictable consequences for those who fall outside the immediate scope of the Bill. What is proposed is full of perverse incentives. The Government have hardly begun to get to grips with the problems of implementation and the labyrinthine assessment process will be a nightmare. If that does not constitute a case for the Government to do some serious rethinking, I do not know what does.
My Lords, as we have heard in this most interesting debate, this is a very difficult issue. The Government’s proposals obviously have within them a paradox, which many noble Lords have examined. I think that we all recognise the importance of care at home. However, we should also recognise that it is but one aspect of the precarious journey sometimes known as the “continuum of care” that many elderly or disabled people have to make. Of course, we should note that only 18 per cent of people die at home. Tackling the funding of one part of that continuum and, in effect, privileging one element of the journey will create a multiplicity of problems which I believe will have serious consequences in the years to come.
In speaking on this matter, I should declare an interest as the chair of the Co-operation and Competition Panel of the NHS and chair of the international operations of McKesson, a distributor of health and social care information systems.
I spent 15 years of my life organising care for the elderly in some detail. In that time, it became very clear to me that there were three key issues: first, quality and appropriateness; secondly, choice; and, thirdly, funding. I think we all accept that quality is not negotiable, but it will become a very pressing issue as the current financial pressures start to bite. For that reason, I welcome the proposal to expand the role of the Care Quality Commission in regulating all aspects of elderly care, wherever it is carried out. However, we need to make sure that the frameworks, assessments and regulation are all properly in place before we proceed.
With regard to choice, in 30 years we have come a very long way in offering a range of services for the elderly. One of those has been the growth of home care—letting people stay where they want to—and all the research points to that being the main preference. None the less, as we have heard from many noble Lords, sometimes that is not practical.
However, it seems to me that the most pressing issue remains funding. As my noble friends Lord Joffe and Lord Lipsey said in their seminal note of dissent in the 1999 report of the Royal Commission on Long-Term Care of the Elderly, to which many speakers have referred, the key issue seems to be the balance between what it is reasonable for the state to provide and what it is reasonable for individuals with resources to pay for themselves. That question has been asked, yet it has remained unanswered—at least for these 10 or 11 years. It was therefore very encouraging to see the excellent government Green Paper, Shaping the Future of Care Together, which sought to examine this issue.
Like many, I am concerned that the Government are taking forward this Bill without the benefit of consultation and, in my view, hastily addressing some but not all of the issues of the current system. I know we feel that we should be able to find the money to meet these aspirations but it is worth reflecting for a moment about the amount of money that we have in this system. In this current year, care of the elderly one way or another will total £21 billion. Of that, individuals already find £8 billion and the state £13 billion. Given the demographic projections, and in particular the rise in the over-85 population, it is clear that by 2030 there will be 2.8 million people in that cohort, placing enormous demands on both home care and care delivered in residential settings.
There have been many speculations about what it might put on the standard rate of income tax if the Government were to bear the whole of that burden. Therefore, at a moment when we are facing such financial challenges in the public sector, it is surprising that we should come forward with these plans. Even if, as many have argued—and I have some sympathy for the argument—we could afford to spend that amount of money, would we be able to contain costs going forward at that level? We have heard many arguments, including on the situation in Scotland and so on, but we have to ask a serious question. What is a sustainable level of funding that we can find to take this proposal forward? The suggestion that we can divert people from residential care is one of the great myths and simply defies the demographics that we face.
Therefore, the question of how the cost is shared becomes critical. Those who have to pay for themselves will have to make a choice about meeting care expenses from savings, property or insurance. Various things have appeared in the Green Paper and in the proposals from the Opposition: free care, mutualisation schemes, insurance schemes and so on. However, most of these proposals suffer from perverse incentives. I shall not revisit that as we have already heard a lot about it today, but of course with many of them the whole question of funding remains unanswered—how are we going to pay for this?
Having worked closely with the elderly for many years, I can say that the greatest fear among those who had money was that they would run out of it. Generally people with assets accumulated in their lifetime accept that they need to spend some of those assets on old age. However, we have encouraged people to be prudent, and at the end of their lives people do not want their lifespan to outlast their assets; frankly, it is demeaning.
I shall not dwell on the many alternative schemes that have been proposed and on how to mutualise them, but I was very taken with the proposal in the 1999 royal commission report by my noble friends Lord Joffe and Lord Lipsey that there should be some form of state reinsurance so that people can plan to find the money to cover either home care or residential care.
As many noble Lords have said, in considering how to spend the money, we need to step back and look at the whole picture. Addressing a part of it is not enough. I was very taken with the points made by my noble friend Lady Pitkeathley on supporting carers. The fact is that throughout the western world 70 per cent of all long-term care is provided by informal carers. I do not like the word “informal”; I think it is pejorative. We are talking about people delivering care, and we should look at how to help them more. Those of us who have delivered care personally know the great moments of panic that carers experience when faced with the unpredictable.
The challenge now is to find an equitable funding balance between the individual and the state, and I think that here lies the paradox. On the one hand, I was very taken by the point made by the noble Lord, Lord Sutherland, about the crumb. On the other hand, like many other noble Lords, I was very struck by the problem of having to build an integrated system to avoid the “hand-offs” and perverse incentives which arise from a non-integrated scheme.
Funding for long-term care is the elephant in the room. We are normally told that the best way to eat the elephant is piece by piece, but in this case I think that we have to get a picture of how to deal with the whole elephant. When the Minister replies to the debate, I look forward to hearing how, in forming a view on this, we can strike a balance between taking what is on offer, which is clearly important, and understanding how that will fit into a national care service.
My Lords, I cannot match the fervour of the analysis of the Bill made by the noble Baroness, Lady Murphy, but I start by saying that it is doubly objectionable. It is objectionable in process and it is objectionable in substance.
The issue of how long-term care is provided and financed has been controversial for more than a decade. The Department of Health, working with the rest of Whitehall, is to be commended on a substantial piece of work which was edging us towards a consensus in the country and across parties. A set of well considered options was laid before Parliament in July, with a consultation process which was due to end in November last year. At a time when the Government have been criticised for weakness in dealing with cross-departmental issues, the Green Paper was a model of its kind. It was signed by seven Secretaries of State, plus the Prime Minister. That must be a record. However, what then happened? Even before the consultation process had ended, one of the signatories, the Prime Minister, in a political forum—the party conference, not Parliament—repudiated the consensus, unilaterally striking out with a new proposal, which cut across the options developed in the Green Paper. The Green Paper had rejected taxpayer funding but this Bill reintroduces it and confines it to one sector, and one sector only, of the care universe without regard to the rest.
My noble friend Lord Butler and I have attended or written briefing for dozens of Cabinet meetings immediately before party conferences. They always contain a sermon from the Prime Minister or the Treasury about avoiding new announcements to conference which are not costed and collectively agreed. Rather than making us wait 20 years, I wonder whether the Minister will tell us whether this proposal went through that process. Not only is the option in the Bill ill considered—I will give an example of that shortly—it illustrates something that is going wrong with governmental processes.
By chance, on Friday, this House’s Select Committee on the Constitution produced a report on the Cabinet Office and central government. One of its conclusions—you will find it in paragraph 97—was that the increase in the power of the Prime Minister had not been kept pace with by the accountability mechanisms on the Prime Minister. This is a perfect example. The Prime Minister has launched a proposal whose genesis was not in the lead department but from his coterie in No. 10. The responsibility for defending this has not rested with the Prime Minister, but has fallen, under our parliamentary system, to the Secretary of State in the Commons, and to the Minister in this House. The Secretary of State has been undermined, left trying to defend something not of his making and, to judge by his performance on the radio this morning, he was finding that difficult.
The Bill is a classic Gordon Brown dividing line. It is not drawn up on merits but has been chosen to set a trap for the Opposition, who either oppose it and are accused of being heartless, or accept it against their better judgment. Looking at the density of population on the Opposition Benches, they have obviously elected to sidestep this challenge, although that means that they are unable to enter into the substance of the debate.
The proposal is equally objectionable on substance. Let me illustrate that from the experience of my family. It is an example which, I believe, has quite wide applicability. My mother-in-law, now 94, has lived on her own for more than 20 years. In recent years, she has been growing frailer, but was coping. Then, as is often the case, she suffered an illness which set her back. The family managed, however, with the help of the NHS and social services, to get her back into her own home, supported by a local care agency, paid for by her. That worked well for 18 months, until she had a fall and broke her arm. That so reduced her mobility that independent living, other than by provision in her home of 24-hour care, became impossible. That is the moment that all families dread, but there was no realistic alternative to her moving out of her home into a home. Happily, she is much better cared for, and she is living much closer to us.
The point of that example is that, at the very moment that her care needs went up from, perhaps, 30 hours a week to 168 hours a week, her eligibility for financial support went down. That cannot make any sense. Crucially, it fails the test set out by the Minister when she said that those with the highest needs must receive the greatest help. It is that injustice, even more than the issue of cost, which I find so objectionable.
We are being asked to vote on a Bill whose details are still unclear and which has received perfunctory scrutiny in another place. It is often the case that a Bill is fleshed out by the details of regulation, but in this case, key principles, which should be in the Bill, are still missing. What is the basis of assessment? Is it the four ADLs—activities of daily living—which do not seem to include cooking, incidentally? What is the true duty of the social services department? Is it to provide care or merely to fund it? What does it cost? Is it all a cruel deception in which hopes are being raised way beyond our ability to deliver?
The effect of the Bill is to pit people’s pockets against their better judgment. In many cases, increasing the care to extend living at home will be the right answer. Many others have correctly argued that. It was for us for a time, but for others, as the example I have given shows, there will come a time when it is no longer the right answer. A financial obstacle is being erected to prevent decisions being taken which are in the best interest of the elderly person.
The Bill, in my view, is so badly constructed, so poorly costed and so weakly scrutinised that if, as is traditional, it receives a Second Reading, I hope that the House will subsequently not allow it to proceed until the unanswered questions are answered. We can then return to the better-thought-out proposals in the original Green Paper.
My Lords, as one of the last speakers in this debate tonight, I am very pleased to say that I support the Bill. I was just as delighted when the Prime Minister announced this Personal Care at Home Bill at the Labour Party conference.
I am very pleased to have the opportunity to contribute to this important debate, and will focus my speech on the impact that the Bill will have on people with Parkinson’s. I am confident that the Bill is an important first step on the road towards improving social care support for people with Parkinson’s. However, it is important to recognise, as other noble Lords have tonight, that it is only a first step towards achieving a much-needed national care service.
I declare an interest, as I chair the All-Party Parliamentary Group on Parkinson’s Disease. I am pleased that Parkinson’s has featured so prominently in both the Bill and the debates about it. Last July, the all-party parliamentary group published a report on services for people with Parkinson’s, which clearly highlighted inequalities that people currently face when trying to access health and social care. I am hopeful that the Bill will address some of the major gaps in social care for people with Parkinson’s, as illustrated in our inquiry, because one of the key issues highlighted in our report was inequalities in social care services across the country.
I am particularly pleased to see that the consultation documents published alongside the Bill indicate that a standard assessment tool will be developed. That is an important step towards ensuring consistent implementation of the Bill across the country. I am equally pleased to see that the Bill will introduce a period of reablement. Preventive intervention, such as therapy services and aids and adaptions in the home, are proven to be cost-effective in the long-term, and can make a huge difference to the lives of people with Parkinson’s.
However, I raise a concern about waiting lists for aids and adaptations in the home, which are currently not mentioned in any of the regulations and guidance for the Bill. The Bill aims to reduce unnecessary admission to care homes, but to achieve that, it is vital that waiting lists for aids and adaptations be addressed. Although the Bill offers additional funding for equipment, which would be provided as part of the reablement process, without a clear requirement for that equipment to be delivered promptly, the Government will not be able to achieve their stated aim of reducing avoidable admissions to care homes. Is it a clear commitment that the regulations under the Bill will address that important issue?
I am also concerned that the focus of the Bill on those with high needs may have the unintended effect of diverting therapy resources from those with less severe needs. It is extremely important that preventive interventions, such as physiotherapy, are available to people at the earlier stages of Parkinson’s disease. Our inquiry showed that those services are extremely patchy and difficult to access. Provision of those services is cost-effective, and capacity needs to be increased urgently to meet the demand.
There are also a few concerns about the assessment process. In Clause 1, new subsection (4C) authorises local authorities to make a person’s eligibility for free personal care conditional on that person undergoing an intensive intervention or reablement package. Although the focus on prevention and reablement is extremely welcome, the compulsory nature of it appears to go against a personalisation agenda in some ways. Again I ask the Minister whether she can give assurances that this matter will be dealt with sympathetically.
The Bill is understandably limited and I recognise the reasons why carers’ services are not covered under the proposals for personal care. However, the APPG report found that far too many carers are struggling to get the support they need, not only to continue caring but to remain fit and healthy themselves. Can the Minister confirm that the guidance will explore ways in which carers can be supported in the rehabilitation phase of the assessment process—for example, through support such as respite breaks, training in moving and handling and in medication management?
I said at the beginning of my speech that I welcome the Bill. I certainly do and I will be supporting the Government tonight.
My Lords, I thank the noble Baroness, Lady Thornton, for introducing the Bill. Everyone who heard the “Today” programme this morning will have recognised that she will not have an easy task. If it is any consolation to her, summing up on behalf of the Opposition when the noble Lords, Lord Lipsey and Lord Warner, are in the vanguard is not exactly a picnic either.
“The present situation cannot go on much longer. People are entitled to security and dignity in their old age and so we must find a way in which to fund long-term care which is fair and affordable, both for the individual and for the taxpayer”.—[Official Report, Commons, 4/12/97; col. 489.].
Those are not my words; they were said by Frank Dobson MP when he announced the setting up of the royal commission.
Since the royal commission the Government have not stood still. They have brought forth a raft of research reports, policy papers and legislation. I pick out highlights, as noble Lords have done already, such as Sir Derek Wanless’s report in 2006, the Government’s Green Paper in July 2009, the dementia strategy and the Community Care (Delayed Discharges etc.) Act 2003. Along the way we have had rafts of research and policy papers, the National Service Framework for Older People and the falls prevention strategy. However, today we are no clearer and no nearer to answering the question the royal commission was set up to answer.
The most dispiriting thing about the Bill is that it takes us back to talking about a narrow, focused part of social care. The great tragedy is that the Bill’s production has meant that work on the costing models for the Green Paper had to stop. When we discussed this matter in the Queen’s Speech debate there was general consensus that, whatever one thought of the detail in the Green Paper, the financial modelling was crucial. The Bill has delayed that. Why is that so important? It is important because, as the right reverend Prelate the Bishop of Norwich said, this is a political issue of some importance. I congratulate the charities and the groups that have worked so hard to make this a key issue for the election.
In truth, all parties are struggling with the issue of the funding of long-term care and this important debate could not come at a worse time. We all know how bad the outlook is for the public services and public service finance. Had we had this debate 10 years ago, the atmosphere would have been different. The Conservatives have brought forward their pledge for the election—a voluntary insurance scheme which would enable people to pay £8,000 in order to meet some of the costs of going into residential care. There has been a great deal of talk about perverse incentives and there is a great deal of concern that such a policy would encourage relatives to put people into residential care before they should be.
As the noble Lord, Lord Warner, said, the Liberal Democrats have put on hold our commitment to free personal care—a decision we did not take lightly. At the same time, we also put on hold our long-held policy of funding free nursery education for all three year-olds. Passionately committed as we are to enhancing the life chances of children, I hope noble Lords will understand that the need to defer both policy commitments has come about because we are in such a difficult financial situation.
I echo the speeches of the noble Baroness, Lady Murphy, and the noble Lord, Lord Sutherland. Debates on long-term care are always a mix of high principle and devilish detail. We will support the Bill going forward, not because we think that it has general overall merit in the greater scheme of things for putting us onto a sustainable future for long-term care but because in the draft regulations and guidance we go one step forward towards something which has been lacking throughout all the debates on personal care—a definition of what it is. The noble Lord, Lord Sutherland, is right: we have known for more than 12 years that we need a definition of what constitutes social care and what will be the state entitlement that is sufficiently clear to enable individuals, by whatever means, including insurance, then to bring in their own resources to top that up. That is why there is a value in this.
The noble Baroness, Lady Campbell, referred to the question of assessment and whether we will have a critical plus band for services and, if we do, how people will be assessed. The noble Baroness loves talking about assessments—so do I. Last week I addressed the AGM of Counsel and Care, where one of my fellow speakers on the panel was Imelda Redmond, the chief executive of Carers UK. She reported that at the moment, in some local authorities, if a person turns up with the person for whom they care to an assessment meeting, the person being cared for can have their eligibility assessed as 50 per cent less than someone with similar care needs solely on the basis that they have a carer, and without that being mentioned to the carer at any point during the interview. Does the noble Baroness agree that that is wrong; that if it is happening it must stop and stop now and does not have to wait for this legislation? I should like assurances that the assessment of need will not include a carer’s contribution but that carers can be taken into account in working out a care plan.
Other noble Lords referred to the activities of daily living, but I shall not go into them because that is a matter for the Committee stage. However, I will ask the Minister for clarification about what needing significant help with those activities will mean because it is on such small details that the daily fate of hundreds of thousands of people rests. The noble Baroness, Lady Murphy, made an eloquent case for saying that we have come to a time when we have to acknowledge that assessment of people who have dementia is different and, therefore, we have to have parallel assessment criteria for them. What somebody who has capacity can manage is not the same for somebody who lacks capacity. It is helpful to have the list of qualifying services set out in the guidance.
In her introduction, the noble Baroness, Lady Thornton, talked about the criteria for NHS care. In her reply, can she say how the criteria for this policy will work with the criteria for continuing NHS care? It is not that long since local authorities and the health service were playing games with one another to see who would pick up the tab for individual people. That stopped when there was an increase in funding. It will reoccur the moment the pinch begins to fall on the public purse. A propos a point made by my honourable friend Norman Lamb in another place, reablement is a good thing and we are all in favour of it, but does the Minister agree that people who need palliative care should not be put through an assessment for reablement? That is simply a bureaucratic nightmare for people and their families when there is no need for it.
On the issue of budget allocation, the right reverend Prelate the Bishop of Norwich talked about local authorities trying to implement this policy and having to cut services for other groups of people. I think it will be different and that social services departments will sit down and look at cutting other services for older people, who are by far one of their biggest client groups. That is the tragedy of having to debate such a small and narrow-focused element of social care. Were I in the unenviable position of being a chair of social services faced with this Bill, I would have to look at the work of my department and say, “Am I going to cut the wardens in sheltered housing? Am I going to cut the transport? Am I going to cut the lunch clubs and the shopping services?” These are all services which help thousands of older people and their families to get by. Given the lack of clarity about the number of self-funders and the capacity of councils to meet the obligations which this Bill places on them, does the Minister agree that this policy needs to be reviewed earlier than the 12 to 18 months proposed, so that we can see very quickly the extent to which it is, or is not, meeting its aims? I share the curiosity of the noble Baroness, Lady Masham, as to which Department of Health budget will be cut in order to fund this Bill.
Finally, there is the proposal of the noble Lords, Lord Lipsey and Lord Warner. I have immense respect for the noble Lord, Lord Lipsey. Over the past 10 years we have done battle on this subject many times. He has consistently taken the approach that he does out of a passion for ensuring that the quality of services for older people in this country improves. I admire him for that. I am afraid we will not be supporting him on these Benches tonight. I have advised my colleagues to abstain for two reasons. The first is a technical one. We on these Benches do not intend to vote either at Second Reading or in Committee unless a matter is of exceptional importance, and I do not believe that this Bill falls into that category. The second reason is this. The Government have raised a whole raft of questions on a pretty thin evidence base. I have never read an impact assessment like it where the word “unknown” appears time after time. But having raised the debate just before a general election, the Government’s proposals deserve greater scrutiny than they received in the House of Common—although, having read Hansard, I would say that one clause got far more scrutiny than usual down another end. However, it needs to be taken much further apart.
We can all argue about the principle and wonder about the economic climate and what we would do if we had the money, but when it comes to a national care service, we are not talking about reordering providers or establishing branding and all that which goes with the NHS, but about entitlement and funding. This Bill does not address funding but it begins, in a very small way, to address entitlement. I believe noble Lords have a right and a duty to examine that in very great detail, so I wish to go forward to Committee stage in order to do that.
My Lords, it is quite clear from everything we have heard today that, rather like one of those trick diagrams where one sees either a pair of human profiles or, alternatively, the outline of two candlesticks, this is a Bill which can be viewed and appreciated from a number of different angles. One of those angles is that which the Government invite us to adopt as we consider the Bill’s proposals, and I would be hard put to disagree that the perspective of the noble Baroness, Lady Thornton, is a natural starting point in this area of policy. Like other noble Lords, I do not think that anyone could cavil at the principle of enabling people living at home who have critical personal care needs to receive such care free. It is a laudable aspiration. It is equally laudable to try to devise ways in which those who need personal care can avoid having to go into residential care, or at the least can delay doing so. Who among us, especially those of us with elderly relatives of our own, could take issue with that aim?
I begin by commending the Government on their worthy instincts. It will however be clear to the Minister that the Bill represents something rather more complicated. The Government have taken 12 years to reach this point. The Royal Commission on Long-Term Care for the Elderly, under the able chairmanship of the noble Lord, Lord Sutherland, contained some extremely valuable analysis of demographic trends and their implications for social-care delivery, and a great deal of the commission’s thinking is relevant to our deliberations today. However, one of the things that the Government took away from that report was the conclusion reached by a minority of the commissioners that free personal care for all was not an idea that was either practicable or, in terms of its net benefits, politically defensible.
The Green Paper published last year restated that conclusion on the back of some home truths. The first home truth is that the current system of social-care funding is under considerable strain. If nothing is done, it will come under progressively greater strain as we move into the future as a consequence of demographic trends. Over the next 20 years we are going to see the proportion of the working population diminish in relation to the number of people of retirement age. To fund personal care solely from taxation would inevitably mean placing an increasing financial burden on those people who are working. The problem with that is not just one of affordability but also one of fairness. A fully tax-funded system would entail a shift of resources from the young, who have relatively fewer means at their disposal, to the old, who have accumulated wealth over a lifetime. It was not surprising, therefore, that the Green Paper explicitly ruled out a wholly tax-funded system and proposed instead a number of options resting in one form or another on co-payment. The paper states:
“We think that the Partnership option should be the foundation of the new system”.
The Bill before us has been heralded as one of the building blocks of that new system, yet its proposals, as we have heard from so many noble Lords, run completely counter to the partnership option. What on earth can account for that? Neither in the Prime Minister’s speech at the Labour Party conference nor at any time since have we had an explanation as to why the Green Paper’s carefully formulated arguments, based in essence on principles of social justice, should have been ignored in a Bill that is meant to represent the very first step along the road to comprehensive social care reform. It is not as if those wider principles of fairness magically disappear. If we look at those older people whom this Bill will benefit, we see that no fewer than half are currently paying for social care, either in part or in full from their own pockets; in other words, people who by definition are not in the poorest bracket of society. Given that the windfall that those people will receive is in large measure to be funded out of general taxation, we are looking, exactly as the Green Paper said, at a large slug of public money going into the pockets of those with means at their disposal. At a time when public funds are under serious strain, it is hard to see the social justice in that.
It is equally hard to see the justice in the discrimination which underlies the Bill. One group of people with critical care needs who happen to be living at home will benefit; those whose needs are equal if not even greater, but who happen to be in residential care, will not. The Government go to some lengths to justify this distinction, but, in truth, their explanations sound pretty hollow. If it is compassion and people's level of need which have motivated the Government to act in the way that they have, why have they not tried to produce a package that would be fairer to all in greatest need, instead of just some?
Let us take the Bill on its own terms. Its key aim, as the Explanatory Notes tell us, is to enable,
“more people to avoid or delay entering residential accommodation”.
The key phrase there is “more people”. In other words, there is a test, as there always is, of value for public money. The more people who benefit from reablement and from personal care at home who are currently not in receipt of those services, the greater is the value for money. We need to look quite carefully at how many more people will actually avoid going into residential care as a result of the Bill. In a full year, the number of people in the highest category of critical need who will receive personal care at home is budgeted at 277,000. Of those 277,000 people, only a tiny fraction, under the Government's assumptions, are not currently in receipt of such care. In fact, the figures, even by the Government's own admission, are a matter of uncertainty, because nobody knows how many people there are whose needs are currently not being met in any form. If we take the £537 million that it is going to cost to deliver personal care in the home as a result of the Bill, it is clear that the net additional benefit conferred by that money will fall, first, on the 2,000-odd people who it is assumed will switch from residential care; and, secondly, on the 5,000-odd people who will stop receiving informal care and switch to social services; in other words, a very small number of additional people set against a very sizeable sum of public expenditure and therefore a very large dead-weight cost. What is the justification for that? It looks like a very poor deal for the taxpayer.
Not for a minute would I wish to belittle the value of reablement, which is the other part of this package. Reablement is a good concept, although it is perhaps just as important for us to focus on prevention as on reablement; sadly, the Bill says nothing on that topic. Nevertheless, as regards value for money, I am fully prepared to believe that, per pound spent, reablement is capable of achieving very considerable benefits. The problem with reablement, as envisaged, is the way in which it has been costed. As we have heard, just about every single figure used in the Government’s impact assessment comes with a giant health warning, but the figures underpinning the reablement calculations look particularly shaky. One hundred and thirty thousand people at £1,000 a head is suspiciously broad-brush. Those whom I have spoken to in local government say that the underlying cost assumption of £30 an hour for 30 hours is likely to be a gross underestimate of what will actually be required.
That brings us on to what the Bill does to local authorities. Local authorities are being told that they must find the money to pay for their share of the cost from extra efficiency savings. I am all for efficiency savings, but how realistic is it to suppose that authorities which are already working to achieve 3 per cent efficiency savings a year, shortly to rise to 4 per cent—a very tall order for many of them—will suddenly be able to find an additional £250 million at practically no notice? Even the Government say that these savings are achievable only over time, but local councils are not being given time: the money has to be found as from October of this year. What is more, given the chasm of uncertainty underlying all the financial assumptions, the annual cost to them may be a lot more than £250 million. We are now led to understand, contrary to what was understood initially, that if the total cost of delivering the Bill should exceed the budget, local authorities will have to find whatever extra money is required; in other words, they are being landed with an open-ended commitment. I should like to hear from the Minister why she thinks that the funding arrangements needed to deliver the aims of the Bill do not run counter to the new burdens doctrine. When it comes to placing new financial burdens on local authorities, the Government have given clear and unambiguous undertakings. I quote from the website of the Department for Communities and Local Government:
“A new burden is defined as any new policy or initiative which increases the cost of providing local authority services … Government as a whole are committed to ensuring new burdens falling on local authorities are fully funded. This commitment is called the New Burdens Doctrine”.
It defies explanation as to why the Government believe that this Bill does not break faith with that commitment.
The squeeze on local authority finances caused by the Bill will be of the severest kind, and it is not hard to imagine what will happen. In the first instance, there will be a stampede of applications for free personal care. When the money available has been used up, local authorities will do their utmost to avoid having to take more people on to their books, and we will find pressure being placed on the elderly to move into residential care instead of staying at home. It will prove harder for people to pass the test of eligibility. Alternatively, or perhaps additionally, in order to fulfil their obligations to those in critical need, councils will be forced to remove social care funding from those who are in lower categories of need. To the extent that this happens, it may drive some people out of their homes and into residential care, thereby serving to dilute the main benefit of the Bill, which is supposed to be to enable more people to avoid or delay entering a residential setting.
These are some of the perverse incentives which the Bill is likely to create. It is inevitable that the ability of the system to look after an increasing number of elderly people in their own homes, however that care is funded, will vary from council to council, if only because of the lack of available manpower. No thought appears to have been given to the training requirement implicit in these proposals or the need to deliver care to an acceptable standard of quality. One is led to the inescapable conclusion that the speed at which the Government are aiming to roll out this policy is grossly imprudent. It is bound to disappoint a lot of people and it will give rise to false hope among those in critical need who find that they are denied free personal care because they fall the wrong side of a certain definitional boundary. A spate of legal challenges seems almost inevitable.
A national policy for care of the elderly requires a long-term view. Hence, any new initiative has to pass one test above all, and that is the test of sustainability. I fear for this Bill because I do not believe that its provisions will prove sustainable in the long term. The haste with which it appears to be have been devised has led some to think that its arrival in Parliament is less about delivering long-term reform and more about playing to the gallery. For all the reasons I have given, I suspect it would not take a jury long to decide which view they preferred.
My Lords, as we might have expected, we have had a lively and informed discussion about the important issues touched on by this Bill, and indeed beyond them. We know that while this is a short Bill with just one substantive clause, it will have great significance for thousands of the most vulnerable adults and older people. I acknowledge that many of the issues that have been raised are about the Bill’s implementation, and that is absolutely right. I expected that and informed the Bill team and everyone else that that is what your Lordships’ House would concentrate on.
Before I deal with the large number of comments that I want to take up, to make and to answer, perhaps I may remind noble Lords that 400,000 people with the highest needs will benefit from the Bill. Some 280,000 of those with the highest care needs living at home, many of whom have already been paying for a long time a great deal of money to fund the cost of their care, will be helped by the Bill, and it will help to end the lottery of personal care charges. It will enable us to give them and their families some reassurance that their personal care will be provided free of charge regardless of postcode.
I turn to reablement, and here I agree with the noble Baroness, Lady Gardner, who said that this was a new word for her. It was for me a month or so ago, but I cannot think of another word that describes what we are trying to do any better. I am sure the noble Baroness probably will be able to do so, but it means helping people to remain healthy and independent in their own homes for as long as possible, and at home is where most people tell us they want to be. It also supports the prevention that we want to put at the heart of the system and builds on the progress we have already made towards personalising services, supporting carers and focusing on the dignity and quality of services. We believe that the Bill will build up the momentum towards the important steps that need to be taken to achieve a wide reform and creation of a national care service.
Several noble Lords made the point that they did not believe the Bill had received enough scrutiny in the Commons. The noble Baroness, Lady Barker, answered that extremely well indeed. The Bill received a full day on Second Reading and a full day for the Committee stage—for a one-clause Bill. There is no question but that Members of the other place had their say. One has only to look at the record to see that. I disagree profoundly with my noble friends Lord Warner, Lord Lipsey and Lord Joffe. We think that this Bill will enable us to do the right thing now. It will end the postcode lottery, remove financial burdens and give real help to those with the highest care needs.
What I should like to do is go through some of the remarks made by noble Lords. I shall deal with as many as I possibly can in the time available, but I am mindful of the hour and the fact that noble Lords may want to get to their dinner at some point. The noble Baroness, Lady Gardner, made a series of points about meeting the costs of training a larger workforce. The issue was also raised by many other noble Lords. The adult social care workforce is made up of 1.5 million workers who are all delivering these vital services. As the services evolve, it is important that employers respond to ensure that their workforce is deployed and equipped to deliver them. In the case of personal care at home, we intend to specifically support council employees through helping to devise training tools. These are being developed by the Social Care Institute for Excellence right now. I was also interested in the noble Baroness’s wise words about her work as a local councillor. She talked about councils having to trawl through their records. The point is that councils are already aware of the needs of people who are already receiving care, but for new people there will of course have to be assessments. That is why we are providing an additional £27 million to cover the administrative costs.
The noble Baroness and other noble Lords raised the issue of where the funding is to come from. It will be provided by the Department of Health, not the NHS, and will come from budgets that are to do with research and development, communications and consultancies. It is not coming from any budgets that affect front-line services or indeed the essential research mentioned by the noble Baroness and the noble Baroness, Lady Masham, into cancer and other important commitments that the Government already have.
The noble Baroness, Lady Campbell, asked various questions. First, perhaps I may say that, as concerns her role in the commission for equality and human rights, of course we are seeking the commission’s advice and we will be having discussions. We regard the commission as a partner in the consideration of how this Bill should move forward. She also asked if we have evidence about the cost and dependency reductions of reablement. The research we refer to is the “use of resources” report, published in November 2009. It showed that 50 per cent of people who underwent reablement had reduced care needs following it, thus reducing the cost of meeting their overall care needs.
Both the noble Baroness and the noble Baroness, Lady Masham, asked whether people would be forced to do this, and I think that the noble Baroness, Lady Barker, raised the issue of people receiving palliative care. I agree absolutely with her that of course that would be inappropriate in terms of what we are intending to do here. However, it will be for local councils to decide whether an individual would benefit from reablement, and local authorities are best placed to work with service users. We in turn will work with local authorities to ensure that there is strong guidance on access to care, an issue we have discussed in the House on several occasions. It is important that the guidance produced as a result of this legislation is strong and coherent, thus helping to take forward joint working between the care services and the National Health Service.
The noble Baroness of course also asked if the care will be portable. We believe that there should be greater co-ordination between councils of people’s care packages when they move. As she knows, we are in favour of a move towards the portability of packages and that is being looked at in the context of the care and support Green Paper. I suspect that we will return to this discussion in Committee, which is exactly why we need to move forward with the Bill.
On the guidance and regulations to ensure that service users are involved in the assessment, the guidance that will accompany the Bill will make it clear that councils should involve individuals in the assessment process to appropriately and sensitively consider their needs. We will introduce an assessment tool to help councils to work with individuals across the piece to assess those who have the highest personal care needs. By offering £130 million to councils to further develop their reablement services, we hope that people will be able to increase their ability to live more independently and reduce their levels of dependency.
I confess myself disappointed with the right reverend Prelate’s remarks, as well as surprised. I take this opportunity to ask the right reverend Prelate, with every respect, to reflect on the letters to my honourable friend Phil Hope from carers’ organisations, disabled people’s organisations and Help the Aged, which urged this House to get on with its job, consider the Bill and take it forward. The right reverend Prelate asked what assurances there are that care will be provided in the most appropriate setting. The object of our proposals is to help people to live as independently as possible for as long as possible in their own homes. I shall return to the issue of homes, which noble Lords have asked about, because it is appropriate that we address that.
My noble friends Lord Warner and Lord Lipsey were very critical of the Bill and made a lot of remarks about why they disliked it. A lot of my remarks will cover some of the points that they made. My noble friend Lord Warner used the word “cruelty”, but the cruelty that he mentions would be in not going ahead with this Bill and not benefiting the thousands of vulnerable adults and older people, as it seeks to do. We expect to discuss this issue with the ADASS and local government; we will be discussing all that in Committee. We are already talking to many expert stakeholders; we are not waiting for the consultation process to finish but have been having an ongoing dialogue. Listening to my noble friends, I reached the conclusion that they are actually opposed to this Bill. I suggest that they stop pretending that this is about parliamentary scrutiny; this Bill will have a great deal of parliamentary scrutiny in this House. I have worked with noble Lords across the House for the past two years in scrutinising Bills that concern care, and noble Lords will know that I commit myself to ongoing discussions and that I have a record for delivering change where change is possible on Bills. That is the commitment that I make to the House now, about how we will take the Bill forward if it goes to the next stage.
I am very fond of my noble friend Lord Lipsey, so I can say with affection that he sometimes overstates his case about things that he feels strongly and passionately. Comparing a Bill that benefits so many vulnerable people to the poll tax Bill is a case in point. We are not rushing at this and I do not think that your Lordships' House will allow us to do so; we will want to have the discussions that are necessary to take this Bill forward. I urge my noble friend to use his undoubted talents to help us to do that and to make the reforms rather than try to halt the Bill’s progress.
The noble Baroness, Lady Masham, asked a variety of questions about where the money will come from, and I hope that I have assured her about that. She raised the issue, as did other noble Lords, about the bureaucracy that might be involved in the assessments. That is a very legitimate point to make. I read the consultation document and have some sympathy with that view; it is exactly why we need to have the scrutiny that this House is so good at. We have a lot to say about that bureaucracy, and the Government need to listen to what noble Lords have to say about it.
My noble friend Lady Turner made some powerful points about the need for this Bill and rightly talked about the fact that this is about individual vulnerable people and their families. She rightly pointed out the firm support that carers’ organisations have given to this Bill.
The noble Lord, Lord Best, and others mentioned housing and homes. I think that that is absolutely right. The cost of the package of reablement can vary, as such packages may involve a variety of interventions. Packages should be developed by the local authority in conjunction with individuals. The noble Lord will know that councils already have responsibility for making adaptations through the disabled facilities grant. It will be open for them to assist people with adaptations to find what is needed and how it is needed.
The noble Lord, Lord Joffe, raised a number of points. He is mistaken to cast doubt on the ability or willingness to implement this Bill. I remind him that most care workers and most local authorities do a very good job and strive to do better, and it is up to us to help them to do this. I disagreed with the noble Baroness, Lady Murphy, and her analysis of the Bill. She was a bit cavalier in her dismissal of the elderly organisations that support the Bill, and I ask her to think carefully about dismissing so lightly the support that the Disability Alliance, RADAR, the Independent Living Organisation and carers’ organisations have given this Bill. That support is not given lightly; these are not organisations that would do the Government’s bidding—quite the reverse. Some of them have made my life extremely difficult in the past year or so.
My noble friend Lady Pitkeathley rightly referred to the Joseph Rowntree Trust and I echo her remarks wholeheartedly about the motivation of carers. Guidance needs to be very clear about carers and we have to start the discussions about that in the next week. That is the commitment that I make to the House.
My noble friend Lady Wilkins asked about the Bill doing more about adaptations in people’s homes. I have addressed that to a certain extent, but she is right to say that these are very important points about the state of people’s housing and how we can reflect that in the implementation of the Bill.
The noble Lord, Lord Sutherland of Houndwood, spoke about crumbs and I am very grateful for them. We believe that this is a step in the right direction for the national care service. His remarks made me reflect on the fact that often the way to get people to work together across the piece is to get them to do something together in the first place, which this Bill will do. Taking money out of health and putting it into this limited area for the most vulnerable will help us along the road. We do not think that the Bill contradicts those wise words about support to the elderly and the need for equity and fairness in the Green Paper and the White Paper that is coming along. It will help us with the aims that we have over the larger issue.
I invite the noble Lord, Lord Low, to use his skills as a parliamentarian to work with us to make this Bill and its guidance stronger and more effective. We have not claimed everything for this Bill, but we claim some good for it. I hope that he will think about putting his shoulder to making the wheel turn better. He made comments about bureaucracy and who would benefit and extending the benefit. I very much want him to be involved in Committee.
The noble Lord, Lord Carter of Coles, made a wise contribution. He asked about the link to the national care service. As I have said, the Bill is not part of, but is a step towards, setting up such a service.
My noble friend Lady Gale spoke with passion about Parkinson’s disease and the support for the Bill from those with Parkinson’s. She talked about carers, and I am pleased that Carers UK and other stakeholders have given their support for the Bill. I add that the experience in Scotland has shown that many carers continuing their caring role were able to shift the balance of care that they were providing by focusing on other tasks to support and improve the lives of elderly and disabled people.
My noble friend asked about waiting lists for aids and adaptations to be addressed in regulations. Councils are responsible for managing waiting lists, and the use of aids and adaptations will be addressed in guidance.
The noble Lord, Lord Turnbull, made some highly political remarks, I think that he has misunderstood the point of the Bill; it is about those with the highest needs who should receive the greatest care, and I would have thought that we would agree about that.
The noble Baroness, Lady Barker, made several important points about eligibility, carers, reablement and people who need palliative care. I think that I have addressed most of the issues that she raised but, if I have not, I will certainly write to her. I agree with her remarks about the need to get on with considering the Bill and taking it to its next stage.
The noble Earl, Lord Howe, raised the issue of whether the Bill is in conflict with the Green Paper. We do not think it is; in a bit of a reversal of roles, we think that it is a redistributive Bill while the noble Earl does not, and I suspect that we will need to tease out in Committee why that is the case and what it is about. On the specific issue of new burdens in legislation, the thing about new burdens is that they are about unfunded initiatives. The cost of free personal care will not be unfunded, though; it will have £670 million of funding in its first year, of which £420 million will come from the Department of Health, so it does not fulfil the criteria of the “new burdens” issue.
I finish by telling noble Lords what other organisations have said to us about the Bill. RADAR welcomes the Bill, which it says has the potential to improve independent living opportunities for at least some disabled people with the highest care needs. The Equality and Human Rights Commission says that it broadly welcomes the Government’s commitment to provide personal care free of charge in certain circumstances for people with the highest need. Counsel and Care, a charity for older people, their families and carers, says that it welcomes the Bill, which aims to introduce free care at home for people with the highest needs. Carers UK says that it supports the Bill, which will help thousands of families caring for people with severe conditions such as dementia or Parkinson’s disease at home, and it has been calling for this for a long time. The Parkinson’s Disease Society says that it welcomes the Bill with its focus on the immediate improvement of social care services, and particularly welcomes the commitment of new money into the social care system.
I thank noble Lords for their valuable contributions, but we now need to move on to the next stage of the Bill.
Amendment to the Motion
At end insert “and that the Committee shall not meet until Her Majesty’s Government have completed, and published their response to, their consultation on the draft regulations which may be made under the Act, if passed”.
My Lords, I take my chastisement from my noble friend like a man, but I do not resile from a single word of what I have said; I would prefer to be in the company of some of those who spoke supportively because I think history will show us to have been right.
A very large number of concerns have been raised today about the affordability of this, whether we have the figures right on the funding, the administration of the complex new system and the sustainability of this proposal. However, we have not spoken much about the fact that it is only eight months from today that the Government have said that they will have the scheme up and running. Many of us have considerable doubts about our ability to implement this and not let people down after the promises that have been made.
I tabled this Motion because the Government have said that they will devote only one day to the Bill in Committee. A host of things are of great concern to many of the people who have spoken today about the practicalities of implementing it. It would be easier to get the Government’s business through in one day if we had actually completed the process of consultation on the content of the regulations and guidance, and we had had from the Government their responses to it. As things stand, I understand that we will not have completed that process of consultation and we will not have that response from the Government about the outcome of it, so we will have to probe all that in Committee in one day without the advantage of the knowledge from the completion of that consultation. That strikes me as a very tall order, so I beg to move.
My Lords, I will not detain your Lordships for long but when the House was a good deal emptier than, for some strange reason, it is now, the noble Lord, Lord Sutherland, suggested that this was a wrecking amendment. I make it clear that it is not. The responses to the consultation have to be in by 23 February, though the Government asked that they be submitted by 26 January. For the Government to respond to that consultation need not take more than a week or two at the most. We can be in Committee, even if my noble friend Lord Warner’s amendment is accepted, by the second week in March, and the Government can have their Bill long before the date on which some other event might come along and interrupt our proceedings. It is not a wrecking amendment; it is an amendment to take the Bill in an orderly way, and I commend it to the House.
My Lords, I support the amendment. A number of us have been reflecting on whether the way that this House scrutinises legislation has yet reached perfection. One of the principles that we are looking at is the question of how the House looks at whether legislation is ready to come to this House. It is apparent to a number of us that the Government ought to make clear before they introduce legislation what their policy position is in sufficient detail to understand it, how they have consulted and what the consequences of that consultation are, and that the detail of the legislation is clear enough that the House is able to scrutinise whether it will actually achieve the policy objectives which the Government are advancing.
I am not an expert on the content of the Bill, but it seems to me from the debate I have heard today that it fails these tests in a number of ways. This is a massively important issue. There is hardly a more important issue facing public policy than how you address the challenge of coping with care for adults when we are faced with demographic changes over the next decade. The Government have, rightly, been struggling thoughtfully with that issue, as evidenced by the Green Paper. As a consequence, this is a huge policy shift, but we have not been given an explanation of the reasons for that shift. We do not understand how it will work in practice, nor what the consequences of the shift will be and for whom. We are certainly unclear whether this shift is sustainable: we see the trail of that in signals that this is only going to last for 18 months, with the hint that maybe it is going to be knocked on the head.
I would not normally speak against my Government in this way, but I do not believe I am actually doing so. Allowing the proper consultation to take place, particularly on the regulations, allows the House to be better informed and do better scrutiny in Committee. I speak with the experience of the Merits Committee behind me; these are important issues that should be transparent. I therefore support my noble friend Lord Warner.
My Lords, I only want to add one sentence: for the reasons that have been given, I urge all those who care about the role of Parliament in these matters to support the amendment. We damage the House’s reputation if, on a matter as important as this, we do not show that Parliament takes its responsibilities seriously.
My Lords, at this stage I must set out very briefly a few issues responding to my noble friend Lord Warner’s amendment and points other noble Lords have made.
In a personal comment to the noble Lord, Lord Warner, I say that he should have some faith and join us in making this happen on 1 October. I also say that to my noble friend Lord Lipsey.
The support that many stakeholders and charities have given this Bill has not just come today; it has been going on for months and months. That discussion continues right through the production of the draft guidance. All these organisations are taking part in good faith and I ask noble Lords to join them in doing so.
We have a duty in this House to ensure we appropriately consider the matters put before us in this Bill. The right place to do this is in Committee and indeed at other stages of this Bill. Noble Lords have suggested that we are just going to have a day in Committee. That is, of course, not true: we will also have the other stages of this Bill.
We should not be here to impede the passage of such a Bill. Let me be clear: this amendment from my noble friend is a wrecking amendment. It would do that, and it would in effect prevent the people who are most in need of receiving this personal social care at home from having it provided.
Noble Lords who have worked with me in the past on Bills will know I am completely committed to discussing these issues right across the House, and I will do that from tonight, if they wish.
I remind noble Lords once more that we have the opportunity in Committee to discuss this further, and I suggest that is when we should do it. I ask the House to reject my noble friend’s amendment, see it for what it is, and let us get on with our job.
1 February 2010
Division on Lord Warner’s amendment.
Amendment disagreed.View Details
Bill read a second time and committed to a Committee of the Whole House.