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Care Services: Elderly People

Volume 743: debated on Wednesday 6 March 2013

Question for Short Debate

Asked By

To ask Her Majesty’s Government what steps they are taking to improve care in the community for elderly patients.

My Lords, I am grateful for the opportunity to open this debate, even though I suspect that many noble Lords might share a faint sense of déjà vu about this topic. However, the fact that care in the community keeps reappearing on our agenda suggests that, despite numerous impressive reports and repeated debates in this House, we are not yet anywhere near solving the problems.

I suspect that few here will admit to any ignorance of the facts, so I hope noble Lords will forgive me if I start by reiterating the nature of the difficulties we face. It may save others having to repeat them. First, the country has entered a prolonged period of severe economic constraint, so there is little new money available centrally. Secondly, we have no control over the demand for social care that is growing at a remarkable rate.

The population is ageing as life expectancy goes up in an inexorable straight line. The current 3 million people over the age of 65 will rise to almost 5 million in the next 20 years, while the number of over 85 year- olds will double from 1.3 million to 2.6 million. We would celebrate this extension of life were it not for the fact that the number with multiple chronic diseases will also increase by about a third, while the number of those with dementia is set to double from the current estimate of 800,000. If that is not enough to frighten you, there is the statistic that one in three people over the age of 85 will develop dementia. That is what I am told. Many of these people end up in an acute hospital, the place least suited to their needs, and the number lingering there unnecessarily is huge. Of the over 85 year-olds admitted, some 140,000 stay for more than 30 days, and the numbers are rising. A diagnosis of dementia is the primary reason for admission in some 55,000 patients a year, in the majority of whom the diagnosis had not been made before admission. Where, I wonder, were the GPs?

These patients are admitted, but too often there is nowhere else for them to go. Social services departments are sorely underfunded and about four-fifths of local authorities are now said to be restricting social care to those with needs graded as substantial or critical. There is a black hole of some £16.5 billion looming in social care funding over the next few years. The gap between the money needed to meet demands and that available is growing year by year. Here we have the nub of the problem—increasing demand from an ageing population acquiring multiple long-term illnesses and a veritable epidemic of dementia, together with social services departments stretched way beyond their capacity now and with a future in which they will be unable to deliver even the basics of care, and all against a background of severe constraints on the money available from government.

We cannot simply go on as we are and try to patch up the current system of an NHS designed for acute hospital care, essential though that may be, while the desperate need is for prevention and the long-term care of the elderly. We must start now to develop a long-term plan to meet these problems. My first question to the noble Earl is: is there any sign that the Government are thinking along the lines of long-term future planning?

At the end of the day, we must ask ourselves where the money is to come from. Of course, some measures could be taken that would help a little. The poor co-ordination between care workers in hospital and in the community has been resolved in a number of well recognised places around the country and more should be done to spread that good practice. Of course, there may be efficiency gains to be made somewhere in the system. Then there is the recent government initiative in the wake of the Dilnot report to help the elderly pay for their care. Will that ease the financial burden on local authorities? I fear not, because although it offers some help to the elderly themselves, it seems more likely to add to the problems of local authorities than to help them.

Then there are the usual calls for funds to be transferred from the supposedly cash-rich NHS to social services. I am very supportive of proposals that NHS and social service budgets should be pooled to fund care for the elderly. That makes a lot of sense and I was happy to see something along those lines in Andy Burnham’s recent speech about a future Labour health policy. We need to think, too, not only about merging budgets but also medical and nursing staff so that they can work across the boundaries between hospital and community. We also need to look critically at how we can incentivise and support GPs who are really the key players in the community. It is far from clear whether they are prepared in the CCGs for commissioning long-term care. Will the noble Earl tell us whether any attention is being focused on the role of GPs there?

What about closing hospitals or beds and transferring the savings? Data showing that up to a third of acute hospital beds are occupied by patients who should not be in hospital at all provide ammunition for those who see considerable savings from cutting bed numbers. That is not easy. If we try to go along that route, we have to look at where the costs of acute hospitals really lie. They lie largely in the staff and relatively less in the number of beds. The workload for the medical and nursing staff of acute hospitals is not determined by the number of beds, or even by the number of long-stay patients, but by the rising tide of acute emergency admissions. It is hard to escape the conclusion that we are not well off in NHS hospital services. Hardly a day goes by when we do not hear of failings in the care of the acutely ill.

If wards or even whole hospitals were to close, that acute workload would not diminish. Indeed, the more rapid throughput of patients through a smaller number of hospital beds would increase the intensity of the work. I am not saying that there would not be any savings made on, for example, heating and lighting bills and perhaps on administration, but the savings to be made, especially on doctors and nurses, would be rather less than one might hope. That may account for the intriguing piece of research evidence from Julien Forder, who published a paper in the Journal of Health Economics in 2009 in which he showed that for every pound spent on community services it was possible to save only a third of a pound on hospital services. Caring for someone in the community is not a cheap option.

Meanwhile the NHS itself is under remarkable cost-saving pressures as it seeks to answer the Nicholson challenge. Hospitals are barely coping in many instances, and the prospect of diverting even more funds is likely to be impossible to bear. I am not suggesting that rationalisation of services into a smaller number of specialised centres is not a good thing—it clearly is—but closing acute hospitals to save money simply to transfer it into the community does not bear too close examination. In any case, there are the calculations suggesting that there will be a shortfall in NHS funding of some £30 billion per annum by 2020 on current trends, so the question remains: where will the funds for social services come from? It is difficult to see much coming from simply integrating NHS and social service budgets, desirable though that may be. Simply pooling two inadequate sources of money does not sound like an answer to me. We have to face the idea that the Government of the day, whoever they are, will have to give a higher priority to care in the community than they have currently been able to do. It is a political decision, and we must think more broadly than simply within the box of the Department of Health.

Are there are any discussions going on between government departments— housing, transport and so on—on plans for future care in the community? How much priority are Governments as a whole willing to give to this compared, for example, with a high-speed train or nuclear submarine, desirable though some may think they are? Do they have a higher priority? These are decisions that only a Government have to face. I do not envy them for that, but in a democracy such as ours I do not believe it is entirely wishful thinking to feel that a clear majority of the population would strongly favour a diversion of resources to areas that they think are of high priority, and I can think of few higher priorities than the way we care for our elderly.

My Lords, I start by thanking the noble Lord, Lord Turnberg, for bringing this important issue to the attention of this Committee. He has adequately covered areas of the economy, so I shall leave that. Care in the community is a critical component of our current health system and an even more critical component of our future health system, and we must ensure continued support for those who require and provide this vital service.

Today I wish to touch on a few distinct aspects of this issue. First, I want to highlight the growing demand for care in the community for the elderly population. As we are all certainly aware, the elderly population are particularly vulnerable to conditions that require long-term care which, if left untreated, can lead to a revolving door of hospital care for the elderly, which is both unhealthy and costly. Building on this, I want to draw attention to the ways in which the newly established clinical commissioning groups can work to improve the quality of care in the community as well as to encourage the use of this type of care. Finally, I will pose three questions to the Minister that reflect my concerns and hopes for the future of care in the community for elderly individuals.

Older people already represent the largest cohort of patients in the NHS, accounting for 60% of hospital admissions. Hospital days are dangerous for elderly people and expensive. Patients are susceptible to infections in the ward and often fail to eat properly while staying in the hospital. Moreover, these stays can encourage a loss of independence, which leads to added problems on discharge. Home healthcare is proven to deliver better outcomes for patients. There is evidence that it can lead to lower costs and reduce admissions to hospital. Home-based models of care have proven to be effective for patients with multiple diagnoses and comorbidities with a high risk of hospitalisation. According to Department of Health statistics, during September and October 2011 some 128,517 hospital bed days were lost as the result of the delayed discharge of people who could have been cared for in the community had the right support had been available.

In order to provide care in the community that is of the same quality as a hospital environment, CCGs must ensure collaboration between acute care, community care and social care. This was clearly called for in the Health and Social Care Act 2012, and we expect CCGs and local authorities to be actively pursuing this practice. It is particularly important for elderly patients as long-term conditions associated with old age are particularly complex to treat and often involve several different types of health and social care intervention. These services are provided over months and years by a range of organisations in the public, private and voluntary sectors, and it is hard to split them into single episodes. Pathway design is a critical and urgent task for CCGs to engage in.

In order to delay acute care for our elderly citizens, we must also refocus our energy on prevention. Joint strategic needs assessments must emphasise the value of preventive care for the elderly, including simple things: measures to decrease falls, improve nutrition to prevent diabetes and encourage community-based programmes such as Dementia Friends. Here the involvement of the voluntary sector can often be critical.

Part of the prevention agenda is about combating loneliness. Isolation is associated with poor physical and mental health in older people, both conditions that undermine the health we seek to provide our citizens. Local providers work together to address this issue and must not fall short in this critical area of care, because it is care. Social isolation affects about 1 million older people and has a severe impact on people’s quality of life in old age. Mentoring projects, befriending schemes and computer classes form part of a solution built to engage an elderly population in their community.

The patient must be at the centre of every health and care system we create. The location and community in which we choose to spend our later years deeply affects our quality of life. By supporting people to remain in their homes for as long as they wish, we provide an invaluable service to those patients we serve. In light of these remarks, I ask the Minister to confirm the following three expectations that relate to CCGs. CCGs will be expected to work alongside local authorities on integrated care pathways for the older population in the community, which might or might not involve shared budgets. CCGs will be expected to enhance preventive services in the community to reduce unnecessary hospitalisations. They will also be expected to embrace a campaign against isolation in the community, working with local authorities, especially among the elderly who wish to stay in their homes.

My Lords, I too thank the noble Lord, Lord Turnberg, for raising this debate. I declare an interest as in the register, and add that I live in a retirement village, I am elderly and I live in a rural area where the boundaries have a postcode lottery as far as health and social care are concerned.

The Health and Social Care Act will be enacted in one month. There is a mandate from the Secretary of State to the Commissioning Board and guidance from the Commissioning Board to the CCGs. We have the theory and we must now enter the practice. The demand now and in the future, as has already been mentioned, will increase among the growing number of the elderly in the population, and we need to ensure that their health is maintained, disease prevention addressed and high-quality, safe, acceptable care given when required, with the emphasis on independent living in the community and, where necessary, adequate support given to allow this to happen. For example, prevention of admission to hospital teams can supply the necessary support to the elderly living alone to remain in their home surroundings, where they will benefit more than they would from an admission to hospital that would be more costly and open to possible cross-infection, leading to a longer recovery period. This is a cost-effective and care-effective way forward.

My first question to the Minister regards integration of organisational services and professional boundaries. What steps are the Government taking to ensure that the theory of the Act, mandate and guidance is being followed, with required training for all concerned? The reason for this question is that currently in many places there is a chaotic situation where, through the lack of training and understanding, care pathways are disrupted and there is evidence that services are not running smoothly and the safety of the patients is in question.

Currently the ambulance services are on red alert due to winter pressures and there are reports of ambulances that are unable to unload patients causing a backlog, with patients being cared for either in the ambulance or in a cold, draughty corridor for long periods before A&E takes over because of the four-hour wait deadline. Those ambulances therefore are not free to take any calls or discharges home. About 10 days ago at 10 pm, there were eight ambulances stuck for over an hour at our local hospital. Last night at 9.30 pm, I checked the local situation. There were four ambulances outside the hospital. One had been waiting for one hour and 15 minutes, one for 36 minutes, one for 20 minutes and the other for 10 minutes, with the crew looking after the patients. It appears that sometimes, to alleviate the logjam, one crew will care for two patients—two ambulance loads—in order to free up an ambulance. It would seem that there are insufficient staff to relieve the ambulance crews and, if they do, it starts the four-hour waiting time clock. The circumstances that I mention involved a majority of elderly patients. Can the Minister assure noble Lords that the Government will take steps to ensure that every opportunity is taken to improve the integration of services in health and social care?

Innovation and research is my next area of concern. The care of the elderly has lacked funding for research into physical and mental conditions, and this situation needs to be rectified as a priority. However, there have been examples of excellent innovations being developed through specific studies undertaken by healthcare professionals as part of scholarships or fellowships. Two come to mind; one involved a nursing scholar who, on an international study, was able to learn about the early detection and diagnosis of melanomas and, on return to this country, has followed this up with a training programme for GPs. The second example was someone who, on her return from the USA, aimed to reduce the mortality rates by introducing specific care bundles. Medical and nursing staff became engaged on her return, with excellent results and, in many places, there is a marked reduction in mortality rates as a result. Can the Minister assure us that there will be an equitable amount of funding for multiprofessional research and innovation specially allocated to physical and mental health, including social care for the elderly?

No Act, mandate or guidance will be effective unless there is inspirational leadership. In my experience, such leadership is not learnt by attending a course for senior managers; it has to be bespoke and fitted to the person’s potential and ability to set the values necessary for high-quality, safe and cost-effective delivery of care. I am president of the Florence Nightingale Foundation and we are able to fund 19 leadership scholars each year. They go through a bespoke leadership programme, funded mostly by the Burdett Trust for Nursing, as well as by contributions from other smaller charities. This has resulted in scholars being promoted and successfully leading services. I ask the Minister if this matter could be explored further with the NHS Leadership Academy and Health Education England to examine bespoke approaches to specific services, especially, and as a priority, to those concerned with the care of the elderly.

My Lords we are all grateful to my noble friend for securing this debate and for his usual masterly introduction and analysis. Whatever our views on the right size for the total health and social care budget, it will always have a cash limit and, in the long period of fiscal austerity we face, that limit will be very constrained. That makes it imperative that we get our expenditure priorities right, especially in relation to the NHS. Our failure to do this is damaging care of the elderly at a time when we are all living longer and, on present demographic evidence, will continue to do so. The number of over 85s will double to 3 million by 2030, with increasing numbers suffering from dementia, as my noble friend has mentioned.

I will confine myself to three strategic points. First, we may be living longer but we are not living healthier lives when compared with many other affluent countries. We are 12th out of 19 such countries, according to a recent study by the Institute for Heath Metrics and Evaluation in Seattle. We can expect in this country 68.6 years of healthy life from birth before disease and disability take their toll. This compares with 70.9 years for Spain, which is top of the pops. Better healthcare is unlikely to change our position much, but a higher priority for expenditure on public health and prevention services is more likely to do so.

Secondly, the balance of what we spend on the NHS and social care is fundamentally wrong for our demographic and disease profile. Under successive Governments we have overfavoured the NHS and have neglected adult social care. There is, however, an opportunity to change this with the proposed Care and Support Bill, now undergoing pre-legislative scrutiny. Here I declare my interest as a member of the Joint Select Committee that will report shortly. That Bill has received a wide measure of support, publicly and politically, especially for its provision for an overarching principle of securing well-being for the recipients of care and support services.

We will no doubt debate the committee’s findings another day. All I want to do here is register the widespread concern that exists that the Bill’s reforms, including the Dilnot changes, will not be adequately funded because of the existing shortfall in funding that has developed over the years. I do not blame this Government particularly for that. In my view, that shortfall now stands at about 10% of the adult social care annual budget, or approaching £1.5 billion, and I suggest it is growing despite the Government’s partial efforts to close the gap. We must not pass a reforming Bill without appropriate funding to implement those much needed changes.

Thirdly, and finally, we need to re-engineer and rebalance our healthcare services and associated expenditure away from our preoccupation as a country with 24/7 services delivered through acute hospitals to more community-based services integrated with social care. Here I may diverge a little from the approach of my noble friend. The core business of the NHS is care with an acute treatment adjunct, not the other way round as it has been for 60 years. We cannot carry on with this pretence that it is in the best interests of patients to have so many clinically and financially unstable and unsustainable district general hospitals claiming to provide a wide range of 24/7 acute services. Do not believe me: listen to what specialist clinicians are saying, particularly the current president of the Academy of Medical Royal Colleges. Sir Terence Stephenson said last July:

“I don’t think it is possible in quite a small country ... to have 200 to 300 24/7 acute centres offering every single discipline … we need to move to a smaller number of bigger centres giving treatment that’s either hi-tech, risky and rare”.

I do not have time to develop this theme today but will return to it in one of our NHS debates next week. Suffice it to say that we need to start educating the public on the need, in their interests, to consolidate these acute services on fewer hospital sites and to create a 10-year development programme and funding for integrated 24/7 community-based services embracing primary community health services—including mental health services—and adult social care. I recognise that none of this will be easy for elected politicians but this direction of travel is inevitable if we are truly interested in preserving our NHS and meeting the needs of our growing elderly population in a sustainable way. I hope the Minister will feel able to reflect seriously on this kind of reorientation as the Department of Health prepares for the next public expenditure review.

My Lords, I also appreciate the opportunity to take part in this debate. Other noble Lords have much more expertise than I have, but I put my finger very gently into the water because this is something I experience. I am a Methodist minister and all my life I have been involved in the care of older people. I look now in my daily newspaper at the births, marriages and deaths, and whereas some years ago the majority of people died in their 60s and 70s, now we have them at 80, 90 or touching 100. This has changed the whole atmosphere and situation that we need to come to terms with.

In rural areas particularly these needs are very acute. A village community will support a person in that village. That person will feel part of that community. Some have lived there all their lives. They know the village and the people around them. Then suddenly everything has changed. I can think of a mixture of places where there were once shops. One village at the end of the war had 29 shops but has no shops now. If you do not have a car, you cannot get away to get your shopping. You cannot get to the post office now, but in any case the way pensions are paid has changed. The bakery has gone. We used to enjoy the bakery and friends of mine ran it. We had five chapels in the area and now four of them have closed and the village church is struggling. The choirs and bands that we used to have belong to yesterday. I did not think that I would ever support the case for keeping pubs open—Methodist ministers do not do that usually—but every week 16 pubs close. They, like the chapel or the church, were a vital part of the community where people could meet, but that is no longer the case. The doctor’s twice-weekly surgery is no more. Two banks used to come on a Friday morning. The banks do not come any more. In many cases, the small neighbouring hospital is already closed and in other places there is great anxiety because the hospital is under threat of closure. In Wales health is devolved, and I wonder whether we could not somehow relocate some of the specialist services that do not need as big a back-up as others, such as rheumatology or dialysis, so that those services would be the core that would justify the existence of that hospital which could then be involved in wider care in that community. I know the arguments for big hospitals. They are great arguments, but families have to travel.

In rural areas, bus services have been decimated. Your friends are elderly and cannot travel very far. We have these problems. In North Wales, we have problems with hospital closures. I ask that people think about whether we can do something in order to have beds available near the community from which that person comes. My mother-in-law kept the local bus service going. She lived in a village four miles from where I live. I used to offer her a lift home when she was 88. She would say, “I’m not having a lift with you. I’m the only passenger on the bus, so I’ve got to keep going on it”, but when she went, the service went as well.

Every part of the community is weakened by the change in lifestyle and so on, especially for older people. There must be intervention to improve the quality of life, the well-being, of the individual. The person needs to feel safe and comfortable in his or her local village. When you retire—I have experienced this, as have some other noble Lords in the Committee—what information do you get? You get information about pensions, but do you get an information pack about the services available in the local community and about how you will get help if you are in urgent need? Some of our organisations do this, but those who retire should be given not only financial information but community information about bus services and so on, if there are any, and volunteer organisations. I must not overstep the mark here all the time, but the best thing we have in Wales and the rest of the UK is the free bus service for elderly people. It has kept routes going. We have services that we must support, but there are ways, not always financial, in which we can help our older people.

My Lords, I thank the noble Lord, Lord Turnberg, for so vividly portraying the crisis that is preventing us celebrating, as we should be able to do, the aging of our population. We can all expect to live to a great age. The noble Lord, Lord Roberts, has described very movingly that life is not always so good. Certainly it is not so good with the number of people who need appropriate care. We have an opportunity to get things right now, and we must do.

I was the lead commissioner for the EHRC inquiry into the needs for care and support of people living in their own homes. We found that half the people in this country were satisfied, but that means a huge number were not getting an adequate service, most of them elderly women. We are just about to celebrate International Women’s Day. It is appalling that they are not getting the sort of care and support that they need. We should be able to do something about their isolation, loneliness and the bad situation that they face, particularly with the impending—if it is not already with us—crisis of dementia.

As chair of the All-Party Parliamentary Group on Dementia, I am aware of this issue every day as this group has the highest attendance of MPs and Peers of any all-party group. People are recognising that this is a huge issue and we have to get it right. I would like us to look at how we can prevent things going as wrong as they have done up to now and get this right, with the help of the draft Care and Support Bill that will come to us shortly. We need to look more broadly at alternative ways of meeting the needs of a huge number of people in our population. I hope that the Government will do this. One way of meeting these needs is to look at the Scandinavian model of hospital hotels, which brings in another sector to help provide appropriate care. This happens almost automatically in Scandinavia. I hope that the Minister will agree to look further at that model. I have a group studying ways of implementing it.

We must also prevent people going into unsuitable hospital care, as the noble Baroness, Lady Jolly, clearly pointed out. We should not do anything to stop people with acute needs going into acute hospitals but it would be far better to transform some of them into local hospitals which deal more effectively with people suffering from one form or another of dementia and other chronic conditions. No MP would ever agree to a hospital closure but they might agree to the transformation of a hospital into one more suited to meet the needs of many patients today. Those patients are badly cared for in hospitals that are unsuited to their needs. It is also very unsuitable for patients with other conditions to be on the same ward as patients suffering from some form of dementia, which is usually the case. The latter ought to be able to stay in the community, but to make this work we need more collaborative working and integration between health and social care. The draft Care and Support Bill will facilitate this to some extent but other measures are also necessary.

We have to hope that local authorities will use the flexibility they have—they do have some—to allocate their money in a different way. However, health, social care and housing need to be integrated under the law, where possible, to enable more co-operation to take place. One way of doing this is to provide more preventive care. Local authorities must realise that they can save the NHS a lot of money if they keep people who have multiple needs, but not acute ones, out of acute hospitals. There has to be co-operation in this regard and local authorities must use any flexibility they have. There is not enough money but there is some money which they could use in this respect. Integration is terribly important.

Another important aspect of the draft Bill is that for the first time self-funders will be included as users of services. A fact that is not publicised is that very often when those self-funders have to go into a care home they pay over the odds. The local authority has negotiated a very low rate per patient but the self-funders are charged more than their care costs. We may approve of that “Peter and Paul” situation but it is not publicised and we should not have that sort of secret “tax” in this country. That has to be looked at by the Government who should make clear what is and is not appropriate as regards cross-subsidies. I hope that the Minister will look at that.

In summary, will the Minister look at the savings that can be made to acute NHS budgets through the provision of adequate care? Will he also look at the Scandinavian model and make sure that staff at all levels are trained in human rights, which the EHRC inquiry insisted on, and will he look at cross-subsidies?

My Lords, I am grateful to my noble friend Lord Turnberg. When I knew I was going to be able to speak in this debate, I went back to a book I wrote in 1988 and there I found a quotation from Kathleen Jones in 1972. This is what she says about community care:

“To the politician, ‘community care’ is a useful piece of rhetoric; to the sociologist, it is a stick to beat institutional care with; to the civil servant, it is a cheap alternative to institutional care which can be passed to the local authority for action—or inaction; to the visionary, it is a dream of a new society in which people really do care; to social services departments, it is a nightmare of heightened public expectation and inadequate resources to meet them. We are only just beginning to find out what it means to the old”,

and “the chronic sick”. When I read that, I was so depressed that I thought, “Have we moved on at all since 1972?”.

What has changed hugely, as many noble Lords have reminded us, is the numbers. There are many more people now in need of community care, but we can agree that the key thing needed for the care of the so-called rising tide is a sufficient supply of good quality community care focused on the needs of the user and their carers. I hope the Minister will agree that this is the most urgent problem facing our society today. It is bigger than education, defence or, above all, the acute sector of the NHS, although sometimes one feels like a traitor for saying that.

The Francis report on Mid Staffs may be a very worthy document, but I submit that it has done us no favours by focusing our attention on the care of elderly people in hospital. Just sort it out, goes the view: appoint a hospital supremo and all will be well. As we all know, that is nonsense. Hospital care provides a tiny proportion of the need, and the real problem so far as older people are concerned is that far too many of them languish in hugely expensive hospital beds, as we have heard, simply because not enough care in the community is available. As one of the witnesses to the Joint Committee on which several of our colleagues have been serving said, community care is always the poor sister of the NHS. The social care system is in crisis, as we have heard, and we shall never solve it, perhaps, unless we learn to rebalance spending and attention between NHS care and social care.

Social care is very good value if we do it right. Am I hopeful? Do I still feel as depressed as I did when I read that quote from Kathleen Jones? I think some progress has been made. The Government have made a step—perhaps a small one—towards accepting the proposals of the Dilnot commission. The Care and Support Bill will come to us during the course of this year, we hope, which gives not only new rights for users and carers but new responsibilities to local authorities to give information, advice and advocacy when assessments are being done. The committee called more than 60 witnesses, and every one of them raised the issue of resources.

When it comes to community care, we always hear that we cannot afford it, but as Andrew Dilnot has powerfully said, it is not a question of cannot afford it but of will not afford it. The noble Lord, Lord Turnberg, has given us some ideas about how we could find the money, and I remind the Committee, as I have done before, that when we accepted the proposals of the Beveridge committee, we were absolutely skint as a nation. We were in the middle of the Second World War and had no money and no prospect of getting any, but we still accepted that visionary report. I maintain that we can do it again. I also maintain that getting care in the community right could be a vote winner because it is no longer about poor services for poor people. It touches everybody. I am sure that everybody in this Room has experienced trying to find community care for themselves or their relatives—or they will within the course of the next year or so. I believe it is something that affects everyone, and therefore it is a very attractive idea for political parties to embrace as we approach a general election. I am sure many of us will be looking at what is said in manifestos about that.

Finally, care in the community, however we improve it, largely means care by the community, and community largely means your family, so I must point out, as I do at every opportunity, that the contribution of unpaid carers is £119 billion. It makes sound economic as well as moral good sense to support them as the main providers of care in the community.

My Lords, I, too, thank my noble friend Lord Turnberg for securing this debate, for his expert and thorough introduction, for setting the context, reminding us of the extent and scale of the issues across health and social care and getting the facts and figures over and done with so that the rest of us do not need to repeat them.

Your Lordships’ House spends a lot of time focusing on care and support for older people. We know that the old way of care pathways that address single health conditions does not meet the realities of an ageing population living with multiple conditions, and we know that prevention and the timely escalation of care of people in the community—in their homes, assisted supported housing or residential care—helps to prevent people going into hospital and to centre care on preserving the best quality of life. Our future strategy must view this issue in the wider context of what Age UK recently described as an, “extraordinary revolution in longevity”, which we all of course welcome and celebrate, both personally and for people generally.

Last week’s Guardian and today’s Independent trail the imminent report of the Lords Public Services and Demographic Change Committee, which will help to provide us with the evidence base for the strategic overview that we currently lack, including on pensions, pensioner poverty, health and social care, housing, income and age issues, social isolation and keeping in jobs older people who want to work. This will be an important report, and I hope that once it is published, the Government will schedule it for full debate.

Noble Lords have also referred to the Care and Support Bill and the pre-scrutiny Select Committee report that is due shortly. I have been following closely the evidence sessions and pay tribute to the expert and thorough work of the committee, four of whose members are here today, and to the individuals and organisations giving evidence. The debate on the detail is for another time, but I was particularly struck by the contributions from housing associations and voluntary sector providers stressing the importance of sharpening up the interface in the Bill between primary care, general practice, social care and housing. There are clearly pockets of excellent practice of NHS, local authority and voluntary sector co-operation and integrated working in the provision of specialist housing and housing support, for example, housing associations providing personal support in sheltered housing, thereby avoiding the need for residential care. I hope that the committee’s recommendations will help to take this agenda forward in an urgent and coherent way and that the Bill generally will provide the framework for enabling many issues that noble Lords have highlighted which would genuinely facilitate the delivery of more effective community and primary care.

This is such a frustratingly short debate that it is impossible to cover much at all, but it has provided us with the opportunity to focus on the need for a longer-term strategy on primary and community care. Noble Lords are, as usual, to be congratulated on providing a thorough debate and including the “big picture” issues of Dilnot implementation, future social care funding and the current crisis resulting from huge cuts in local authority budgets that make meeting existing and future demands impossible. We are, of course, also in the midst of the soul-searching and determination to do things better that come in the aftermath of the Francis report on the situation where frail, vulnerable older people received the worse care possible, as was referred to by my noble friend Lady Pitkeathley. I echo her concern that while the serious issues of failure of hospital care raised by Francis need to be addressed, we do not want the NHS to turn its full focus on to NHS hospital care and turn away from the need for primary care to step up to the plate if there is to be a dramatic shift to care in the community.

However, it is important to acknowledge the emphasis that Francis places on the importance of primary care and GPs. He points to the vital continuing relationship that GPs have with patients and the need for GPs to undertake a monitoring role on behalf of patients who receive acute hospital and other specialist services. As he puts it:

“They have a role as an independent, professionally qualified check on the quality of service, in particular in relation to assessment of outcomes. They need to have internal systems enabling them to be aware of patterns of concern ... They have a responsibility to all their patients to keep themselves informed of the standard of service available at various providers”.

Most importantly, Francis stresses that GPs need,

“to take this continuing partnership with their patients seriously if they are to be successful commissioners of services”,


“exploit … this new role in ensuring their patients get safe and effective care”.

That is one of the key questions for today’s debate. Are the Government confident that CCGs can meet the challenges of providing primary and community care? How is their focus to be shifted from hospitals to supporting community care? I look forward to the Minister’s response to the many questions asked by noble Lords.

On commissioning, I am getting to be a bit of a broken record on highlighting the need for effective commissioning of the community services that mainly benefit older people, such as chiropody, falls prevention, continence care and audiology. These are vital services that help to maintain well-being and independence, both in the community and in residential care. Yet, as Age UK has repeatedly pointed out, they are currently significantly undercommissioned and there are huge problems and variations in standards and availability of services.

I suspect that my recent experience locally when I took my disabled partner for his chiropody appointment and learned that Virgin Care would be taking over the previously supplied NHS services and would be dealing with problems only, not routine care such as clipping toenails, is rapidly becoming standard practice. The Department of Health’s guidance underlines the importance of foot care and the difference it makes to the lives of older people leading to reduced pain, increased mobility and a reduced risk of falls. Continence care support is also vital. If you talk to carers, it is such a major issue and can often tip them over the edge so that they stop caring. Of course there is also the impact it has on the person who is cared for. What action are the Government taking to ensure effective commissioning of chiropody, continence care and other key services such as audiology? Will GP commissioning seek to increase the number of district nurses who are under enormous pressure at the moment but who are so vital to community care support for people with long-term health conditions? Will it be able to reverse the current alarming decline in the number of specialist nurses, such as diabetic and epilepsy nurses, who play such a vital role in helping patients self-manage their condition in the home?

My Lords, to do justice to a subject as vast and crucially important as this one is impossible to achieve during the course of an hour’s debate. However, I thank the noble Lord, Lord Turnberg, for introducing this question so succinctly and capably. I will address as many issues as I can in the time available but I undertake to write to those noble Lords whose questions I do not manage to cover.

We know from listening to care users, their carers and voluntary organisations how care and support needs to change, and how the system has yet to adapt properly to meet the new demands and expectations of modern Britain. I was very struck, as I always am, by the clarion call sounded by the noble Baroness, Lady Pitkeathley, on that theme. As the noble Lord, Lord Turnberg, highlighted, the system will face further demands with an aging population at a time when we face financial constraints.

Last year’s care and support White Paper is an important step in changing that. It will sustain and promote what works and challenge and change what does not. It will promote well-being and independence instead of waiting for people to reach a crisis point. The White Paper, together with the draft Care and Support Bill, will shape the care sector for years to come. The noble Baroness, Lady Greengross, was right to say that this is an opportunity. This is the most comprehensive reform of social care legislation in over 60 years.

We must all welcome the fact that we are living longer but, as the noble Lord, Lord Warner, reminded us, managing the fiscal consequences of this will be a key challenge of the coming years. However, we must recognise that for the foreseeable future government funding will be constrained and we must plan on that basis. We want to get the engine working as efficiently and effectively as possible so that the fuel that we put in gets us to where we need to be.

Effective reform of public services is central to our response if we are to meet the needs of an aging population and ensure long-term sustainability. We have put in place an ambitious programme of reform across a wide range of government policy areas including pensions, health, social care, housing and employment. The Government are providing an extra £7.7 billion over the spending review period to protect access and support vulnerable people.

We know that care and support needs to adapt to respond to changes in demand and expectation. These challenges create an opportunity for local authorities to innovate and explore new ways of working, better meet the needs of their local populations and optimise the use of available resources. Many local authorities are already innovating and we are committed to supporting them to deliver further service improvements and to helping other authorities learn from what works. We want local authorities to maximise the use of reablement services that help older people recover from acute episodes and reinvest money from high-cost residential and nursing home care into other services. We also want local authorities to embrace the potential of new technology because we know that at least 3 million people with long-term conditions and social care needs could benefit from the use of telehealth and telecare services.

One of the biggest changes that the White Paper sets out is moving from the reactive service that we have at the moment to a proactive service that helps people stay healthy and independent in the first place—change that better meets and manages future demand and, as the noble Baroness, Lady Greengross, and my noble friend Lady Jolly emphasised, prevents people needing to go into acute hospitals and supports them to regain independence after they leave. As people live longer, the advantages of that approach, focused on preventing or postponing care needs, are both immense and glaringly obvious. That approach is part of our mission to improve the health of the nation as a whole. That is why we have built an approach that will enable local authorities and GPs to innovate and devise local solutions to tackle not just the symptoms but the wider determinants of health. On my noble friend Lady Jolly’s three questions, the answer in all cases is yes.

To support this, we will include in the Bill a duty on local authorities to take steps to prevent delay and reduce needs for care and support in their area. The noble Lord, Lord Turnberg, mentioned the pooling of budgets between the health service and social care. All too often the discussion on integrated care is focused around the integration of structures, funding streams or processes rather than the perspective of patients and service users. This has led to excessive focus on the means to achieve integrated care rather than the end of a better experience for patients and service users. We want to encourage and support local experimentation to allow local areas to provide integrated care at scale and pace. We are working with the sector to support local initiatives and identify what needs to happen to drive this at a national level. We want to learn what works well, how to overcome barriers and promote best practice. For example, Torbay commissioned and provided care for local areas as a single organisation and has shown comparatively lower levels of emergency admissions, shorter hospital stays and minimal delayed transfers of care.

The noble Lord, Lord Turnberg, talked about the role of GPs in caring for elderly people. The quality outcomes framework, which is part of the contract with GPs, provides incentives that reward practices for how well they care for patients, including for long-term conditions that often affect elderly patients. The Government have proposed changes to the GP contract, and a stakeholder consultation has recently finished. Under these proposals, and in addition to the QOF indicators, we would invite GPs to participate in a new directed enhanced service that would further encourage GP practices to co-ordinate and manage the care of frail older people and other high-risk patients predicted to be at risk of unscheduled hospital admission.

The noble Lord, Lord Turnberg, also spoke about out-of-hours care. Earlier this year, the NHS Commissioning Board announced that it is to review the model of urgent and emergency services in England including out-of-hours care.

The noble Baroness, Lady Emerton, focused on the social care workforce, its skills and the need to promote leadership. The care and support White Paper recommends increasing capacity, enhancing capability and developing leadership in the social care workforce. The department is working with partners to attract more people to, and increase apprenticeships in, social care, as well as raising standards and improving leadership. Working with the National Skills Academy for Social Care to publish the leadership qualities framework for adult social care is another important aspect of our programme. That framework sets out the attitudes and behaviours needed for high-quality leadership at all levels which, as the noble Baroness rightly said, is rather different from passing an exam. There is no single, definitive model of integrated care and support, as I am sure the noble Baroness will accept. Some localities are further advanced than others. We are developing the concept of pioneers to support rapid dissemination and uptake of lessons learnt, and are keen to maintain momentum and accelerate the adoption of new models of co-ordinated care and support across the country. Our ambition is for person-centred co-ordinated care and support to become the norm over the coming years.

Returning to the draft Care and Support Bill, it will introduce important powers and duties that will further integrated working, including a duty of co-operation, integration and ensuring that people have clearer entitlements. We are also committed to developing a measurement of people’s experience of integrated care to be included in future outcomes frameworks. This has been included as a placeholder in the NHS and Social Care Outcomes Framework 2013-14.

As I have said, we want to encourage local experimentation to allow local areas to provide integrated care tailored to people’s needs and preferences. We are working hard with partner organisations, including the NHS Commissioning Board, Monitor, the Local Government Association and the Association of Directors of Adult Social Services, to support those local initiatives and to identify what still needs to happen to drive this at a national level. This work will in turn be informed by the outcomes of the four community budget sites.

The noble Baroness, Lady Greengross, asked me some specific questions about self-funders. I undertake to look into the issues that she has raised. I certainly will study the Scandinavian model and I undertake to write to her about that.

I finish by reaffirming the Government’s aspiration to make this country one of the best places to grow old in, where older people get excellent treatment, care and support when they need it. Our biggest priority must be to transform what we offer to meet the challenge of an ageing population. If we fail to address this, our health and care system will not be sustainable for older people, or indeed for any of us. We must develop and promote a culture of compassion across the health and social care landscape, where quality of care is considered as important as quality of treatment and where every person can be confident that they will be treated with compassion, dignity and respect by skilled staff who are on top of their game and have time to care.

Committee adjourned at 6.17 pm.