Thursday 28 January 2021
The Grand Committee met in a hybrid proceeding.
Arrangement of Business
My Lords, the hybrid Grand Committee will now begin. Some Members are here in person, respecting social distancing, and others are participating remotely, but all Members will be treated equally. I must ask Members in the Room to wear a face covering except when seated at their desk, to speak sitting down and to wipe down their desk, chair and other touch points before and after use. If the capacity of the Committee Room is exceeded, or other safety requirements are breached, I will immediately adjourn the Committee. If there is a Division in the House, the Committee will adjourn for five minutes.
The time limit for the following debate is three hours. Lord Forsyth of Drumlean? Can we try again for the noble Lord, Lord Forsyth of Drumlean? All other speakers, please be on mute. We are still experiencing some technical problems, so we will adjourn for five minutes.
Social Care Funding (EAC Report)
Motion to Take Note
My Lords, I am pleased to introduce the Economic Affairs Committee’s report, Social Care Funding: Time to End a National Scandal.
We published our report in July 2019, and yet, 18 months later, we still await the Government’s response. The Government are accountable directly to Parliament. They have a duty and a responsibility to reply to committee reports in a timely way, usually within two months. Some 18 months ago, we said:
“With each delay the level of unmet need in the system increases, the pressure on unpaid carers grows stronger, the supply of care providers diminishes and the strain on the care workforce continues.”
Just 20 days after our report was published, the Prime Minister stood on the steps of Downing Street and said
“we will fix the crisis in social care once and for all with a clear plan we have prepared to give every older person the dignity and security they deserve.”
Now, more than ever, urgent government action is required.
Before I explain our conclusions, I would like to thank the committee staff who produced the report: Sam Newhouse, Luke Hussey, Michael Berry, Ben McNamee and Lucy Molloy. Especial thanks go to our special adviser Professor Richard Humphries, whose support was invaluable. I also thank my noble friend Lord Tugendhat, the noble Baroness, Lady Bowles, and the noble Lord, Lord Burns, who leave the committee today under our rotation rules. All of them have made a huge contribution to our deliberations and participated in no fewer than nine inquiries.
I must begin by praising our care workers. They have been on the front line of the pandemic. They have put their own health and safety to one side to care for and protect the most vulnerable among us. Care workers have performed an immeasurable service for our country but clapping alone will not help put in place the major reform that the sector so desperately needs.
In May 2020, I wrote to the Chancellor to press the case that this report deserves renewed attention now that the needs of the sector, and the heroic service and sacrifice of its workforce, have come to the fore of the nation’s priorities. In response, the Chancellor said:
“The Government’s number one priority for adult social care is for everyone who relies on care to get the care they need throughout the COVID-19 pandemic.”
In July 2020, I exchanged letters with the Minister of State for Care in which she assured me that the Government were due to meet shortly to discuss our report and any further reflections on reform. Finally, in October 2020, the Minister, my noble friend Lord Bethell, said that the pandemic had delayed the Government’s work on designing a sustainable social care funding model—words, words, words and broken promises.
Let me be clear. It is quite wrong to suggest that the Government could not have, and cannot, bring forward a plan for social care reform because of the pandemic. The opposite is the case, and I hope my noble friend will not repeat this calumny when he reads out his departmental speech this afternoon. The pandemic has revealed the centrality of social care and the need for no more dithering, no more Green Papers, no more delays; major reform must take place now.
We held a private meeting with care workers, and the stories we heard were truly humbling. We heard of frustration at being described as “just a carer” and that the sector is no longer seen as attractive. We heard from burnt-out workers, who cannot afford to run a car, forced to take multiple train journeys to get to work, working 14- to 15-hour days with take-home pay less than can be obtained for stacking shelves in a supermarket. Social care workers deserve better than this. They should be rewarded and treated as a highly skilled and caring profession. We concluded that career structures, training and the establishment of a professional structure were urgently needed.
Social care is a job-rich sector at a time when, sadly, unemployment is soaring as a consequence of the Covid-19 pandemic. The Resolution Foundation said that it would take an extra 180,000 care workers just to bring the ratio of carers to the over-70s population back to its 2014 peak. That is 180,000 just to get back to where we were in 2014. In our most recent report, on employment and Covid-19, we repeated that the Government should expand the number of care workers by increasing funding to the sector, with stipulations that it should be used to raise wages and improve training and conditions. It is time to turn our hands from applause to actions which give our social care workers the deal they deserve.
We have had enough of excuses for procrastination such as “The Government cannot bring forward plans for reform without cross-party consensus.” Everyone knows there is a consensus in Parliament and the country that we need to commit the resources that are desperately needed to support our most vulnerable citizens, young and old.
In May 2020, when our committee held its annual session with the Chancellor, we pressed him on the problems faced by the care sector. He said that the absence of a consensus over funding is a significant barrier to reform, along with its expense. That translates from Treasury speak to “I don’t want to spend the money.”
Since then, the Government have continued to kick the can down the road. More speeches have been given accepting the need for reform, yet cross-party talks have been delayed, and the proposals the Government have promised have been pushed back again. There was consensus in our cross-party report on a fully costed, long-term solution. The duty now falls upon the Government to bring forward a plan that reflects the cross-party consensus that does exist.
We drew attention to dwindling access to local authority funding, and the increasing pressures that result in the rationing of care to people who are in desperate need. Recent figures from the IFS show that between 2009-10 and 2017-18, per-person spending on social care for the over-65s fell by 31%. Significant investment is needed to buck that trend. We examined various options for how funding social care can be made sustainable. Having done so, we recommended that social care be funded largely from general taxation.
A central theme of our inquiry was the question of fairness. Our report identified three ways in which the present system is unfair: disparities between adult social care and the NHS, between those who fund their own care and those who receive local authority funding, and between different local authorities.
On the first of these, the UK has an ageing population, and many people have complex and difficult social care needs which they must fund themselves. The disparity with the NHS, which is free at the point of use, is striking. Why should support be free for cancer patients but not those suffering from motor neurone disease, for example?
Dementia was cited by several witnesses as an example of this disparity. The costs of caring for dementia can be long-lasting and, in some cases, catastrophic. The Alzheimer’s Society told us that the typical dementia care costs are £100,000, rising to £500,000 in some cases.
Secondly, care homes charge self-funders more in order to make up the inadequate amounts paid by local authorities. The Competition and Markets Authority estimated that self-funders paid 41% higher fees than the local authority rate. Witnesses said this amounted to a cross-subsidy that is unsustainable. We concluded that there is a real danger of a two-tier market emerging, in which care homes are driven to market to self-funders, reducing the availability of places for individuals sponsored by local authorities.
Thirdly, local authorities differ in respect of the cost pressures they face and their ability to raise funds. The result is that a postcode lottery has emerged. These disparities are growing with every day of government inaction. Reports suggest that the Government have been looking at private insurance as a way forward. I am grateful to the Association of British Insurers for the briefing that it sent to colleagues for this debate and which reflects the committee’s conclusions. No country relies primarily on private insurance to fund adult social care costs. It cannot provide the amount of funding required by the social care system, not least because roughly half of public social care funding is spent on people who are of working age; it is not just about the elderly.
Instead, we concluded that social care must be brought closer to the NHS by introducing free personal care. Personal care is about funding the basic activities of daily living: help with washing, bathing, dressing, mobility, eating and drinking. It does not include other, more expansive, activities, such as assistance with housework or shopping. Those in care homes would still pay for their accommodation and assistance with less critical needs. Those receiving care in their own homes would not have to pay accommodation costs, which may encourage care users to seek essential help with personal care early.
As the ABI says in its brief, a universal offer from the state would provide a clearer foundation on which people can plan and make their own provision where they need to top up. If personal care was free, individuals would likely be expected to top up their hotel costs with private funding. An insurance or asset-based top-up market could grow to support this. We concluded that the costs of care should be shared between individuals and the taxpayer. We were told that basic entitlement to publicly funded personal care would cost around £7 billion, if introduced in 2020-21.
We concluded that the Government should adopt a staged approach to providing the additional funding. We said that they should immediately invest in adult social care to restore quality and access to 2009-10 levels, estimated now to cost £10 billion. They should then introduce free personal care over the next five years.
In July 2018, the then Prime Minister announced that NHS funding would be increased by £34 billion over the next five years. This amounted to a spending increase in real terms of £20.5 billion. That increase alone is almost as much as the total spending on social care. It is time Cinderella was taken to the ball.
I have been a Conservative for nearly 50 years. I served in local government for five years, in both Houses of Parliament for 36 years and as a Minister for more than a decade. Of course, during that time, I have supported policies that I was uncomfortable with and promoted others that I regret, but I have never felt the sense of shame that I feel today at our failure to act on the funding of social care and to tackle, in the words of the title of our report, “a national scandal”. I beg to move.
My Lords, I am delighted that we have at last got this debate, and I share the frustration of the noble Lord, Lord Forsyth, at the time it has taken. He has been an indefatigable leader and chairman of the Economic Affairs Committee in the time that I have served on it, and I am most grateful to him and my colleagues on it for all the work and energy that have gone into not only this report but others, where we have tried to be practical and helpful and to make achievable suggestions for policy change.
I am also grateful for the passion with which the noble Lord, Lord Forsyth, has dealt with this and spoken about it today. My passion is somewhat dimmed by defeat, in a way, because it feels as if this is something that I have been banging on about for ages and we are still not really getting anywhere—but I am sure that everyone in the sector feels the same.
I will focus particularly on the plight of the care workers because that is my background and area of interest. The noble Lord, Lord Forsyth, has mentioned them, but it is worth going into some of the privations that they suffer in a little more depth. They are under- valued, underpaid and definitely undertrained; they do not have the status of nurses or even of childminders. The sector is subject to very weak regulation: we just do not know who they are or what qualifications they hold, and they are not registered with any professional body. The workforce of 1.8 million people in England is almost invisible—that is, until you need them, when they become very important.
The low status and poor treatment of care workers have led to a really vicious downward spiral in one of the most difficult sectors for workers, with a huge amount of exploitation. It is not just that they are badly paid; most of them earn less than the minimum wage, if you take into account the fact that many of them do not get paid for working in between clients. They are not paid for the journeys that they make and are often subject to very exploitative zero-hours contracts, which destabilise their lives and make it extremely difficult for them to do their work properly.
The workforce tends to be older women or migrant workers, which may very well account for the fact that they are not given much priority within the health and care service generally. They are overlooked and, as I say, we do not really know who they are. Turnover among care workers is enormous—between 30% and 40%—because they are badly paid; sometimes the supermarket down the road is offering a pound an hour more, and they have to go. They are often the main wage earner in their family, and they have to go where they can earn the most money, so there is a terrible, very rapid, turnover.
In the context of the Covid crisis that we are suffering, care workers are seven times more likely than the rest of the population to become infected with it. There is a huge amount of absenteeism at the moment because of illness or isolation, and there is a vast unmet need for care workers at the moment.
The other issue that is important when we talk about care workers is the fact that they have no career opportunities. Attracting people into the profession is very difficult: there is no progression and it is seen as unskilled work, which it most certainly is not because, so often, they need to have the skills to deal with complex feeding methods, using hoists for moving patients, dressing wounds and administering medication, as well as providing vital domestic and emotional support for the care recipients. They have to do all of this in 15-minute slots, if they are a domiciliary worker—
My Lords, social care funding for older people or those with a disability has been put in the “too difficult” or “too expensive” box for as long as I have been involved in health and care policy—about 20 years. At every general election since 2010, there has been a promise to fix it, and, sure enough, after the 2019 general election, as we have heard, Prime Minister Johnson joined his predecessors and promised to address the issue “once and for all”.
State provision of social care is not easy, it can be expensive and there is no right way to do it. The German and Japanese models are often quoted; they involve members of the public contributing to an insurance system that will pay for their care once they need it.
England has no state provision of social care. We have a system whereby the person’s needs are addressed and, after a means test, they will find if they are eligible for financial support from their local authority. This will go some way towards the provision of their social care, either in their own home or in a residential setting, but not accommodation costs.
Local authorities pay out at different rates. I sat on the joint scrutiny committee for the Care Bill 2014. We heard of families moving to a neighbouring county to ensure that they were eligible for a more generous provision. Sometimes there is a need to top up from savings or by selling or remortgaging the family home. Some with long-term care needs might, for many years, face care costs that seem reasonable at the outset but will quickly erode savings. So the proposed cap is welcome.
The proposal to introduce free personal care over the next five years should be adopted. This would require an immediate investment of £8 billion—the estimate from the King’s Fund and the Health Foundation.
The other part of the care system is for those adults with disabilities; the majority—1.5 million—have a learning disability. Until last year I was chair of a charity which cared for over 2,000 adults with a learning disability. With help, such people can lead a fulfilling life. Many are in residential care or supported living. The funding from this comes from local authorities, which hold the responsibility for their care. Each year the conversations with commissioners become more difficult, as local authorities’ budgets are stretched and the costs of caring rise.
As the noble Baroness, Lady Kingsmill, said, care workers are paid poorly, and should be receiving the real living wage of £9.50 per hour but many do not. Those who work in the care of either older people or those with a learning or physical disability are not unionised, as nurses are. They are not regulated; nor are they required to have formal qualifications, but many would take the care certificate. Someone who has been fired for negligence or worse can walk out and get a job straightaway. This should change.
Whichever way you look at it, the current system is no longer fit for purpose. There is a sustainable solution. The report of the Select Committee of the noble Lord, Lord Forsyth, offers a route map for the department. Mencap estimates that £3.2 billion would stabilise the system. So, when they have a moment, the Prime Minister, the Chancellor of the Exchequer and the Secretary of State for Health and Social Care should read this report, and do what successive Governments have promised to do: fix the funding of the care system. This would be welcomed by so many older people and their children.
My Lords, I declare that I chair the National Mental Capacity Forum and am a Bevan Commissioner. This commendable report provides a way forward, recommending that there must be an appropriate national funding formula. That formula must be fair, recognising that areas of high costs are often in areas of less business buoyancy, meaning that the desire to make local authorities more fiscally self-reliant risks widening gaps in provision and worsening the postcode lottery.
The report was prophetic. The pandemic has shown that social care cannot be used as a pressure valve for the NHS. It has also revealed to the nation, as the report points out, that social care sector staff providing direct care are underpaid and undervalued and that their personal well-being has often been overlooked.
Personalised care has two distinct roles. One is providing all the personalised care underpinning and integrated with healthcare interventions, often delivered by health and social care staff working together. Any division based on budgets creates an artificial split, with expensive bureaucratic processes if a person’s care moves from one sector to another, either geographically or by diagnostic category.
The other role of personal social care is to support people—often working-age adults—in their own homes, to allow them to live well and contribute in our society. A key part of this role is in the prevention of healthcare problems arising. Yet this prevention role has been chronically undervalued, even though it saves avoidable expenditure from the health budget. The future of public health in social care needs much greater emphasis.
During the pandemic, some charities have instigated innovative programmes to deliver social care and support, several seeing great results in improving mobility and independence. But current funding difficulties for charities have revealed our overreliance on this sector over years.
The report highlights the workforce—without a workforce any structure will fail and there will certainly be no resilience. Will the Government urgently look again at a proper career structure with parity of esteem and of pay for those in social care? Percentage pay increases simply widen the gap between the lowest paid, who do the work with the most vulnerable, and others. Staff need their travel time between homes recognised and to be able to park on arrival. They need ongoing training and supervision, with support for their own well-being—if they feel cared for, they are better able to care for others. Those receiving social care are potentially very vulnerable, which is why a proper registration and revalidation process of social care staff would set a national standard and could provide a focus—to nurture staff, helping them feel pride in their work and more respected. Their work is highly skilled and low paid, and their indemnity needs sorting out across the sector in the long term as part of an integrated system.
Form must follow function in a fair national funding formula that recognises our duty to each other in society. In this way, we might be able to move forward. To not heed this report will worsen our problems.
My Lords, I add my own expression of gratitude to the Economic Affairs Committee for such a clear and coherent report, based as it is on such careful research and presenting us with such direct and forthright conclusions. Its basic principles for reform are eminently sensible. Like others, I applaud the emphasis, pace Dilnot, on a partnership approach to the funding of social care, and the principles of free personal care, with a cap on accommodation costs, and increased funding enabled by general taxation. I will focus my brief contribution on principle (j), which reads:
“Invest in the social care workforce and ensure a more joined up approach to workforce planning with the National Health Service.”
If that is ignored, any increase in funding will run the risk of being wasted.
We are all well aware of the current situation in this country. The number of older people and working-age adults requiring care is increasing rapidly. Some 1.4 million people over 65 have unmet care needs. Covid has reminded us of just how crucial care homes and carers are in our society, alongside NHS workers and social services. Yet, as the noble Baronesses, Lady Kingsmill and Lady Finlay, have pointed out, carers are usually undervalued; they refer to themselves as second-class citizens; they are underpaid, underqualified and under- resourced, with a chronic staffing shortage that is getting steadily worse.
There are too many adjectives there beginning “under”. It is no wonder that there is a turnover rate of nearly a third in such an underregarded profession, with poor levels of both retention and recruitment. As we have already been reminded, what is so obviously needed for carers is a combination of proper status, good and appropriate training, and reasonable pay. The report before us has significant implications for all of those, as pages 24 to 29 make clear.
With regard to status, if the social care workforce of 1.6 million is to be developed and stabilised, there needs to be more parity of esteem with their 1.4 million NHS colleagues. That necessitates a programme of vocational as well as academic training, which will provide social care staff with the qualifications and career structure that are currently lacking.
In its turn, that should prompt levels of pay, especially in publicly funded institutions, that begin to reflect the value to society of the service being offered. None of this can happen without a substantial increase in funding, which is why the report is so important. That is before even considering the possibility of support for the 5 million or so unpaid carers who do such a great job and save us vast sums of money every year.
However, it involves more than just financial commitment, crucial though that is. This report, like so many before it, is about a change of culture, which is why the greater integration of health and social care to which it refers is so vital. We have a renamed department, but the transformation that that implies must go beyond its title. When asked recently about his biggest hope for change, Sir Simon Stevens replied:
“Seeing health and social care as two sides of the same coin.”
The Select Committee on the Long-term Sustainability of the NHS has exactly the same aspiration.
It has already been observed that, despite many positive and encouraging statements over the years, there has so far been a huge political reluctance to grasp this particular nettle, despite the cross-party consensus mentioned by the noble Lord, Lord Forsyth. I appreciate that much time and attention is currently focused elsewhere, but we would be grateful to know from the Minister whether Her Majesty’s Government have any timetable in mind for the sort of reform of our social care system that, as this report makes clear, is so urgently needed.
My Lords, this is an excellent report and its stark conclusions are as relevant today as when it was first published. Social care is severely underfunded, with the most deprived areas being the worst hit. More than a million adults who need social care are not receiving it and the system is riddled with unfairness. We are in a vicious cycle. After decades of reviews and failed reforms, the level of unmet need rises, the pressure on unpaid carers grows, the supply of care providers diminishes and the strain on the undervalued care workforce ever increases.
The core recommendation of £8 billion to be spent immediately to restore quality and access to adult social care has been widely supported. So, too, has the recommendation to introduce free personal care, such as help with washing, dressing or cooking, to be funded through general taxation over a period of five years, at a cost of £7 billion per year. The committee argues that this is simple, fair and not much more expensive than other proposals for reform. But, given the history of many reviews, we should not underestimate the barriers to its adoption, and I would like to mention five of those barriers.
First, adult social care has never commanded the priority that it deserves. The way that care homes have been dealt with over the pandemic is of course illustrative of this, with a lack of priority given to them in relation to PPE, testing and the movement of infected patients from hospitals to care homes.
Secondly, those in care homes would still pay for their accommodation and assistance with less critical needs like housework or shopping, so it is not the whole deal.
Thirdly, I am by no means certain that the costs of even limited free social care have been fully quantified. The experience of the NHS at its beginnings is instructive. Nye Bevan had assumed that, after a few years, the costs of the NHS would come down as the NHS caught up with the backlog of patients who had been unable to afford treatment before. That proved to be a trifle optimistic.
Scotland’s experience is relevant. The King’s Fund and Health Foundation 2018 report A Fork in the Road warned that the introduction of free personal care in Scotland had
“created unexpected levels of increased demand for domiciliary care which we might also expect to occur in England.”
They estimated that, with free personal care, the number of people receiving publicly funded domiciliary care in England would almost double. My concern is that free personal care would be underfunded and long waiting lists would be the result.
The fourth issue is that, in arguing for a mainly publicly funded solution, the committee’s hope for a market for private care insurance would be likely to develop in a system where personal care costs are funded by the state. This was the hope of Sir Andrew Dilnot who argued in his report, which the Government accepted, legislated for but never implemented, that limiting the risk for insurers by a cap on individual costs could help to provide a sustainable market for private social care insurance. The insurance market was unenthusiastic and I would like to hear more from the chair of the committee about how the committee thinks a more positive response would come from these proposals.
Fifthly, the committee says that cross-party co-operation will be necessary if progress is to be made on reforms to social care funding. I wish the committee well on this. Ever since Andrew Lansley’s description of Andy Burnham’s proposals in 2010 as a “death tax”, cross-party consensus has looked an ever distant dream, though I accept that it is desirable.
None the less, and despite the evident challenges, this is surely a good basis on which the Government can build their long-anticipated Green Paper.
My Lords, this report was published in 2019 and I share the frustration of the noble Lord, Lord Forsyth, about the delay in debating it, which I must say is indicative of the treatment of social care by successive Governments.
The history is stark. As long ago as 1999, a royal commission proposed more generous means testing for residential care and free personal nursing care. Nothing happened in England, although I think that free care was introduced in Scotland. In 2011, the Dilnot commission proposed a cap on lifetime care and a more generous means test. The coalition Government legislated to implement these proposals, but the Conservative Government in 2015 postponed their introduction and, in 2017, this postponement became permanent. As Jeremy Hunt said earlier this week:
“It was the silent cut that people didn’t notice until too late”.
In 2017, the Conservative Government promised a Green Paper, but nothing happened, perhaps because of fears about the so-called dementia tax in that election campaign. The 2019 Conservative manifesto promised urgently to seek cross-party consensus on this issue—nothing has happened.
Urgent action, as all noble Lords have indicated, is now required. In 2018, 14% of older people were reported to have unmet care needs. This situation will clearly have deteriorated as a result of the pandemic. To make things worse, we know that, as we speak, there are over 100,000 unfilled vacancies for workers in residential homes—a possible side effect of Brexit—and we also know that finance, as the report says, is forcing care homes to prioritise people who are self-funding over local authority provision.
I therefore endorse the call in the report for cross-party consensus on social care and the demand for a White Paper now to set out the options for funding. I agree with the conclusion in the report that additional funding for adult social care should be provided as a government grant, paid directly to local authorities and funded from general taxation, and that personal care at home should be free. The current postcode lottery in domestic care provision is manifestly unfair. Is there any wonder that local authorities cannot cope, bearing in mind the cuts imposed by central government since 2010? I also agree that there should be a cap on residential care, as Dilnot recommended and as is suggested by the report.
But we should also not forget the position of unpaid carers, without whose help the whole system would collapse. It is estimated that there are 9 million unpaid carers in this country, many of whom have been badly affected by Covid, as Mencap demonstrated this week. The report emphasises the importance of not allowing the body of impartial carers to diminish. Is it too much to ask the Government to increase the carer’s allowance of £67 per week by a further £20 per week, as Sir Edward Davey has called for?
My Lords, I refer to my interests in the register. I thank the noble Lord, Lord Forsyth, for steering this excellent report. We can no longer ignore the impact that chronic underfunding and political indecision about adult social care are having on the well-being of individuals—something the pandemic has shone a spotlight on.
First, I question whether it is possible sensibly to debate social care for older people at the same time as social care for working-age disabled adults, who are far too often overlooked in debates on social care reform. Perhaps older adults have more political clout. It does not make sense to ignore or exclude a group which, according to the Association of Directors of Adult Social Services, accounts for 64% of demographic pressures on the sector and approximately half of social care spending in England—I know that the noble Lord referred to this.
Secondly, we need a two-way collaboration between health and social care: interdependence rather than dependence. The NHS cures us of disease and mends bones; social care helps to cure loneliness, mends social inequalities and unlocks potential. For social care to achieve its mission, it must have personal fulfilment and independent living at its heart. For many working-age disabled adults, social care is not personal care but rather the support to develop skills such as cooking and maintaining a home so that they are able to make meaningful decisions about how to live their life and to grow in confidence, perhaps to find employment, to make friends and to play an active role in the community. Proposals that include funding mechanisms based on housing wealth, assets, floors, caps and insurance seem to forget about the impact that such models could have on working-age disabled adults. While free personal care would undoubtedly benefit many people, one concern is that underfunding could facilitate a drift towards the medicalisation of social care, where individuals’ horizons are reduced and the goal of the system becomes merely to keep someone alive.
Thirdly, social care must have a better-paid and trained professional workforce, with a meaningful career structure to reward dedicated staff and producing a talent pipeline that creates an avenue for experienced staff to develop, become mentors and pass on their knowledge and skills to a new generation. We know the problems that plague the workforce, including that some people take short-term jobs to fill employment gaps, but it is mainly that low pay and poor career progression lead to high turnover and poor retention. With more than 100,000 vacancies, we cannot underestimate the challenge. These problems are not new. In 2016, I chaired an expert reference group for Health Education England on building a direct support workforce to deliver the transforming care programme for people with a learning disability and/or autism who display behaviour described as challenging. Without adequate support and effective collaboration between social care and community mental health services, that group faces a real risk of ending up in inappropriate in-patient units at huge cost, both personal and financial. Of course, many people post Covid will want to avoid congregate care settings. This will need a different approach to career development and career structures.
The social care sector needs an immediate injection of funding to help improve pay and stabilise the sector, as many have already said, as well as reform in the ways that I have briefly outlined with respect to working-age disabled adults.
Before I call the noble Lord, Lord Taylor, I remind all participating remotely to keep their microphones on mute unless they are called to speak.
My Lords, I refer to my interests as set out in the register. However, I have a personal interest in the subject of the report, as, way back in 1987, an announcement was made by the then South Lincolnshire Health Authority that it was to close Holbeach Hospital. I was active in the local community and the area generally and perceived this to be a considerable threat. The hospital provided general bed care; there were consulting rooms for out-patient clinics and a physiotherapy department. It worked with local GPs and hospital doctors to provide the substantial rural community with health and social care. To cut a long story short, with local support, we negotiated a takeover of the premises by forming a local charitable trust, which then raised the money needed to improve the building up to registration standard at nursing home level and entered into a contract with Lincolnshire County Council for the funding of 22 beds. An agreement was reached with the health authority to continue with six doctors’ beds, the out-patient clinics and the physiotherapy department. We reopened in 1989.
I chaired the Holbeach and East Elloe Hospital Trust for 18 years. When I came to your Lordships’ House, I became its patron. The trust has thrived and maintains support locally. As a result of income generated and bequests, we soon purchased the freehold and doubled the number of beds to 47, including 12 re-enablement beds under the doctors’ supervision.
I congratulate my noble friend Lord Forsyth of Drumlean on chairing the committee and producing such a full report. Reforming the sector will be one of the most challenging undertakings for our Government. With such a complex system, it is important to look at all the options on the table. Notwithstanding the challenges, putting social care on a sustainable footing, where everybody is treated with dignity and respect, is imperative.
It is not as though we need a reminder, for the past year has shown just how vital this sector is for people who rely on social care. I welcome the Government’s recognition of the challenge that this sector faces during the pandemic by providing £1.1 billion of ring-fenced funding, which is vital to help put measures in place to improve infection prevention. How much funding have the Government made available for the costs associated with increased testing in care homes?
I want also to focus on the quality of care received by those who rely on adult social care. Despite increasing challenges, it is important that we recognise that the sector continues to provide high-quality care and support. I was encouraged to read that 85% of adult social care providers are currently rated good or outstanding by the Care Quality Commission. I think that the Committee will welcome this figure and want to pay tribute to the care givers, who are doing such a fine job, as many noble Lords have said, during such difficult circumstances.
All social policy areas have been put under pressure as a result of the pandemic, for they are interrelated. Social care, healthcare, pensions policy, the benefits system and even education all play a part in a civilised approach to need, even in the best of times. We need a consensus—
My Lords, I declare my interest as vice-president of Carers UK. I am greatly indebted to the noble Lord, Lord Forsyth, for finally securing this debate and very pleased to participate—as pleased as I was, in fact, when I first read the report in July 2019, not just with its content but mostly that it existed at all.
In the 23 years I have been in your Lordships’ House, I have taken part in many debates on social care and have been wont to call those who join me “the usual suspects”. We were a relatively small band who banged on about this subject whenever we got the opportunity and frequently used the expression “a national scandal”, as it is used today. I have to tell your Lordships that it makes pretty depressing reading to go back to those other debates on social care because the problems remain the same and so little progress seems to have been made. But the noble Lord, Lord Forsyth, and his colleagues are not the usual suspects and they reached the same conclusions.
The committee found a situation which, I think it is safe to say, shocked its members. If it was bad in the summer of 2019, how much worse is it now after the ravages wrought by the pandemic? The situation is bad for everyone: for local authorities, for the NHS and for care homes. It is very bad for family carers, as the report acknowledges. We all know now that families and friends are holding the social care system together by providing support for the most vulnerable in society. Many were at breaking point before the current crisis and are now sick with worry. We are asking even more of these unpaid carers than ever before. They urgently need to be supported and their contribution, worth billions of pounds, recognised.
If Covid-19 and the additional focus it has brought on the inadequacy of the care system have any positive outcome, it may be that we are finally forced to take bold decisions about the funding and provision of social care. Over the years, we have all witnessed the endless recommendations about how to reform the system: the reviews, the royal commission, the unenacted legislation and, of course, the endless broken promises. What we need now is a decision of the level and quality that our forebears took in relation to the NHS, but this time it must be about reshaping health and social care around today’s needs, not those of the population of a post-war Britain.
We cannot go on as we are, trying to do more with less, managing demand by simply not meeting it and by being dishonest with the public and the voters. No Government have ever made it clear to the public that responsibility for paying for and arranging care rests with individuals and their families. If they are not prepared to reform the system, the Government must at least be prepared to promote clearer public understanding of how the system works, what people can expect and, more importantly, what they cannot expect.
This problem is not going to go away; it is only going to get worse. The question is not whether these costs will arise, but how they will be met. Will they be met by the public purse or by private individuals? Every independent review of the past 20 years has recommended that future funding of social care, as well as healthcare needs, should come from public, not private, finance. The needs of individuals cannot be divided up neatly into health or social care needs. The time for debate is surely over. We have enough research and experience to enable us to take this decision—to decide on reform. All we need is the will to do so. If we have the will, we can end this national scandal now.
I now call the next speaker, the noble Lord, Lord Campbell, after whom I will call the noble Lord, Lord Lansley.
My Lords, I do not claim expertise, as some of the earlier contributors to this debate obviously have. But at my age I do declare an interest—and if I have an interest, then I have some share in the embarrassment that politicians of all parties should feel at the fact that the problem of the care of the elderly has been so unresolved and for so long.
Reference has been made to the Sutherland report. It is important to remember that it arose out of a manifesto commitment of the incoming 1997 Labour Government, promising a royal commission into long-term care for the elderly. It was launched by the late and much-missed Frank Dobson, who was then the Secretary of State for Health. In doing so, he said that the arrangements for the long-term care of the elderly were so unsatisfactory that they could not be allowed to continue much longer. That was in 1997.
Sir Stewart Sutherland, as he then was—later, of course, Lord Sutherland of Houndwood, and a Member of your Lordships’ House—was invited to conduct the royal commission, but his proposals were rejected by the Government as unrealistic and unaffordable. They were summed up in the expression now most frequently used as “free care for the elderly”. As has been mentioned, they were in fact implemented in Scotland, where it is fair to say that they have not been without criticism.
Let me fast forward, as we must, to the present. As has been said, in July 2019 the Prime Minister said he had a plan to give every elderly person “dignity and security”—remember those words. The Conservatives’ manifesto for the 2019 election claimed that they would build a cross-party consensus to answer the problem. Nothing has happened in respect of that. In January 2020, the Prime Minister yet again said that he had a plan; in June 2020, the Health Secretary said something similar. It is to the credit of the noble Lord, Lord Forsyth, that he has not allowed this matter to rest.
I am struck by the conclusions in the report, a few of which I will refer to: on inadequate funding, increased demand, pressure on family members to fill the gaps, and the geographical disparity in provision across the country. These issues are not new but have been characteristics of this problem for as long as it has been recognised. It is not necessary to agree with every word of every sentence of this admirable report but let me point out this: the Labour Government failed, the coalition Government failed, and the present Government are failing, by way of procrastination.
I will leave your Lordships with this thought to finish. Think of the thousands of elderly men and women who have suffered indignity and insecurity since 1997. That is why I join the noble Lord, Lord Forsyth, in saying that we should not feel embarrassed; we should feel ashamed.
I am pleased to follow the noble Lord, Lord Campbell. It is an abject failure on the part of our political system that the reform of social care funding has not been achieved to date. I will refer briefly to what was my responsibility. In 2010, I asked Andrew Dilnot to prepare a review and make recommendations. His proposals continue to form a part of what should be the reform of social care funding in the future, but I do not think that people quite appreciate the value of what he proposed. It was not just that there would be a cap on the costs people would have to meet, creating, as it were, a fundable and insurable proposition. It is also that there would be a substantial increase in the capital thresholds and a taper, such that under his proposals nobody would have had to lose more than 40% of their total assets.
That would give people the reassurance, even if they were to self-insure or be self-funders, that they would not work all their lives and then find, as a consequence of the catastrophic effects of Alzheimer’s or dementia, for example, that they lost everything and their families got nothing. We have to arrive at this point and make this funding reform happen. I absolutely agree with the noble Lord, Lord Forsyth, and his committee that the cost will not be met simply by the Dilnot reforms. It will require a major injection of government funding. The cost of personal care support should be shared between individuals and the state. To my mind, the great benefit of Andrew Dilnot’s proposals is that people pay towards their costs with only a proportion of their assets; they do not lose all that they have built up during their lives.
I want to make one other point. Why did it not happen? We legislated for it in the Care Act 2014 and it was supposed to happen after the 2015 election. I was not a part of government at that point. I remember somebody in the Treasury saying to me that because part of the process of paying for this involved removing the domiciliary care exemption for people’s own homes, 200,000 people would pay more and only 100,000 would benefit. This quite ignored the fact that most of the 100,000 who would benefit at any time would themselves, on some previous occasion, have been the recipients of domiciliary care.
The noble Lord, Lord Hunt of Kings Heath, is quite right: if we go down this path and do not remove the anomaly of the domiciliary care exemption for one’s own home, we will have an enormous increase in domiciliary care relative to residential care. This would not be desirable, so it has to be paid for. National insurance on older workers is clearly one part of it and removing the domiciliary care exemption is another, but a broader contribution from taxpayers will inevitably be part of it too. But it should not be taxpayers alone, otherwise the intergenerational lack of fairness of young people contributing to the future care of older people, in circumstances where those older people do not contribute but have large assets, would be intolerable.
My Lords, this is one of those issues that many people do not think about until it affects them or a family member. Successive Governments have thought about it a considerable amount but have chosen to do nothing. As a result, it has become —as described by the National Pensioners Convention, among many others—the Cinderella of public services, inadequately funded and not delivering for many people, when they need it most. This debate, therefore, is important although belated. I am grateful to the noble Lord, Lord Forsyth, and for this most comprehensive report and findings, which are relevant not just to England but to other parts of the United Kingdom.
The Covid pandemic has exacerbated many of the problems that we face and accelerates the need for reform. There always seems to be a good reason—not least financial—to put off reform in this area; it keeps being delayed and delayed. It was good that, in his first speech as Prime Minister, Boris Johnson promised to fix the crisis in social care but, as many noble Lords have rightly said, we now need action. I trust that the Government will soon produce proposals to support and sustain a modern social care system, and that these will be implemented as quickly as possible. I would be grateful if the Minister could tell us what his timescale for reform is.
There is a lot of confusion and misunderstanding around what the state can and cannot provide in social care, unlike the care provided by the National Health Service, which is free at the point of need. The United Kingdom faces a growing ageing population, with higher, more complex health needs. The decline of family and community networks increases the demand for public services. The costs of social care are a significant burden and fear for older people and their families. Social care should be treated, like the NHS, as a core public service: people need to be able to access it when they need it, at all times. That means sustainable funding over the long term, not continued short-term fixes, if they can be called that.
Many families are shocked to discover the labyrinthine process that they have to negotiate when they seek help, at a time when there is often a great deal of stress and strain. The do not understand how health needs are fully met by the state and free at the point of need, yet care needs are means-tested. This can lead to terrible shocks when they are faced with massive care costs. We need to move to the position of free personal care for those who need it, at the very least.
A high quality of care is absolutely essential and, for that, as other noble Lords have said, there must be proper training for care workers, which invests in and respects them, in the same way as there is for those who work for our National Health Service. Low pay needs to be urgently addressed, as do ways to improve retention and recruitment of staff. I add my voice to those who have already talked about recognition and support for the millions of unpaid family carers, who do an incredible job delivering a considerable amount of care across this country, in normal circumstances, but who, during the pandemic, have worked heroically to care for and protect their relatives at home. Many of them are elderly, and likely to suffer from poor health themselves and be in the lowest income bracket. There are estimated to be over 1 million people, maybe 1.5 million, aged over 65 with an unmet care need. That is truly shocking in this day and age. The current system is disjointed, piecemeal and underfunded. That must end as soon as possible.
My Lords, 12 years ago, I was the chairman of the Care Quality Commission, the regulator for the quality of health and social care. I was chilled when I saw the impact of the funding arrangements for social care on people’s access to care and the quality of care they received. Nothing much has changed in the funding system over these 12 years. In the meantime, adult social care needs are rising exponentially and funding has decreased in real terms, even with the recent additions to budgets. Local authorities are responding by raising the eligibility bar for social care, so that you have to be on your knees or virtually destitute to get funded care.
People who cannot access care are hidden at home and are a burden on unpaid carers. For those who can access it, what is the quality of that care? Much care provision at the higher end of the spectrum is fine, but it became clear to me at the CQC that care providers, funded at the very basic levels that local authorities can afford, simply cannot provide a quality service at that cost; nor can they pay the staff who deliver it more than the minimum wage. Providers either live on the edge of going bust or flee to the self-pay end of the business.
The result is that many of the less well-off in our society, who have been unable to amass savings or capital, because they have been in poorly paid jobs or unable to work due to illness or disability, are in a poor position. They are faced with a lack of access to services, poor-quality services and being looked after by staff who are often transient and paid a minimum wage, and have no qualifications and little training. I ask noble Lords: would you relish that prospect for your mum or disabled member of your family or—now that we are getting older—for you or me?
Successive Governments have failed to grasp the nettle. In 2019, the Conservative manifesto committed to building cross-party consensus and bringing forward a lasting solution, but it has not. It spoiled that assertion by continuing the old Conservative shibboleth that no one should have to sell their home. I believe that equity release schemes should not be off the table.
Three things need to happen. First, cross-party consensus talks should be set up now, be independently chaired and have a strict deadline to bring forward both proposals and implementation plans. Secondly, a progressive and pooled contributory system for pre-funding care costs should be set up, as a matter of urgency. It should be kept simple and communicated effectively to the public, in personal terms that talk about care for their family members, so that we get away from these appalling headlines of “death taxes” and “dementia taxes”. Thirdly, radical changes in social care staffing should be fast-tracked, covering qualifications, training, regulation and pay.
The Economic Affairs Committee is right: it is time to end a national scandal. The Government are politically nervous about tackling the issue, as a result of the sorts of headlines I talked about. Right now, Covid has meant that the public understand the challenges and importance of social care more than ever before. Can the Minister tell us that the Government will act now and that we will not get another Green Paper, and that we stop letting down the most vulnerable in society and the staff who are trying hard, against all the odds, to care for them?
My Lords, at a time when your Lordships’ House is under fire, there can be no better example of its value than the document we are debating. The committee achieved in a matter of weeks what has eluded Governments for over 20 years.
In December 2000, the Queen’s Speech said:
“The legislation will also take forward my Government's response to the Royal Commission on Long Term Care for the Elderly.”—[Official Report, 6/12/00; col. 2.]
That was the Sutherland commission. Nothing happened. At the end of the Labour Government’s time, they were back where they started with the 2009 Green Paper Shaping the Future of Care Together. The coalition agreement echoed what Labour said in 1997:
“We will establish a commission on long-term care, to report within a year.”
But Dilnot suffered the same fate as Sutherland.
In 2017, the Queen’s Speech said:
“My Ministers will work to improve social care and will bring forward proposals for consultation.”—[Official Report, 21/6/17; col. 6.]
Nothing happened. The last Queen’s Speech said:
“My Ministers will seek cross-party consensus on proposals for long term reform of social care.”—[Official Report, 19/12/19; col. 7.]
Again, nothing happened, as the noble Lords, Lord Razzall and Lord Campbell, said. That is the background to the substantial achievement of my noble friend and his committee.
Some critics may say that this consensus has been achieved at an unaffordable price—not so. The chairman of the committee, my noble friend Lord Forsyth, is a notable hawk when it comes to public expenditure. I put “Lord Forsyth, control of public expenditure” into Google and got 860,000 hits. On his committee are two former Chancellors and two former Treasury Permanent Secretaries, with the imperative of public expenditure restraint in their very DNA—I do not imply that the other noble Lords on the committee are a soft touch. This is not a body of men and women who will come up with something unaffordable. The next step should be a White Paper and legislation.
I have two comments to make in the time available. I do not agree with paragraph 8:
“We share the concerns of many witnesses about the Government’s plans to make local authorities more fiscally self-reliant.”
I think local authorities should become less dependent on central government, not more, and I hope the forthcoming Green Paper will give them more powers and a broader income base. I understand the committee’s concern that some local authorities are less able to spend on social care than others, but that should be rectified through the revenue support grant, not by making all local authorities more dependent on the Government.
My other comment is about the moral hazard from free personal care, touched on in paragraph 106:
“There may be a deadweight cost to the introduction of free personal care.”
It is a dead weight as some will no longer have to pay and others may opt out of caring to benefit from the free package.
This raises the broader issue of responsibility between the family on one hand and the state on the other, touched on by the noble Lord, Lord Hunt, and my noble friend Lord Lansley. Dilnot’s view is straightforward:
“For those who can afford [social care] it should not be free”.
But that does not address the fundamental problem that the noble Lord, Lord Forsyth, identified in his powerful speech—the unfairness of the present regime for people with, for example, dementia. A possible way to minimise both the moral hazard of people opting out and the initial cost is to look again at activities that might qualify for free personal care—for example, cooking and dressing. These activities could be performed by family members without imposing huge burdens on them. Therefore, to bring the costs down initially, they might be excluded from the free package where there is an alternative. But this is a detail that we can iron out when, as I very much hope, legislation based on this high-quality report is introduced in the next Session of Parliament.
My Lords, I thank my noble friend Lord Forsyth of Drumlean and the members of the Economic Affairs Committee for the production of such a thought-provoking and rightly challenging report and for initiating this important debate.
While there are clearly long-term issues that need to be addressed, in my view the Government’s number one priority during the current coronavirus crisis should be to ensure that adult social care is available for everyone who relies on it and that they get the care that they need throughout the Covid-19 pandemic. My brief comments today concentrate on this.
I know that, as we started 2021, many families had hoped that we would slowly return to our normal lives, but the new lockdown has shown the unpredictability of living life in a pandemic. This demonstrates the real need to make sure that the sector has all the resources that it needs to continue offering care.
I hope that in his response the Minister will be able to tell the House more about the £120 million workforce capacity fund and how that funding is going to help the sector to deal with the growing workload as a result of the pandemic. The winter months in particular are more difficult for those who need care and those who support them. The Secretary of State for Health outlined the adult social care winter plan last September. I would like to ask the Minister two questions in relation to that plan. First, what feedback have the Government received from the adult social care stakeholders in response to that plan? Secondly, how has the plan been adapted in the wake of the new variant of Covid-19 and the lockdown that has followed?
Lastly, I want to pay tribute to all those who work in the sector—all the carers, nurses, support staff and their families, especially in these exceptionally difficult times.
My Lords, I should remind the House that I am a vice-president of the Local Government Association.
This is an impressive report and I congratulate the committee on its work in addressing the key issues so effectively and on trying to encourage some urgency in government thinking. I want to talk about resources and, in particular, the funding issues identified by the committee in paragraphs 156 and 157. I agree with the committee’s conclusion:
“Social care funding should not be reliant on locally raised revenue which has little connection to local demand for social care.”
I also agree with this:
“The additional funding needed for adult social care should be provided as a government grant, distributed directly to local authorities according to an appropriate national funding formula which takes into account differences between local authorities in demand for care and ability to raise funds from local taxation.”
That is the right approach. I just wish the Government would share the committee’s view that social care funding should not be as reliant on locally raised revenue as it is now.
Unfortunately, there has been a deliberate government policy to force up council tax well above the rate of inflation to help to pay for social care by means of the social care precept that the Government introduced in 2016. This has resulted in council tax payers being required to pay up to 15% more over the last five years. Presumably, in the absence of any solution to the funding crisis, council tax will go on being increased in this way through the life of this Parliament. This approach means that councils able to generate higher receipts from their council tax base can raise more money for social care than poorer councils, when it is often the poorer councils that have the greatest demand for social care.
At the general election in December 2019, the Conservative Party manifesto guaranteed not to increase income tax, national insurance or VAT in this Parliament. These three taxes bring in almost two-thirds of UK tax revenues, so the decision not to increase them means that the Government intend other taxes to bear the burden. Council tax is one of those, so, for a sixth year now, council tax is increasing well above the rate of inflation. Up to 5% is permitted from April, of which a maximum 3% increase is for the adult social care precept. We should be very concerned about this and the fact that this constant rise in council tax forced on councils impacts most of all on poorer families who are already facing greater financial pressures from the pandemic.
My Lords, our country’s care system has never been under such pressure as over the last year. I am sure that noble Lords are as grateful as I am to live in a country that could financially afford to step up to the challenges of the pandemic and has worked day and night to make sure that everyone is treated with dignity and respect. Many countries around the world do not have our financial resources—we are indeed very fortunate.
The numbers speak for themselves. The Government have made available £4.6 billion to local authorities to address pressures on local services. There is an additional £1 billion of funding available for social care in 2021-22. Public spending on adult social care services has increased in real terms in every year since 2015, reaching £18.8 billion in 2020. In 2021-22, the Government expect to provide local authorities with estimated funding of around £3 billion to help to manage the impact of Covid across their services. These are very substantial numbers, but they are not just numbers. They translate into countless real people and real families getting the care that they need.
However, the funding system needs reform. This is indeed a complex area and I welcome the Government’s proposals on improvement, which I understand will be brought forward this year. I also welcome the Government’s appreciation that anyone needing care should never have to sell their home to pay for it.
The number of home care agencies in England has significantly increased, from 5,780 in 2010 to 10,294 in January of this year. That is almost double the number of home care agencies. According to CQC registration data, pressures on adult social care from the pandemic do not appear to be translating into significant amounts of reduced capacity or service closures, but this data should of course continue to be closely monitored.
We are not without challenges. Some providers of care settings designated for the discharge of Covid-positive individuals from hospitals have had difficulties securing sufficient levels of commercial insurance cover. This is why I welcome the recent ministerial Statement that new arrangements will provide temporary, state-backed indemnity cover for clinical negligence, employer liability and public liability to designated settings that have been unable to source adequate insurance cover.
This has been an incredibly difficult year for all of us, but there is clear evidence of the tremendous work and effort that the Government have put into ensuring that our care system delivers for everybody. There is always more to do and areas where improvements must continue to be made.
Finally, I would like to pay tribute to all those workers in care settings, who have faced probably the most difficult year of their professional lives and have made our country so very proud.
My Lords, I too congratulate the noble Lord, Lord Forsyth of Drumlean, and the Economic Affairs Committee on their incisive report. Social care funding has become a postcode lottery, as he said at the outset of this debate, and a national disgrace. Her Majesty’s Government should increase funding by at least £10 billion to restore the 2009-11 levels of quality and access. I agree that social care should be largely funded by general taxation. It should not be funded by local authorities, which, as we have heard, results in variegated levels of care across the country. However, given the challenges facing social care provision, we should be even more ambitious. The old age dependency ratio is increasing, while the number of working-age adults needing care is multiplying. Those receiving social care should not rely on future generations to cover their care costs. Deferred payment agreements should be a right so that no one receiving care is ever forced to sell their home while in care.
Social care should be paid for through taxation. Let me be specific. Those receiving care should pay for it through an inheritance tax, formerly and more properly called death duties, paid on their passing from their estate only if they have the means. The existing £500,000 inheritance threshold could be maintained. A majority of beneficiaries would not be affected; they would receive that inheritance only after the tax was paid. For example, the Tax Research UK blog has estimated that if inheritance tax was raised to 80%, double the current rate and similar to that paid after the Second World War, it could raise £174 billion—virtually enough to pay for the entire pandemic, let alone social care.
We have to recognise that we are facing a wartime-like crisis exacerbated by the pandemic, which requires a wartime-like response. Currently, a lucky half of young people will inherit 90% of the nation’s wealth; the rest will struggle. Of that wealth, 90% is presently owned by just half of elderly households. The desire to leave everything to one’s family and siblings is not as strong as it once was. Equity release is increasingly popular. People want to enjoy their lives now but be secure in their own homes in old age for as long as possible. Domiciliary care is the preferred option for many, and it should be provided by the state.
Instead of taxing the general population and businesses into the ground or looking at a wealth or property tax, we should tax people for their social care only after they have passed. This avoids squeezing the asset-rich and cash-poor while they are alive. It would be a death duty, not an inheritance tax. There would still be plenty to inherit. Inheritance has doubled in the last 20 years and is expected to do so again in the next 20. If the issue of funding social care and other essential public services is not addressed, and the lucky half benefits by inheriting the bulk of the country’s wealth, intergenerational inequality will worsen—something the noble Lord, Lord Lansley, mentioned. Instead of levelling up, the Government will find that they have created even more inequality and regional disparities, and our society and public services will be the poorer for it.
The noble Lord, Lord Liddle, is not able to take part in the debate, so I call the noble Lord, Lord Lancaster of Kimbolton.
We were told that you were not on the call at the beginning of the debate and did not hear it.
No; we do not want to deny you the opportunity. Please speak to us now, Lord Liddle.
I am very sorry; I was on the call and heard the excellent speech of the noble Lord, Lord Forsyth. I first pay tribute to him for his chairmanship of the committee, and his ability to produce an objective analysis and a report that commands a wide degree of consensus. I have always regarded him as one of the finest speakers in the House but he is normally making arguments I totally disagree with, so I am delighted to be able to congratulate him on this report.
Secondly, I declare my interest as a member of Cumbria County Council. That is very relevant to this debate because, frankly, we cannot go on as we are with what are, basically, patchwork solutions to the funding crisis in social care while relying on council tax supplements to fund the bulk of the patching that is necessary. We are in a terrible dilemma this year in Cumbria. Should we put up council tax by 5% in real terms during this Covid crisis, when so many workers are on low incomes and the self-employed are in great difficulty? It is very unfair. It would be unfair in any event because council tax is very inequitable in the way that its burden falls. We must find a better solution. I was pleased that when we debated this, the noble Lord, Lord Greenhalgh, said that in his view council tax needed reform. That would be a very good first step.
Thirdly, this is an area where we have to be prepared to contemplate some unconventional state intervention. I am a free market man by nature, or a social market man, but on wages, working conditions and training, we should go back to some kind of wages council cum training board which is determined with a remit to raise standards in this sector.
Finally, there is a need for some intervention to sort out the corporate structure of the sector. Far too many care home chains have been ruined by private equity and loaded up with debt. This needs sorting out without giving a present to the shareholders, so some government intervention is required. I am also in favour of a reform of inheritance tax and of the charging system so that people do not lose the whole of their wealth that they want to pass on but the burden of social care is, basically, paid by the better off through a reform of wealth taxation.
My Lords, in recognising that the unifying message of this debate is to call on government to act, I want in the brief time I have available to comment on three areas.
The first is adult social care reform. I start by seeking reassurance from my noble friend the Minister that the Government intend to continue to work closely with local and national partners to ensure that the approach to reform is informed by diverse perspectives, but in particular from those with lived experience of the care sector, both providers and recipients. It is clear that a stable social care provider market and a qualified and committed workforce will be absolutely central to delivering the widely held ambition for raising the quality of, and access to, social care. Equally important are the recipients of care, and I hope that reform will not come at the price of the long-held desire to empower them by supporting people to live independently in their own homes and communities, for as long as possible.
My own 90 year-old father’s desire to stay in his own home comes above all else. One of the biggest challenges he faces, though, is the quality of information on offer to assess his options. I welcome the Government’s plans to tackle this issue. This is particularly important if we are to encourage recipients and their families to make decisions about their long-term care ahead of time, so they are enabled to plan for their care and make better choices rather than ending up forced into knee-jerk decisions.
The second regards the workforce. I take this opportunity to pay tribute to the social care workforce in all their forms, paid and unpaid, who have more than ever demonstrated unwavering compassion and dedication while under the most enormous pressure during this pandemic. As we have heard, one particularly irritating aspect is that they are often spoken about as being “unskilled” and paid accordingly. The reality is that few jobs require a more diverse range of skills, particularly soft skills.
It is vital that the spotlight we have seen placed on the social care workforce during the Covid-19 pandemic is transformed into a long-lasting legacy of recognition for them. This would perhaps help address the biggest single challenge facing the sector, which remains recruitment, despite two successful recent government-backed campaigns.
The Government announced a £600 million infection control fund in May 2020, now extended until March 2021 with an additional £540 million. This is most welcome, not least because it can be used for measures such as helping maintain the normal wages of staff who may need to self-isolate. Equally welcome has been the £120 million of additional funding that was announced earlier this month to help local authorities boost staffing levels in the care sector. What lessons have been learned from the use of this fund when it comes to delivering resilience to a fragile sector once the pandemic is over?
However, the vast majority of care workers are employed by private sector providers, who ultimately set their pay independently of central government. While local authorities work with care providers to determine a fair rate of pay based on local market conditions, I would be interested in my noble friend’s view as to whether the time has come for the Government to consider setting a national benchmark.
The final area concerns quality of care. We need to recognise that the vast majority of care services provide high-quality care and support. As of January 2021, 84.6% of adult social care settings are currently rated good or outstanding by the Care Quality Commission, and, for most people, the experience of adult social care and support is incredibly positive. However, one of the biggest single factors in determining the CQC rating for a care home is the quality of the management, which is why my final question for my noble friend the Minister is: should we consider, as the report highlights, a more structured approach to continual professional development for the sector?
My Lords, I commend the noble Lord, Lord Forsyth, and his committee on this excellent report, proposing clear recommendations in what is a very complex area. I agree with many of them and underline the strong sentiment that we do not need further reviews, consultation or Green Papers; we need government action now or a White Paper with a clear implementation timescale.
Covid has cast a harsh spotlight on a highly fragmented, fragile and underfunded sector reliant on unpaid carers and piecemeal local arrangements, with care providers going out of business or handing back contracts. Other serious flaws in the system include a widespread lack of awareness that social care is not free at the point of use, underpaid staff with little career progression or professional development—leading to high vacancy rates and turnover—and a postcode lottery which leads to unjustifiable variations between places in access to care and its quality, often depending on a local authority’s ability to raise revenue.
The adult social care winter plan commits to providing free PPE to care homes until after the pandemic. What plans do the Government have to extend this pledge until at least late spring? Despite some short-term injections of government funding since 2017, years of significant underfunding, coupled with rising demands and costs, have combined to push adult social care services to breaking point. The Select Committee report points out that funding for adult social care in 2017 was below 2010 levels. It calls for an immediate injection of £8 million to restore care quality and access to 2010 standards, with free personal care available universally by 2025. I fully support these recommendations.
Any long-term reform must take account of the needs of working-age adults, who account for nearly half of the total social care budget, and unpaid carers as well as older people. Many working-age disabled people do not own their own houses—which, unfortunately, is how this political debate is mainly couched—and have not been able to save for care costs.
When it comes to paying for a new system that includes free personal care as a universal entitlement, it will have to be a partnership of public funding and private contributions by the citizen. Like the noble Lord, Lord Lansley, I believe that we should look for a solution through the prism of intergenerational fairness—a way in which all generations contribute but no one generation feels unfairly burdened. The Select Committee report touches briefly on this issue, which is to be applauded.
However, there is one aspect on which I take a different view from the committee. Rather than our relying primarily on raising the money needed from general taxation, I would like to see a funding solution with some element of hypothecation. I had considerable sympathy with the recommendation of the Barker commission that an additional percentage point of employee national insurance contributions for those aged over 40, raising some £2 billion in total, be earmarked for adult social care. This is similar in concept to the proposal put forward by the Intergenerational Fairness Forum of a new system of social care insurance contributions, at a rate of 1%, from the incomes of all working adults from the age of 40 until they stop working. Looking to the over-65s, as I argued in our debate earlier this week on inter-generational fairness, the case for individuals who continue to work beyond state pension age continuing to make national insurance contributions should also be part of the equation.
The shockingly high number of deaths in care homes in the first wave of the pandemic is a matter of national shame. We owe it to those who died and their families to ensure that a properly funded social care system, providing quality care to all, is a fitting legacy.
My Lords, I applaud the hard-hitting and very practical report of my noble friend Lord Forsyth and his committee, and I hope that it will provide a real springboard for the Government to take action at last—like many other speakers, I think “at last” is very much the phrase to use. I also applaud the masterly overview provided by my noble friend Lord Young, and I hope that that will also be taken seriously into consideration.
I do not pretend to have the kind of expertise that other Members in this afternoon’s debate have shown, but I remember, as a very young, inexperienced MP, wondering why there was a divide between healthcare and social care—it seemed to be wholly artificial. Now, with my greater experience, I realise that it was a tremendous error which has led to the social side being left behind and, as many others have said, badly treated in terms of the workers, their pay and so forth. I hope that, in future, there will be a much better effort to bring together these two sides of the profession, as I see it.
I have some, rather unusual experience of being in a residential care home after a very serious illness some four years ago. I did not feel able to go to my own home alone, so I was fortunately able to book into a very good residential care home, but what I saw amazed me. There were good workers, and I was greatly impressed by the care they showed to the various residents, including me, and the great skills that were required. It was a real eye-opener for me, and it makes me very anxious that they should all receive proper training and have a proper career structure and better payments. I very much hope that this will be one result of the debate we are having this afternoon, based as it is on the excellent report by my noble friend Lord Forsyth.
In a very short time, I will pay tribute to the unpaid carers—in other words, family and friends of people who need care, who do it for nothing. However, it does not come as nothing for them: in many cases, they will have had to give up, quite possibly, well-paid jobs because they cannot combine really good careers, and all that they involve, with caring on a day-to-day basis. It is not necessarily that they were unskilled or low-paid workers themselves, and, therefore, the sacrifice from them is very much greater. I do not think that this has ever been recognised.
I would be interested to know what the cost would be if we paid even the minimum wage to all those unpaid carers; we might then get a much better idea of the valuable service that they provide. We should take far more care of them, giving them some respite care in particular—because I feel that many of them get to the end of their tether. If they could just have a nice little break, it would permit them to go on, whereas, in other circumstances, they break completely. I hope that this will be the end of the pussyfooting of various Governments and that we actually get on and do something for the social care sector.
My Lords, I also commend the members of the committee for their impressive report. We are fortunate to have such distinguished and experienced Members of the House of Lords focusing their attention on one of the most difficult and urgent problems of our time.
Despite that urgency, and as many others have said, this it is a problem that successive Governments have ultimately failed to confront, although I was struck by the comments from Care England, in the report, about the lack of progress over many years, despite all the different reviews and commissions,
“all of which seem to come to similar conclusions—the system needs to be properly funded.”
The committee has made its recommendations and they have been broadly welcomed. While I fully appreciate the difficulties of the past year caused by the pandemic, I hope the Minister will be able to give some indication as to when the Government will be able to respond to its recommendations.
I also appreciate that, for there to be a proper response to this issue, there needs to be the type of cross-party co-operation that the committee has so ably demonstrated. For there to be wider consensus, there needs to be a better understanding of the social care system. The committee quite rightly says that, for this to happen, the system needs to be less complex and easier to understand.
I am no expert in this area but I emphasise that, if we are to have a proper conversation, we need to stop treating social care as the NHS’s poor relation. As demonstrated by this debate, this is not a new concept by any means and was part of the 2019 Conservative Party manifesto, but the pandemic proved again that we have some way to go. The desire to protect the NHS was understandable, but we now know that policies designed to prevent hospitals from being overwhelmed pushed a greater burden on to care homes. Yet again, social care was deemed the second-class citizen.
As my noble friend Lord Forsyth of Drumlean pointed out, by 2023-24, the NHS annual funding increase will be
“more than the entirety of local authority adult social care expenditure.”
This situation surely cannot continue, but if any good has come from the pandemic, it is a greater focus on and appreciation of the fundamental role that social care plays in protecting many of our most vulnerable.
Care England suggested in the report that there was
“a hesitancy by politicians to increase funding for a system that is not well understood by the public”.
Meanwhile, the Nuffield Trust pointed out that new proposals
“are often put forward as part of election campaigns at a point in the electoral cycle when there is minimal incentive for cross-party cooperation.”
As we reach a point of greater understanding and with some years until the next election, I sincerely hope that this is the time to find consensus and for Government to finally come forward with the solution that has evaded us for so long.
My Lords, this is a fine report. I hope the noble Lord, Lord Forsyth, will forgive me if I concentrate my remarks on the recommendation with which I profoundly disagree, which is that of free personal care introduced over the next five years, so that it is universally available by 2025-26. I can at least claim to be consistent on this, because I signed a minority to the report to the royal commission saying so.
Why? It is bloody expensive—£7 billion. That is the same amount as is said to be needed to be put into the present system to make it workable. I would prefer to see this money devoted to better care for the less well-off. It would inflate demand. In Scotland, the demand for care in people’s homes doubled when free personal care was introduced. Speaking now as a socialist—if that is allowed—56% of people in need of care, more than half, are paid for by the state already. The £7 billion I have talked about would all go to the remaining 44%, most of them not rich people, but comfortably off. It seems an extraordinary proposition that the state should pick the pockets of the less well-off to subsidise the better off.
The weepy old argument drummed up to whip up support for free care is that people are forced to sell their homes to pay for it. This is simply not the case. First, if you are getting care at home or go into a care home leaving a dependant in your house, the value of the house is excluded from the means test, so you are not forced to sell because you need the money.
Secondly, anyone who does not want to sell can go to the local authority and borrow the money, which is repaid after their death. They do not have to sell their home during their lifetime.
Thirdly—this has been referred to—there is an alternative route for most homeowners that does not involve the state at all. You take out an equity mortgage on your house and use the proceeds to buy an immediate-needs insurance policy, which will go on paying your care home fees for as long as you live—problem solved. L&G, which is the most progressive company, recently went into this market offering increasingly innovative policies. They solve most of the problems that we are worried about with older people having to pay for care.
Finally, and more consensually, I strongly endorse the committee’s emphasis on the need for consensus. It has been tried before, as the noble Lord, Lord Lansley, was saying. First, the Tories branded Labour’s proposals a “death tax”. Secondly, Labour branded the Tories’ proposals a “dementia tax”. This is no way to do business.
I would like to make a positive proposal for how to stop it. You need not exactly a chairman but an appointed neutral mediator, who tries to find common ground between the parties. The great advantage of that, and I have had personal experience of this, is that, if one party or the other tries to get off the agenda and seize party-political advantage by sabotaging the talks, the mediator can call out the offender. I am hopeful that, if you had talks with such a mediator, you could produce a system that, more or less, satisfies everyone.
My Lords, being the 28th speaker in the debate, I fear that all that needs to be said has been said. I do not wish to repeat points that already have been made. Therefore, I limit my contribution to, first, thanking the noble Lord, Lord Forsyth, and his committee for this excellent report. It will bring tears to the eyes of those who read it, particularly carers, those who need support and the general public. I say well done to the noble Lord, Lord Forsyth, and the committee. I plead to the Committee to support this report and bring the greatest possible pressure on the Government to commit £8 billion immediately.
My Lords, I declare my interest as a vice-president of the Local Government Association. I know we all agree that the committee’s report is an excellent contribution to the debate on the future of social care funding. In it, the committee recommends that adult social care is given a long-term sustainable funding settlement for the benefit of those who use and work in these services. I absolutely agree with these sentiments.
As this report highlights, publicly funded social care support is reducing, as smaller budgets have forced local authorities to limit the number of people who receive public funding. Covid-19 has shown the value of social care services and their importance to our society, but the pandemic has also added significantly to the financial pressures on council services. In its submission to the Treasury’s budget consultation, the LGA called on the Government to use the announcement to set out a clear timescale with specific deadlines for how reforms to adult social care provision, eligibility and funding will be introduced. A programme of reform for social care, led by national government, will be essential as we look to improve services and reduce inequalities.
The legacy of Covid-19 for social care and, most importantly, the people who use social care services, must be a reset, not simply a restart. This impetus should spur our thinking around long-term reform of care and support, which should be built on cross-party co-operation, as has already been mentioned. I hope that the Government will work with all parts of the social care world, particularly people with lived experience and local authorities, on a way forward that is informed by the many valuable lessons from the response to Covid-19 on the role and value of social care in all our lives.
I would also like to see the Government commit to a new deal for the care workforce, comprising action on pay, training and development, career progression and professionalisation, and recognition. To achieve those aims, the LGA has suggested that the Government commission an independent review to gather evidence and make recommendations, so that planning for the future of pay and reward in adult social care can begin. Ultimately, we must think about adult social care as an economic opportunity, rather than an economic cost. Reforming pay and reward for those working in adult social care will attract people to work in the sector, fill existing vacancies and benefit local economies.
Adult social care can play an important role as we seek to recover from the pandemic. In bringing my remarks to a close, I point out that the response to Covid-19 has highlighted the essential value of social care to the wider public. It is vital that this support be harnessed to deliver the long-term reform of the adult social care system that we so urgently need. I look forward to working with the Government and Members in both Houses to take this agenda forward.
My Lords, the noble Baroness, Lady Uddin, has withdrawn from the debate, so I call the noble Baroness, Lady Browning.
My Lords, I fully support this report. There are one or two things in some of the detail of it that I would like to see tweaked, but the thrust of it is absolutely right. This is a national scandal and it is far beyond time that the Government started to put it right. I support everybody who has said that this report should be the basis of a White Paper and not a Green Paper, because action is now needed.
I want to make merely a couple of points that are perhaps not covered in the report. I was reminded, when we were talking earlier in the debate about trusts, of the not-for-profit sector, which I believe has a lot to offer, particularly in care homes. Around the country, there are many homes that are run by trusts—we heard from the noble Lord, Lord Taylor, that new ones have been set up under trusteeships. Their great advantage is that, very often, they are small and locally based and therefore serve a particular client base. One hardship of the instability of the care home sector is that, when homes close, people often need to be moved well away from their relatives and areas where they have lived for many years. Therefore, in order to provide nationally a good mix of care that is affordable and of good quality, the not-for-profit sector could play a much bigger role than it does now. I would like us to look at that in a White Paper.
I will also pick up the funding of personal care, which many speakers have mentioned. I can see why some colleagues with a big local government interest are not very keen on this because they can see the bill. We are looking at billions; this is not a penny-on-income-tax policy. But we should look in more detail at what we mean by personal care. What does the day of somebody who needs personal care look like? It is not just about whether they can get dressed or have a meal provided by somebody in the household. Very often, particularly for those with Alzheimer’s or dementia, it is a question of not knowing what clothes to put on and perhaps dressing in the most inappropriate clothes. When it comes to food, it a matter of have they eaten or have they not? People with dementia may forget within half an hour that they have in fact eaten. Maintaining nutrition is therefore very important. This is a group of people who will wake up at 4.30 am or 5 am and think it is time to get up. They need full 24/7 care.
None of this is “medical” according to the definition of the word, but the demands and effect on carers can be quite catastrophic if those basic needs are not met. A failure in nutrition or in personal hygiene—for people who cannot look after themselves as far as their personal hygiene is concerned—can cause urinary tract infections or all sorts of problems that lead quickly to the need for doctors to be called or hospitalisation. I therefore would not underestimate the importance of personal care. It is something that must be factored in.
We have heard a lot about the political parties coming together; I agree that they will need to join together if this is to be successful, but please can we still do more to bring together social services and the NHS? In my experience as a Member of Parliament, whenever I came across a problem in this area, I would have to personally call for a case conference—and who would be sat round that table? Health, social services and the people involved with the problems. There seems to be a real lack of initiative to come forward and the reason is very simple: when you get those people round a table to sort out a problem, it costs money. They will do anything to avoid getting to the point where they have to sit round a table and commit money. I understand why—it is not easy, but we have to overcome that relationship between health and social services if this is going to work; otherwise, we will have these glass Chinese walls, where it is the responsibility of one and the other one does not want to know.
Finally—I have gone over my four minutes—not all households are one-person households. Often there are two people—two elderly people; two parents, perhaps—who need the help.
My Lords, it is a great pleasure to follow my noble friend Lady Browning. It is always well worth listening to and taking note of her wise words.
This has been a fascinating and very well-informed debate, as we expect from your Lordships’ House. My noble friend introduced the report very forcefully and the Economic Affairs Committee should be roundly congratulated, not only on the detail in this report but on succinctly describing this issue as a national scandal. It is indeed. I am disappointed to hear of the delay of even a response to this report.
One disadvantage of being the last Back-Bencher to take part in a debate is that most things that I wanted to say have been said at least once. However, if there is one thing that cannot be repeated enough, it is to pay tribute to the many care workers, their employers and, indeed, those unpaid carers so eloquently praised by my noble friend Lady Fookes.
Although this debate is about how to fund social care, I wish to add something that I have noticed over the years when visiting care homes, which is the increased isolation felt by those who have poor knowledge of English and who might even find the food offered to them rather alien.
I add my voice to all those who have asked the Government to stop prevaricating and sort this out.
My Lords, I declare an interest as a vice-chair of the Adult Social Care APPG. This has been an excellent debate on an excellent report, and almost without exception everyone has said that they support virtually all its recommendations. Those who have had issues have had one or two specific points only. But here we are—again—in another year with yet another debate where we discuss the scandal that is the funding of social care in this country.
In fact, this problem is more than just four or five years old. Twenty-five years ago, when I was a member of Cambridgeshire County Council, there was cross-party agreement that the social care funding system was in deep trouble and needed urgent reforms. Sometimes it really does feel like Groundhog Day. However, this report provides a megaphone to government by expertly identifying the urgent issues facing our social care system. It has made a series of excellent recommendations that have received broad consensus across the parties, and even across the sector.
This debate has also demonstrated that the problems are well known and, in policy terms, much has been done to start to address them. Along with other parties, so ably listed by a number of Peers including my noble friends Lord Razzall and Lord Campbell, and the noble Lord, Lord Young of Cookham, we note that the Conservatives had reforms to social care as key manifesto promises in 2017 and 2019, yet here we are still waiting for even the first and most basic of initial announcements. Why are the repeated calls of this House, the Commons, the sector, residents and their families still falling on deaf ears? I urge the Minister and this Government not to start from scratch again with further prolonged consultation or a Green Paper. What we need now, as my noble friend Lady Tyler said, is action and a White Paper which truly addresses the unfair way in which social care is funded and provided.
The comparison has already been made this afternoon between dementia care and cancer care; it is always worth repeating to demonstrate the total unfairness. Worse than that, the noble Baroness, Lady Browning, just mentioned the case conferences where the NHS and social services are at loggerheads about deciding whether something is personal care. I have witnessed this myself when sitting in on a meeting where a discussion about incontinence was whether it was actually due to the dementia, in which case it would be personal care, or due to osteoporosis and a crushed vertebra, in which case it would be nursing care. This is ridiculous. One of the problems with the current system is that it pits one part of it against the other, and that should end.
The founding principle of our much loved NHS is to provide care that is free at the point of use and ensure that no one is bankrupted or pays catastrophic costs for their care. This principle must also apply to long-term care. We need to revisit and update the Dilnot commission to make sure that the amount people are expected to pay out of pocket is capped with, as the report says, the cost shared between the public purse and the social care user.
The pandemic has rightly drawn attention to the plight faced by our social care workers, and I very much agree with Sir Andrew Dilnot’s evidence to the committee. He said:
“It is easy to neglect how wonderful the people providing this care are and, by and large, they are fabulous people working in circumstances that many people would not find desirable.”
During the first lockdown, we saw evidence of care workers leaving their families and going to stay in care homes for its duration to look after and protect their residents. That is the sort of commitment we see from the workers, so it is wrong that social care staff are not regarded in the same light as NHS healthcare staff. There needs to be a complete attitude change, in government and more widely, about the workforce: their supply issues, their pay levels and parity of investment, treatment and esteem between the sector and the NHS. I believe there should also be a royal college for social care to confirm their status and develop best practice, and to raise the esteem of social care workers.
As the noble Baroness, Lady Pitkeathley, outlined, unpaid carers face a really difficult task and this past year, particularly, has been a major problem with the pandemic. These carers have to navigate ever-changing, complicated government guidance to care for those they love, while facing increased anxiety as there is no one to take over if they fall ill or have to self-isolate. Unpaid carers must be part of the conversation on social care reform. Currently, there are just under 1 million full-time carers, relying on the carer’s allowance of just £67.25 a week. It is the lowest benefit of its kind. What does that say about how we value this sacrifice and commitment as a community? Raising the carer’s allowance would certainly be a start. However, it is not sustainable for mostly female, unpaid carers to continue to hold up the care sector with their free labour. We need to take the report’s recommendation and restore access to local authority funding to ease the pressure on friends and family carers.
I add here a brief word about young and child carers. Their education often suffers and although there are things in legislation about it, they are not universally applied. These young people need that support because they face a real difficulty in trying to manage caring for their relative as well as their education. I applaud local government, where some councils have extremely good young carers’ groups, whose work should be spread across the country as good practice.
As well as funding and support, we need to start being innovative in our approach to social care. This means thinking about how we could enrich lives and our communities and not regard those who need care as perhaps a burden. Schemes such as the Humanitas home in Holland, where university students are offered free accommodation in exchange for volunteering with residents, demonstrate how we can look across sectors to find inventive solutions to societal issues. Good adult social care can transform lives and, in turn, prevent mental and physical ill health, providing savings for the National Health Service in the long term and, most importantly, improving the quality of life for all the residents, whatever their age. Those Dutch university students said that it transformed their views about what they wanted to do in their future lives.
Working-age adult social care patients were mentioned by my noble friends Lady Jolly and Lady Tyler, and the noble Lord, Lord Forsyth. They all made the vital point on adult social care being about so much more than the elderly. That those with long-term disabilities and learning disabilities are treated as if they are in the same category as those who have perhaps led a full life must be remedied sooner rather than later. A fair system would recognise that they are different to those who have had the advantage of 40 years’ working.
Finally, many noble Lords have demonstrated that the impact of the pandemic has laid bare the perilous financial position of our care sector. Let me be clear: I am not referring just to the emergency short-term funding via local authorities, which has been vital. The pandemic has exposed the imbalanced relationship between the NHS and the care sector, demonstrating the need for the long-term financial commitment required to fulfil the recommendations of this report. I am referring to the paucity of local authority funding—not the fault of local authorities, because their own funds have been cut so badly, as so well outlined by my noble friend Lord Shipley—for those who cannot fund their own care. This results in even higher barriers to access local funding, as the boundary below which you cannot get funding is raised higher and higher.
As for the care providers, they have faced extraordinary increases in rising insurance premiums and exclusions, and insufficient clinical indemnity. I note that the Government have come in to help on indemnity, but only until the end of March. Please will the Minister look at this and address it? Care homes are already overwhelmed and it is not as if they are going to solve this in the next six to eight weeks. Although the Government have introduced that cover, it does not provide the broader indemnity required after the pandemic to put homes on a parity with the NHS in future. Worse, the future viability of some care homes is at risk, with staff shortages causing reductions to capacity, not least as a result of workers leaving the country following our Brexit. Beds are not being filled because people are reluctant to go into homes after the high death rate in the first lockdown. The big warning, though, is that any future pandemic preparedness must take into account the impact on the social care sector, with clear guidance on how to protect residents and those requiring care.
What do we think has been the impact of the two years of inaction since the committee’s report was published? How many individuals have not had access to the care they need, or been bankrupted to pay for care? How many individuals have reached a crisis point and put pressure on our NHS in its time of crisis, as they have not had access to appropriate community care? This excellent report makes it clear that the time for action is now. Will the Minister please make sure that happens?
My Lords, I too congratulate the committee on its excellent report. We have waited a long time for this debate and, of course, for the Prime Minister’s ready plan for social care that he said he had when he took up office 18 months ago, just after the report was published. I also thank the noble Lord, Lord Forsyth, for his strong advocacy and efforts to keep the report alive and kicking, his continued pressure on Ministers on the need for urgent and long-term action, and his pushing for this debate.
Noble Lords have stressed the devastating impact of Covid-19 on social care. As October’s annual CQC State of Care report said:
“Social care’s longstanding need for reform, investment and workforce planning has been thrown into stark relief by the pandemic”,
thrusting a long-recognised crisis into public consciousness and, with it, awareness of the quality of care, unmet needs, the pay and conditions of social care staff and the lack of co-ordination between NHS and care providers. Age UK has described the “battering” of the social care system from Covid 19, which it was in no position to receive. It stresses that social care staff and the services they deliver are being stretched appallingly thin, with older and disabled people and their families left to pay the price.
Noble Lords have today brought their expertise and experience to the range of issues covered by the report in respect of both Covid-19’s impact and what needs to be done to address the current crisis and build a long-term, sustainable social care system. I want mostly to reinforce some of the issues raised about domiciliary and residential care. Let me first stress our strong support for the report. Eighteen months on from its publication, it remains a solid basis and stepping-stone for moving forward and breaking the cycle of chronic underfunding of social care, of unmet need and of the unfairness and disparity in entitlement to care in the NHS and the adult social care system.
The fundamental principles espoused by the committee have widespread support among the social care stakeholders and community: funding social care largely from general taxation; the top priority of restoring local authority funding for social care to 2010 pre-austerity levels; ending councils’ dependence on locally-raised financing for social care; a new, £7 billion-a-year system for providing free personal care to help people with basic daily needs; and major investment in a new deal for the social care workforce and joined-up workforce planning with the NHS.
Most of all, the report plays a vital role in setting out the scale of the funding required, based on Health Foundation, King’s Fund and ADASS research, just to begin to address current and unmet need and future demand. We have heard the figures repeated this afternoon: £1.5 billion extra this year to maintain the levels of service provision of five years ago and £2.4 billion extra to local authorities just to stop the funding gap from widening even further. The Minister well knows this, so I hope that his response will not just restate the Government’s cash injections into the social care system. Extra cash is always welcome but, to emphasise, periodic cash injections, announced mostly during a crisis and too late, buy only a few months of shoring up already fragile services.
Proper funding and support for domiciliary care must be an essential part of a sustainable system. It is social care’s front line, and its scale and reach are often not widely recognised. If residential care during the pandemic played a grim catch-up to NHS services, then domiciliary care was often an afterthought even to care homes. Its dedicated, low-paid care workers, nearly 700,000 of them in England, visit people’s homes daily, moving from client to client and providing a vital link with the outside world on which they depend, particularly if clients are without family or carer support and especially during the pandemic when most have been unable to leave their homes, or their daycare or support clubs, while community services have been shut down. As a carer myself, regularly in touch with many local carers, I fully support the committee’s recognition of the huge further burden that underfunding of services has placed on unpaid carers.
As with residential care, during the pandemic there have been widespread reports of desperate agency care managers ringing around to try to get the PPE they need. Government recognition and funding are needed to cover the extra costs involved in this, as well as the staff shortages and absences arising from a combination of positive Covid cases following PCR testing, self-isolation following contract tracing, shielding and childcare responsibilities. What additional funding has been provided specifically for domiciliary care, PPE, testing and additional staffing costs in 2020? ADASS estimates that an additional £480 million funding is needed in England now to increase the provision of care at home for older and disabled people so they can live independently, with good care, and be kept out of hospital.
On the key issue of free personal care noble Lords, including my noble and good friend Lord Lipsey, will be well aware that we have long advocated it as a basic entitlement for people with substantial and critical levels of need for help with washing, toileting and other daily living needs that will enable them to live safe, independent lives in the community. We applaud the committee’s recommendation on this vital issue. As it points out, free personal care is fair and better aligned with NHS entitlement than the current system, and it would help keep people more mobile and active in the community rather than needing residential or hospital care.
In England, more than 350,000 older people are currently estimated to use home care services, 257,000 of whom have their care paid for by their local council. The United Kingdom Homecare Association estimates that 249 million hours of home care are delivered each year. It is a service which a further 1.6 million older people should receive but do not, because they do not meet current eligibility criteria or there is just not the funding for it. Does the Minister acknowledge that the domiciliary care service needs urgently to be substantially expanded to meet current and future demand?
We know that there has been deep concern about the Care Act easements arising from the Coronavirus Act during the pandemic. Seven councils used this provision in the first wave, mainly to relieve them of duties to carry out care and financial assessments and care planning reviews and visits. The CQC website has not been updated since last July, so can the Minster tell us whether any further councils have used the easement during the second wave? Will the Government provide a full breakdown of the services or activities affected by them? Age UK’s November survey showed that one in seven of those receiving care before the pandemic have since seen a reduction in their care; that is, 210,000 people either receiving less care or no longer receiving any.
On residential care, the Minister is on record as saying that he sees nothing wrong with the current business model, yet he will know that one of the “big four” independent care home providers, Four Seasons, is riddled with some £50 million worth of debt and that, in any event, the big four—the others being HC-One, BUPA and Barchester—cover only around 15% of the overall market. The bulk of England’s 15,600 residential homes are small, privately owned or voluntary sector-run. Although LaingBuisson reports that no home closures were triggered by Covid-19 through the first lockdown, occupancy fell by 8%. Care England has referred to occupancy rates as “historically low”. As the property agency Knight Frank predicts, small, older care homes will be most affected, as they will find it harder to cope with this. Moreover, of more than 6,500 care homes which have 40 beds or fewer, half do not have facilities to support care during a pandemic. Future care home design will need to provide wider corridors to enable social distancing, larger rooms with full en suite and wet-room facilities as standard to promote residents’ safety and isolation, adapted fixtures and fittings to limit touch points, and safer, more separate visitor areas with enhanced communication systems.
The report strongly underlines the unsustainability of the current system of residential care, particularly fears that the number of publicly-funded care places will decline if care homes are driven to market just to self-funders because councils are unable to meet the real costs of providing care. Does the Minister agree that any future model for residential care will be sustainable only if councils are adequately funded to meet the full costs of care?
The actions proposed in this report enjoy widespread support, as today’s debate and the submissions from key stakeholders have clearly demonstrated. As a starting point, it sets out fully-costed proposals that would begin to restore social care funding to pre-austerity levels, ensure that local government was fully funded for providing care, and address the truly urgent need for people to get free personal care support to meet essential daily living needs. Noble Lords have commended the recognition that a new deal is desperately needed for health and social care staff. That is surely no longer in doubt for anyone who has seen their selfless, remarkable and dedicated response to the pandemic.
My Lords, I join those who have congratulated my noble friend Lord Forsyth on securing this debate on this most important subject. The Economic Affairs Committee has done a huge service with this remarkable report. I reassure him and the committee that reform of adult social care is one of the most important priorities for this Government. It was a manifesto commitment and remains a major priority for us.
One of the silver linings of this awful pandemic has been the widespread appreciation for our carers, paid and unpaid, and I start by acknowledging the many fine words from noble Lords about the hard work of carers. I pay tribute to them and the incredible work they do every day. We owe it to them to get these reforms right.
The House of Lords Economic Affairs Committee, in its excellent and often-praised report, and many noble Lords today have made important points on social care which I want to address systematically. The committee’s report sets out the need for reform of adult social care, and on that the Government completely agree. I reassure noble Lords that, as detailed at the spending review, the Government are committed to sustainable improvement of the adult social care system and will bring forward proposals this year.
My noble friend Lord Lansley spoke with candour about the challenge facing Ministers, and I completely agree with him. Putting social care on a sustainable footing, where everyone is treated with dignity and respect, is one of the biggest challenges that our society faces. This is a complex area, a range of options are being considered, and we very much look forward to working with other parties on building a consensus around these reforms.
As many noble Lords noted, a stable social care provider market and a qualified, committed and well-paid workforce will be central to our ambitions to raise the quality of and access to social care. We want to empower recipients of care by supporting people to live independently in their own homes and communities for as long as possible. A number of noble Lords noted the Cinderella status of the sector. We want to improve the information provided to the public on the social care system, enabling them to plan for their care and make better choices when the time is right for them, and to raise the status of the sector in the public consciousness.
As regards our direction, we have made absolutely clear our commitment that nobody needing care should be forced to sell their home to pay for it. Our ambitions will necessarily take place on a longer timescale because of the pandemic, but, as the PM reaffirmed at the Liaison Committee in the House of Commons, we will bring forward proposals this year.
On social care funding, we recognise that the Covid-19 pandemic has imposed significant pressures on the social care sector, but I agree with my noble friend Lord Forsyth that the pandemic is not an excuse for inaction. In fact, it is a reason for supporting the social care sector, and that is exactly what we have done. We have now made £4.6 billion available to local authorities so that they can address the pressures on local services, including social care, that have been caused by the pandemic.
I remind noble Lords, including the noble Lord, Lord Hunt, of some of the measures we have undertaken during this period. Through the infection control fund, set up in May, we have provided over 1.1 billion of ring-fenced funding for the care sector. This has funded important measures for infection prevention and control, such as financial security for staff who are isolating, as well as PPE. On 23 December, we announced an extra 149 million to fund costs associated with increased testing in care homes, to help ensure the safety of staff and residents. Today’s announcement of the test and trace results shows the impact of that money. On 16 January, we announced another £120 million of funding to help local authorities to boost staffing levels in the care sector, which could include setting up their own staff bank to assist care homes when their staff need to isolate.
As well as this specific funding for Covid-19, we have also provided councils with access to an additional £1.5 billion for adult and children’s social care in 2020-21, on top of maintaining £2.5 billion of existing social care grants. As announced in the recent spending review, we are providing councils with access to over £1 billion of additional funding for social care in 2021-22. This includes £300 million of new grant funding for social care, on top of the £1 billion social care grant announced last year, which is being maintained in line with our manifesto commitment.
The Government are also enabling local authorities to access up to £790 million of new funding for adult social care through a 3% adult social care precept or top-up to council tax bills. The Government recognise, as is cited in the Economic Affairs Committee report, that the amount that each local authority can raise from this precept is dependent on a number of factors: for example, council tax bill levels. We are looking to address this through using some of the social care grant funding for equalisation. We also expect to provide councils with estimated funding of around £3 billion to help manage the impact of Covid-19 across their services, including in adult social care, and to compensate for income losses. This is a substantial track record of investment during a time of national emergency, and a significant response to the Covid pandemic.
I will say a word about market fragility. The report raises concerns about the strength of the social care provider market. As many noble Lords have noted, this market is varied and includes public, private and voluntary organisations. This is both a strength and a weakness. As noble Lords have noted, not all providers last for ever, but I reassure the noble Lord, Lord Liddle, and my noble friend Lady Browning that entering and exiting is a normal part of a functioning market, and local authorities should have appropriate plans in place to minimise any disruption of services.
I agree with my noble friend Lord Young of Cookham. I say to the noble Lord, Lord Shipley, that local authorities are best placed to understand and plan for the care needs of their populations, and to develop and build local market capacity. That is why, under the Care Act 2014, local authorities are required to shape their local markets.
To push back gently against the noble Baroness, Lady Brinton, on capacity, the number of overall care home beds has remained broadly constant over the last 10 years, from around 460,000 beds in 2010 to around 458,000 beds this month. At the same time, the number of care home agencies in England has increased. There are over 4,000 more care home agencies now than there were in 2010. This reflects the growing trend, noted by the noble Baroness, Lady Wheeler, towards caring for people in their own homes wherever possible. This is largely to be welcomed.
A number of noble Lords commented on the quality of care. I am grateful to the noble Baroness, Lady Young, for her testimony on her time at the Care Quality Commission, which is the independent regulator of all health and social care services in England. It notes that 84.6% of all social care organisations are currently rated as good or outstanding. As my noble friend Lord Lancaster put so well, this is testament to the hard work of so many people in adult social care, who speak of positive experiences in adult social care. We should not forget this.
I also want to cover unmet demand. We have enshrined in law, through the Care Act, the responsibility of local authorities to meet eligible needs. This eliminated the postcode lottery for eligibility across England. Under the Care Act, everybody who appears to have needs is entitled to an assessment. If, following the assessment, they are found to have eligible needs, the local authority has a duty to meet those needs, subject to a financial assessment.
That brings me to the difference highlighted in the committee report and raised by my noble friend Lord Forsyth between, say, cancer care, which is funded by the NHS, and other conditions that people may be living with, such as dementia, and those who have to pay for that care. The reason for this is the type of care required. There are limited treatment options for people living with dementia, so care is predominantly social care and support, rather than the medical treatment afforded by the NHS for those who have cancer. Social care, as we know, is subject to means testing. As I mentioned earlier, the Government are committed to social care reform, so that no one has to face excessive social care costs in their lifetime, whatever their underlying need. In answer to noble Lords, such as the noble Baroness, Lady Hollins, who asked about a timetable, we will bring forward proposals later this year.
The noble Baroness, Lady Finlay, and the right reverend Prelate the Bishop of Carlisle, asked about personalisation and choice. The report raised concerns about disabled people not having choice and control over basic decisions in their lives, such as when they get up in the morning and whether they can leave the house, due to lack of care and support.
My noble friend Lord Taylor of Holbeach was quite right when he called for dignity and respect in social care. On that, the Care Act introduced new functions for councils to focus on promoting well-being and prevention, including offering personal budgets, which are designed to give people control and choice over how their care is planned and delivered. It is based on what matters to the individual and their needs. It enables a new relationship between people, the care system, and health and care professionals, and is a step towards offering people the chance to have a say about their own care. The evidence suggests that, by doing so, people are more satisfied with their care, have better outcomes and can explore more innovative approaches to meet their needs.
I agree with the noble Lord, Lord Razzall, and other noble Lords that our NHS and social care system is facing increased pressure and that it needs to be fundamentally transformed and adapted to meet this demand. Our mission is to deliver integrated health and care services by placing people at the centre of the health and care system, working with them holistically to deliver the outcomes that matter to them most.
I want to say a word about the workforce, but, before I do, let me recognise the very large number of tributes paid to it by noble Lords. I completely acknowledge the comments on the status, training and workload of those working on the front line of social care. As the report recognises, the 1.5 million people who make up the paid social care workforce provide an invaluable service to the nation. We are indebted to their selfless dedication, and we have a duty to give them the support they need.
I have already mentioned the infection control fund to the noble Lord, Lord Liddle, and I reassure him that the £1 billion of funding to which we have given councils access in 2021-22 is designed to ensure that key pressures in the system are met, including the national living wage and national minimum wage. I reassure my noble friend Lady Fookes that the increase in the national living wage means that many of the lowest-paid workers will benefit from at least a 2.2% pay rise next year. The vast majority of care workers are employed by private sector providers, which ultimately set their pay. They must abide by national wage legislation, but they are independent of central government. Local authorities work with care providers to determine a fair rate of pay based on local market conditions.
On recruitment and vacancy rates, which were raised by a number of noble Lords, including the noble Baroness, Lady Hollins, we completely recognise that adult social care employers can struggle to recruit and retain the right number of staff. We are pleased that the vacancy rate reduced to around 7% for the period March to November 2020 from 8.4% in February 2020. We want this to reduce further and are working alongside stakeholders in adult social care to support a growing workforce with the values and skills to deliver high-quality, compassionate care.
It is vital that the spotlight we have seen placed on the social care workforce during Covid-19 is transformed into a long-lasting legacy of recognition for the workforce, as was noted by a number of noble Lords. We will celebrate their work and give them the acknowledgement and appreciation they deserve. To answer my noble friend Lady Fookes and the noble Baroness, Lady Brinton, we have responded to calls to provide the social care workforce with a shared identity to unite the sector. CARE badges are currently available free of charge, to be worn as a symbol of pride across the social care sector, and 1.1 million of them have been provided.
To noble Lords who asked about unpaid carers, I say that, like the report, the Government recognise the vital role unpaid carers play, especially given the difficulties the coronavirus pandemic has placed on those caring for family members, relatives and loved ones. We were all moved by the testimony of the noble Baronesses, Lady Kingsmill and Lady Wheeler. I want to pause for a moment to reflect the country’s gratitude to the people who have stepped up to help one another in their communities during the pandemic, alongside those who care day in and day out for their older or disabled loved ones. As the noble Baroness, Lady Jolly, said, this pandemic has highlighted the invaluable contribution of unpaid carers just as much as that of NHS and social care workers.
I reassure the noble Baroness, Lady Pitkeathley, that we have supported unpaid carers throughout the pandemic by funding the work of a number of charities that support carers, by publishing guidance tailored to carers, and by working with the social care sector to strike a balance between maintaining day care and respite services that we know are critical to many families and controlling infection risks.
In 2018, we set out a two-year programme of cross-government action on unpaid carers in our carers action plan. We will continue to work with carer organisations to support unpaid carers’ access to the support they need to maintain their own health and well-being while continuing to support their loved ones.
This is a comprehensive report. This debate has raised some really good points, and I acknowledge the frustration felt by many that there has not been more progress on this agenda. However, as my colleague, the Minister of State for Care, wrote in her response to the committee chair, this is an important priority, and we are working hard to make progress on it. We are considering the report’s recommendations carefully, and, as the noble Lord, Lord Lipsey, rightly acknowledged, we remain committed to cross-party talks to build a consensus. We remain committed to this vital work and will bring forward proposals later this year.
My Lords, this has been a brilliant debate and I thank everyone for taking part. I am slightly embarrassed by the tributes paid to me—I just chair the committee. It is a fantastic committee; we reached a consensus and we did so by listening to people and acting on the evidence before us. One thing I can guarantee is that this brilliant debate in the House of Lords will not even be acknowledged by our critics, who present us in a quite different light.
A number of key points have been made, drawn from the report, about the importance of raising the standing, status and training of care workers. The noble Baronesses, Lady Kingsmill and Lady Finlay, my noble friends Lady Fookes, Lord Lancaster, Lord Taylor, Lady Eaton and Lord Randall, and the right reverend Prelate the Bishop of Carlisle all made these points. I must say to my noble friend the Minister that the answer is not to issue people with a badge, but to take direct action in order that people are properly rewarded in a proper career structure with proper training.
Points were made about the litany of reports and broken promises and the requirement for action this day by my noble friend Lord Young of Cookham, the noble Baroness, Lady Jolly, and the noble Baroness, Lady Pitkeathley—who has been on to this, as she said, for years and has led the way, describing herself as something of a lone voice. She must be reinforced by the degree of consensus that she has heard today. My noble friend Lady Browning and the noble Baroness, Lady Brinton, pointed to that.
I ask my noble friend the Minister: what did the Prime Minister mean when he said
“we will fix the crisis in social care once and for all with a clear plan we have prepared to give every older person the dignity and security they deserve”?
That was in 2019. This is 2021. Saying, “We will bring forward proposals this year”, when we are still in January is not really reassuring, given the urgency and the strength of feeling shown in this debate. I am also grateful that my noble friend Lady Pidding and the noble Baronesses, Lady Hollins and Lady Brinton, all pointed out that this is not just about the elderly; it is about young people of working age, on whom half the budget is spent.
One point that has come out very strongly is that it will be necessary to spend this money. We all know that the reason why this has been delayed and we have had endless Green Papers and so on is that the Treasury simply does not want to spend the money—a point that my noble friend Lord Lansley underscored and which was also raised by the noble Lords, Lord Hunt, Lord Truscott and Lord Campbell. The Minister surely can see that the overwhelming message from this Committee is: “No more delays”.
Something that I think is very important and which came out in our report is that many people are completely unaware of the services that will be available to them until the point that they themselves need care or a relative needs care—it comes as a profound shock. People across the country do not realise how limited the services are, which is one reason why politicians of all parties have been able to get away with not addressing this problem—a problem that hits people and causes enormous stress at the time that they are probably most vulnerable.
There has been a universal cry that local authorities are being asked to do the impossible and do not have the resources. I say to the Minister that sticking plasters brought in for particular situations do not deal with the systemic problem of funding and the pressure that local authorities are under. These points were made by the noble Lords, Lord Razzall and Lord Shipley.
I am grateful to my noble friend but he is pretty lucky that we are having to hold this debate virtually and are not able to intervene to challenge some of the points in his departmental speech. If he seeks consensus then he should look around him: there is consensus in this Committee; I have never known a debate where this was the case with almost every single speech. There were arguments about the odd detail here and there, but only one speech did not praise the report, which came from my noble friend Lord Sarfraz, who said that he was impressed with the proposals coming from the Government—I do not know whether he has inside information or has had a look at what lies ahead. The message from this debate is absolutely clear: no more delays, no more Green Papers, no more proposals. Let us have a White Paper and legislation, and let us move forward and say thank you to those people whom the Minister rightly praised but who need more than the recognition of a badge. They need to be given a proper career, and we need to attract people to that career, which offers prospects for many of our young people who face unemployment as a result of the impact of Covid-19.
That completes the business before the Grand Committee this afternoon. I remind Members to sanitise their desks and chairs before leaving.
Committee adjourned at 5.20 pm.