House of Commons Hansard Debates for 26 Jun 1989

Mr. Ronnie Fearn (Southport) : On numerous occasions in this House during the past two years I have experienced a phenomenon known as deja vu when we have debated serious issues, such as that we debate today. There may be many reasons for that. One is that the Government never listen to the pleas of the public or the Opposition, no matter how forceful their case may be.

When I first entered the House in May 1987, I did not expect to participate in so many debates on care, of which I believe this is the seventh. I am not sure whether the hon.

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Member for Livingston (Mr. Cook) feels the same, but the House has heard a great deal from him on the subject in recent months. I note that he did not speak in the care in the community debate which I introduced on 19 April and which covered many of the points raised so far today. That aside, I cannot deny that I welcome this opportunity to discuss the subject and to highlight the plight, suffering and degradation of many of our citizens.

When I opened the previous debate on this matter, I pointed out the critical position in which many thousands of mental health patients found themselves as a consequence of pressures on health authorities and hospitals. Those pressures resulted in many mental health facilities closing and patients being discharged from units without being found alternative arrangements and with no provision for their care being made in the community.

In that debate, I also highlighted the difficulties faced by numerous elderly people who were unable to care for themselves and were not receiving the services they needed because health authorities and social services departments did not have the resources--this was true of those in my own constituency. The authorities were not receiving the resources or the financial or manpower help to cope with their needs.

I also referred to the effect that demographic changes and the great increase in the number of elderly people would have on services in the future, and of the increasing number of elderly people who would be totally dependent and in need of 24-hour care. I also mentioned the direct and disturbing effect which the proposals in the National Health Service White Paper--I refrain from using its title because I believe that it works against patients, particularly those in need of chronic care, rather than for them--would have on community services.

I am sorry to say that everything I said then still applies today and, because of the nature of the subject, the numbers in need of care and support services will have multiplied, and the distress and anxiety felt by those individuals and their carers will already have taken its toll. It is an absolute disgrace that so many vulnerable people should be left without the support services that they so desperately need--some of them, such as the mental health patients who are discharged into the community, without even a roof over their heads.

Even worse, it is obvious that the Government are aware of the difficulties and the disorganisation which confront all who are involved. It is also obvious that the reason for the Government's lack of action is purely ideological. Words fail me when I contemplate the possibility that the major stumbling block is not Conservative ideology but the stubbornness and idiosyncrasy of one person--the Prime Minister.

I was pleased to hear the Leader of the House say last Thursday that he hoped that the Government would bring forward proposals about the Griffiths report before the summer recess. The Minister confirmed that today, although I did not hear the "two weeks" mentioned by the hon. Member for Macclesfield (Mr. Winterton). I was a little worried to hear him say, however, that the question whether to hold a further debate on the matter would best be considered then. I should have hoped that, once the Government had announced their proposals, we should have the opportunity to debate them in full.

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We must ensure that all the consequences of the Government's proposals are clearly worked out and that no area of community need is ignored. Reports that the Cabinet Committee will now recommend that local authorities play the major role in managing community services are welcome up to a point. Not so welcome is the report that a hard-fought battle is being waged about the amount of control that the Government are to have, with the likely result that councils will be forced to contract out services to the private sector. I would have some trouble accepting these proposals in their totality. The Social and Liberal Democrats' green paper, "Prescription for Health", states that we would

"implement the Griffiths proposal for making local authorities the lead agency for co-ordination of delivery and development of services, but with certain additional safeguards and modifications." Hon. Members will find our green paper comprehensive and interesting. Should they want to read it without purchasing a copy, I should certainly let them have one. I shall not quote it in full, but no doubt hon. Members will read its contents soon.

One of the safeguards that we want would be an increase in the statutory obligations of local authorities to ensure that certain client groups who are not covered by present legislation--the elderly, for instance--are not given lower priority. We should like the introduction of a general- management style organisation, with clear functional responsibility, delegated authority and budgets. Above all, we recognise the need to tackle present inadequacies of funding and to provide the additional resources that Griffiths implies. This is necessary if care in the community is to work well.

Although we see many of the attractions of a puralist approach to the provision of care, under which local authorities are the enablers, we would have difficulty supporting enforced contracting out. The local authority should decide that. If voluntary organisations were given security of funding they would make a valuable contribution to community care, and in some cases the private sector would have a part to play, too. I know the Minister mentioned £36 million being put into the voluntary sector, but to my knowledge no authority has the security of knowing that funding will be forthcoming year after year, or that it will increase.

It cannot be stressed too much that there will never be an adequate alternative to public provision in all types of services. Public provision must remain an option for the individual and must always be available as a last resort. Local authorities must be given the means and the power to provide systems of services based on individual clients and their carers' needs--ideally, systems selected by those in need of the services.

One of the most serious consequences of the Government's drive to reduce public spending regardless of the human cost is the appalling state in which social services departments find themselves. There are serious shortages of all groups of staff across the country, and alarming shortages in some areas. Needless to say, they tend to be in the most deprived areas and in places in which housing is virtually impossible to find or its cost is out of most people's reach. At a time when reported child abuse cases are at their highest ever level--as we heard in the Standing Committee considering the Children Bill--and when the number of mentally ill and elderly people in need of care is on the increase, it is imperative that social

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services departments be given the means to rectify the problem. Many of them are collapsing under the pressure, and it is now up to central Government to do something about that.

I hope that before any new enterprise resulting from the Griffiths recommendations is embarked upon, the problems being faced by social workers and other social services groups will be well and truly ironed out. Unless they are, the smooth implementation and success of any scheme is doubtful.

Many organisations involved in health and community care services are worried about the lack of reference in the recent proposals to the responsibility of health authorities in relation to community care services ; perhaps general practice services should be included in this context. Doubtless the Minister will mention them. Some medical and health services are inextricably linked to community care services--for example, geriatric psychiatry, various out-patient services, discharge procedures and many community health services. I hope that the Government have something in mind which will ensure that the services required by community care clients are available and within easy reach.

I am convinced that the present proposals are nowhere near adequate to cover these needs. In the last debate on this topic, I pointed to the valuable service with which the millions of informal carers provided the country. At that time, I did not say that it is estimated that 100,000 children carry some of the burden of this care. Although it is right that young people should be taught responsibility and care for others, they should not bear the brunt of our failure to provide the resources that are necessary. Youngsters facing difficulties must not be overburdened and must be as free as possible to pursue a course that will lead to self-fulfilment and independence.

The current approach to informal carers in general is in danger of creating an ever increasing circle of dependency. It would be far more sensible and cost-effective in the long term to take more care of our carers by providing them with the financial and support services which they undoubtedly need and by ensuring that we do not hasten the day when the informal carers themselves become dependent on the care of others.

The long-term aim of any policy for care in the community should be to enable people to lead their lives as independently as possible and to ensure that the quality of their lives is as good as it can reasonably be expected to be. Community care and health care are not appropriate services to be subjected to market forces. Too many customers will be left defenceless. Two-tier systems will develop. A person in need of such care should not have to fight to receive it. For the common good, it is part of the Government's duty on behalf of us all, who may well need these services one day, to enable the individual to live life as fully and independently as possible by ensuring the provision of comprehensive and good quality care services for all.

5.29 pm

Mrs. Gillian Shephard (Norfolk, South-West) : The hon. Member for Southport (Mr. Fearn) has confessed to a feeling of deja vu in this debate. It is true that two points always emerge from debates on community care. First, the policy has been around for a long time. Indeed, it has been pursued by Governments of different hues for at least a

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quarter of a century. Secondly, although, and even to judge by this debate, it is clear that there is no absolute consensus on what is meant by successful community care, some useful principles over that period have--as is to be expected and hoped--emerged to govern what can and cannot work in care in the community.

A most useful contribution to the debate was the Audit Commission's report "Making a Reality of Community Care" which was published in 1986. That identified the following principles : strong and committed local champions of change ; a focus on action, not bureaucratic machinery ; locally integrated services cutting across agency boundaries ; a focus on the local neighbourhood ; a multidisciplinary team approach ; and a partnership between statutory and voluntary organisations.

I would add another principle to those of the Audit Commission, which is that residential and institutional care should remain part of the spectrum of care in the community to cope with crises, and with respite care when it is needed. That is not just for the mentally ill, but for the elderly who can suffer crises of illness or of chronic difficulties and need to be admitted to hospital for a time but can then be returned safely to the community, and for people with a mental handicap who, from time to time, can cope well in the community but who, perhaps for a short period, need to be returned to institutional care--sometimes to help those who are caring for them. A wide range of principles are established on which community care can operate. I believe that there has been a recognition in the Department of Health, which has been underlined by my hon. Friend the Minister this afternoon, that there is a need to retain some inpatient care within the full range of community care.

While all those of us who are concerned with health and social service issues are eagerly awaiting the Government's response to the Griffiths report, those who know the practical difficulties involved in community care provision sincerely hope that the response, when it comes, will draw heavily on experience in the field. I hope, too--here I am not in agreement with the hon. Member for Oxford, East (Mr. Smith), who has left the Chamber --that ample time will be allowed for discussion and consultation, especially bearing in mind the criticisms that have come from a not dissimilar quarter about the so-called lack of time for discussion and consultation on the National Health Service White Paper. We need time to draw together experience from those working in the field. It is most important that consultation is taken seriously and built most thoroughly into the White Paper.

I make those points specifically because, if there is one comment to make about community care it could be that there is a multiplicity of ways of making it successful. Some of those ways have emerged from the Government's own pilot projects which were begun in 1984-85 and which were generously funded with a large sum of money from joint financing allocations. Twenty- eight projects were selected and every health region and every client group was represented. The university of Kent was commissioned to assess the projects, and I believe that a final report on its assessment is awaited. Perhaps my hon. Friend can refer to that in his final comments.

Other ways of providing community care will certainly emerge from the private sector and will be supported from this side of the House. Experiments with sheltered housing and care provided on a continuum in the private sector, not to mention some valuable work and experiments done

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by the Federation of Private Residential Home Owners, provide interesting examples of partnerships between the statutory and voluntary sectors, which should be developed and followed up. In that connection, it is worth mentioning that for many people who will be in their 80s after the turn of the century money may not necessarily be the main problem. The main problem for those people, who may have access to the income from the disposal of their homes, will be personal security and the knowledge that they will be cared for to the end of their lives. Those will be the most important considerations in the minds of such people and the private sector should be, and I believe will be, ready to face that challenge. Indeed, it is the least that we can expect of it, given that £1 billion of taxpayers' money is currently going directly from social security funds to finance people in private residential homes. While the vast majority of those homes are well run, the response to Griffiths must suggest ways in which the use of that £1 billion is effectively monitored and targeted.

Although there is a clear need for a strong Government policy framework in community care, there is an equally strong case for that policy to be interpreted locally and in accordance with local needs. That was, indeed, the thrust of the recommendations emerging from the Audit Commission. That may seem an obvious point, but it needs making because on the ground there is a such a wide diversity of provision and problems across the country. For example, Surrey has the problem of a number of clusters of large psychiatric hospitals and hospitals for the mentally handicapped. The solutions for Surrey will not be the same as, for example, those for west Norfolk, where the health authority is in the fortunate position of building up from scratch the provision of community care for the mentally handicapped and the mentally ill. There are similar clusters of large hospitals and institutions in the north-west of England, which no doubt give particular point to the remarks of my hon. Friend the Member Macclesfield (Mr. Winterton).

Mrs. Ann Winterton (Congleton) : On the question of large community homes, is my hon. Friend aware that in the north-west of England in my constituency, there is one specific home called Cranage Hall hospital, which is an excellent example of what could happen? That hospital could turn into a village-type community, with a revolving door principle, so that people who are already in the community can go back into the hospital home for specific respite care and to use the facilities. It is set in beautiful grounds. It has not only been supported by the local community for some considerable time, but the community has contributed to many of its facilities. The Congleton Lions, for example, have recently contributed a rumpus room. Is my hon. Friend also aware that parents and relatives of mentally handicapped people in residential care are often concerned that homes may be closed and that their children may be moved elsewhere, rather like a pound of carrots, without being fully consulted?

Mrs. Shephard : I was not aware of the particular examples that my hon. Friend drew to the attention of the House, but, knowing her excellent record and her

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knowledge of her area, I am sure that the House will wish to give the fullest possible credence to her praise of the work of those particular institutions.

It is worth remembering, when one is talking about institutional care, that the people who are least enthusiastic about it, are those who are consigned to it. That must be borne in mind, too, when one is considering a balanced spectrum of care for the mentally ill and the mentally handicapped.

Other variations in what already exists on the gound can be centred on the number of private residential homes and the amount of private residential accommodation which is available, and that varies enormously across the country. In the south-coast resorts and in parts of Norfolk, there is an enormous concentration of such provision. In parts of northern England, Wales and Scotland, clients and patients do not have the same range of choice.

Sir Roy Griffiths's report laid emphasis on the important role of social services departments as providers, organisers and enablers for community care. He saw them as facilitators. However, that is not a very revolutionary concept, because in the best-run authorities that is a role that they already fulfil. They, together with health authorities, organise joint financing for community care, they grant aid to the voluntary sector, either directly or through joint finance, they co-operate with the private sector and, for example, in Norfolk they are actively involved in training provision with the private sector. They must inspect and monitor standards in the private sector.

I am assured that there is now no resistance to the concept of direct and specific funding to local authorities from central Government. I hope that, when the Government's response to the Griffiths report is announced, it will take account of the current role of social services departments and note that their attitudes and activities have changed greatly and become extremely realistic over the past five years.

I want to consider briefly community care for the mentally ill--a matter which I have raised several times in this House. As my hon. Friend the Minister said in an earlier debate :

"hospital closures should be occurring only as a consequence of the development of better alternative forms of provision. The closure of hospitals per se is in no sense a primary aim of Government policy."--[ Official Report, 1 February 1989 ; Vol. 146, c. 406.] I know that my hon. Friend has been visiting as many health regions as possible to see what is happening at the grass roots. I am sure that as a result of that, he will sympathise with the frustration felt by many people working with the mentally ill that huge sums of money are currently locked up in keeping open large, old-fashioned hospitals when, if that money could only be released before the closures, it could be used to provide a range of suitable alternatives, including in-patient care, as part of the spectrum. My hon. Friend referred to that in his opening remarks. He referred to the East Anglian health region where bridging finance has been used to good account.

Despite that, a mechanical problem remains which concerns not principle or resources, but the budgeting procedures which make the co-ordination of the closure of large hospitals--which, in so many places, are totally unsuitable to the needs of the modern day patient--and their replacement almost impossible to achieve. I raised that matter with my hon. Friend in an earlier debate and

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he assured me that the Government would be exploring actively ways to work with the private sector to release capital as bridging finance from old, unsatisfactory, crumbling, uncomfortable psychiatric hospitals which were destined for closure. I hope that my hon. Friend will be able to say something in his reply about any progress which may have been made in that respect.

The sheer complexity of the joint financing mechanism is most off-putting and a sure way of discouraging health authorities, local government, voluntary organisations and the private sector from working together. Whatever else comes from the Government's response to the Griffiths report, I hope that there will be a radical simplification of the current mechanism of joint financing. That mechanism is the greatest possible disincentive to the kind of working together between the authorities concerned that we all want to see.

5.42 pm

Mr. David Hinchliffe (Wakefield) : If there is anyone left in this country who still does not understand the reasons for the opposition to the Government's proposals in their White Paper on the National Health Service to running the NHS on market principles, he need only consider the current state of free-market community care. That shows precisely what will happen if we allow our caring services to be run on the lines of market principles.

Today's debate is not simply about the Government's political indifference and incompetence : it is about the appalling human consequences of leaving the care of dependent and vulnerable people to the marketplace. It is about the human tragedy of a care policy which has led to insecurity and fear for thousands of elderly and handicapped people who are victims of a system that is geared nowadays primarily to business interests instead of to properly thought out social care.

The current shambles which is described as community care arises directly as a result of the Government allowing provision to be determined primarily by the free market. For the past 10 years or so, decisions on policy have been determined primarily by business motives and not by the needs of individuals. In effect, the Government have freed the market, but conveniently they have ignored the fact that many potential consumers of care have no real choice, in many instances have no purchasing power and often do not want or need the product of institutional care which is being forced on them.

In his opening remarks, the Minister referred to £1 billion being poured through income support into private residential care. I want to draw the Minister's attention to the report from the Public Accounts Committee, which stated that nearly a quarter of the individuals in private institutional care who receive income support could have remained independent in their own homes in the community had proper community support been available. We are talking about £250 million a year of income support which is used for people in private institutional care who do not want or need to be in institutional care. That is very worrying.

I have been interested in community care since I entered social work in the late 1960s. The Government's record on community care is one of turning the clock back generations, away from genuine community provision and back to institutional care as the main response to elderly

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and mentally handicapped people who are in need. I reject that policy, because it belongs to the dark ages. It has no place in the latter part of the 20th century.

The Minister talked about getting people out of isolated Victorian institutions. In many areas, the isolated Victorian institutions which have been used by the NHS over many generations, which I admit are totally unsuitable for care, are being closed. However, they are being re-opened privately to provide the same kind of care. I hope that the Minister will visit my constituency soon and see Snapethorpe hospital for which closure has been proposed. That is the most modern hospital in my constituency. I will show the Minister Sandal Grange, an isolated Victorian institution which was closed 10 years ago because it was deemed unsuitable for the care of elderly people. The people were moved to Snapethorpe hospital. Sandal Grange was sold off and re-opened for precisely the same function in the private sector. Vast numbers of mentally handicapped people are being moved from outdated Victorian public institutions into outdated private institutions. That policy is a non-starter.

The Government have not only concentrated resourcing on the creation of institutional care ; they have cut resources to fund preventive networks and support services. I challenge the Minister to tell us in his reply how he has increased the resources. We all know that there has been a huge growth in need in terms of the number of elderly people who are dependent on support, while the funding for that support has not been increased relative to the growth in need. The Government have created an incentive to enter institutional care by attacking local authorities' abilities to provide real community provision.

I noticed a letter in the British Medical Journal on 9 January last year from Dr. Bennett, a geriatrician at the London hospital. He referred to problems he has encountered when families refuse to take back an elderly relative from hospital care because they cannot cope with caring for the elderly relative in the community. Dr. Bennett stated :

"The patients are alone and frail, and they and their carers are desperate. All have experienced failings in the health and social services--a home help sick and no replacement available, day centre waiting lists of many months, faster and faster discharges from hospitals into community support' despite mental and physical frailty

Places in old people's homes are diminishing rapidly and waiting lists grow. Increasing pressure is put on all concerned to consider private care. For my patients this means leaving a community they have known for 80 or more years and moving 80 kilometres away for an affordable place, beyond reasonable visiting reach for most relatives."

That is what is happening in hospitals. That problem probably confronts geriatricians throughout the country, with families saying, "We cannot go on caring for our elderly dependant because there is no support."

There is a desperately urgent need to examine also the ease with which the present system allows the individual's independence to be removed. Under Government policy, families who have been struggling to care for their elderly, physically or mentally handicapped relatives are told, "Sorry, their condition is not bad enough to merit the provision of a telephone. Sorry, we can provide a home help only two hours a week. Sorry, we can provide meals on wheels only twice a week. Sorry, we can provide respite care, so that you can have a break, only one week of the year. Sorry, we have no day care facilities but we will put you on the waiting list for day care once a week."

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When relatives finally give up the ghost and say, "We have had enough," what is on offer? There is a no-questions-asked offer of £140 a week if the relative concerned is packed off to private institutional care. That is not on. A similar level of financial support should be available to relatives who are struggling to care for their dependants in the community. There should be no incentive for them to wash their hands and say, "Let us put them into an institution, wash our hands of them, and make our lives much easier and happier."

My experience is that Government policy makes it as difficult as possible for the elderly to remain independent in their communities, and as easy as possible to slip them away into private institutional care, which is in no way humane. There are people in institutional care who do not want or need it, and who would be happier receiving support in the community. It is an indictment of Government policy--this has been admitted by hon. Members in all parts of the House--that people are placed in private institutions because of a lack of appropriate Health Service or local authority provision. For many elderly people, entering private care may be just the start of their problems. Apart from losing their independence and having to move from the place where they have lived all their lives, there are the financial consequences, to which my hon. Friend the Member for Oxford, East (Mr. Smith) referred. In many cases their capital dries up and their home has to be sold. There is evidence from Age Concern, which I know has written to the Minister for Social Security, that homes have been sold when the carer is still living there, so that the person who gave so much care over the years suddenly finds himself homeless. That is a consequence of the person entering private care requiring the capital from the sale of their property to pay for their fees. Subsequently, the resident may have to move to a cheaper home, and could ultimately end up in a local authority part III accommodation.

A number of people who have lived in my constituency all their lives, and who were compelled to enter private care because Health Service provision dried up, were moved 20 or 30 miles away. Six weeks later, under the provisions of current legislation, they were deemed residents of that new area, and were unable to secure local authority funding to return to part III accommodation in the locality in which they lived all their lives. It is scandalous to shunt people miles away from their natural homes when they are at their most vulnerable and need help and support of the kind that should be available in the final years of their lives.

I am sure that my hon. Friend the Member for Oxford, East is familiar with the recent work of the Oxford welfare rights group on income support as it relates to private residential care in Oxford. It found recently that 69 per cent. of those living in private homes cannot meet their fees but depend on top-ups from relatives or outside agencies to meet them. In Oxford, there is an average shortfall of £37 per resident per week. I have no reason to believe that that situation is not to be found elsewhere.

Evidence from registered homes tribunals reveals the way in which many elderly or handicapped people become pawns in the operation of free market care. There is proof--some of it published by my hon. Friend the Member for Peckham (Ms. Harman)--that private homes, many of

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which operate on a very tight profit margin, cut standards to keep down their costs. Research by the north London polytechnic published in 1985 also revealed that private residential homes cut staffing levels to save money, to the detriment of their residents. I could speak at length about the problems of provision for the elderly, particularly in the private sector. However, I am not anti-private sector. Rather, I am concerned that the Government allow the fate of vulnerable people to be placed in the hands of individuals who are preoccupied only with profits, and when the elderly or handicapped person's income dries up, they are sent down the road. That is the point at which private care finishes, and that is my grievance against the profit-based system, which is an unsuitable basis for health and social care.

The present system cries out for urgent changes, far beyond those that Griffiths has on offer. The Griffiths report makes a very conservative response when radical changes in community care are needed. We must address all needs, and public investment must be concentrated on preventing, not creating, the institutional dependence that the existing system so often creates. The Government's free market experiment in community care is an abysmal failure, at the cost of billions and billions of pounds. More importantly, it has failed at great personal cost to many elderly and handicapped people, who have endured great misery as a result of the Government's policies.

5.56 pm

Mr. Peter Thurnham (Bolton, North-East) : The hon. Member for Wakefield (Mr. Hinchliffe) claims that he is not anti-private sector, but most of his speech comprised a long diatribe against it. My experience is that it performs in a much better way than the public sector.

I support Griffiths's recommendations, and particularly paragraphs 1.3.3 and 1.3.4, which go to the heart of the debate. They refer to "building first on the available contribution of informal carers and neighbourhood support."

They add that local authorities should act as the

"designers, organisers and purchasers of non-health care services, and not primarily as direct providers, making the maximum possible use of voluntary and private sector bodies to widen consumer choice, stimulate innovation and encourage efficiency."

The hon. Member for Wakefield cast doubt on the role of the private sector, claiming that only the public sector can meet the needs of the community, whereas I believe that the whole essence of care in the community is building on and reinforcing private and voluntary efforts. Our response to the Griffiths report should reinforce and enhance private and voluntary work. Although, obviously, no payment is made for voluntary work, a recent report valued its contribution at £11 billion by comparison with the £6 billion at which the Audit Commission valued public sector provision. Therefore, two thirds of the effort is currently made by voluntary workers, and that sector should be reinforced.

The Government are right to deliberate carefully over the Griffiths report. Obviously the National Health Service White Paper had to be published first because provision there is of a different order, amounting to a cost of about £24 billion. It was only right and proper that the NHS review should be conducted first, before the Government turned their attention to community care. We all look forward to the Government's response, which I know will pay full care and attention to the way in which informal

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carers can work with voluntary bodies such as Crossroads, which perform a very effective role and provide greater value for money in the provision of care and services to people needing help at home than the public sector can now, or could ever do in the future. I was disappointed by the speech of the hon. Member for Livingston (Mr. Cook). The Opposition are engaged in a flirtation with popularity in the opinion polls at present, and I imagined that that might lead to some new thinking and, perhaps, a more statesmanlike approach in today's Opposition debate. I heard no new thinking, however ; the Opposition's only solution appears to be more expenditure, although the present Government have provided more money than Labour.

Mr. Favell : Given the number of mentally ill, mentally and physically handicapped and elderly people who we all hope will live in the community, it is surely stupid to expect local authorities to provide everything. To denigrate the efforts of the voluntary bodies is sheer stupidity.

Mr. Thurnham : It is significant that the Labour party's review disagreed with Griffiths on that very point, suggesting that local authorities should be the providers. That is the heart of the difference between us.

The recipients of services--the patients and the carers--want a greater say. I thought that I was beginning to agree with the hon. Member for Livingston when he said that he wanted a policy that would enable users to play their part, but he did not go on to explain how he thought that that could be achieved. My hon. Friend the Member for Norfolk, South-West (Mrs. Shephard) said that the answer lay in a multiplicity of services, but the Opposition seem to think that there is a simple bureaucratic answer to the problem of providing such massive amounts of care for such vast numbers of people, most of whom want to be cared for at home rather than in institutions. I can speak from personal experience, having fostered and then adopted a handicapped child who had been in care for six years. That is an example of how the best care is--and, I believe, should be--provided in the family home. Every child should have the love of a family. One of the most surprising statistics that I have seen recently appears in the survey by the Office of Population Censuses and Surveys on the prevalence of disability in children, which states that 5,500 children in England, Wales and Scotland are in institutional care. My inquiries had suggested that there might be as many as 3,000, including those in Northern Ireland ; the OPCS figure is nearly twice that, and shows how much more should be done to help families to continue to care for their own children and to foster and adopt children.

An OPCS survey on disability in adults states that about 50 per cent. of the 210,000 people in category 10--the most severely handicapped--are being cared for in private households. If the most disabled people can be cared for at home that is where our efforts should be directed, and I support the calls for more respite care and home helps.

Mr. Andrew Rowe (Mid Kent) : Does my hon. Friend agree that one of the most striking features of community care is the smallness of the amount required by the many people who want to continue to care? The reason why we are all so anxious to hear the Government's response to Griffiths is that Griffiths has made a real attempt to find a way of co-ordinating the finance available so that it is

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possible for consumers to demand the small amounts that they want, rather than waiting for ages to receive the large amount imposed on them.

Mr. Thurnham : I agree. It is not just a question of the smallness of the amount, however ; it is also a question of the type of help required. One of the current difficulties with local authority provision is that people must take what is on offer, and if what they want and need does not coincide with that it is too bad. They may be told that their child is too handicapped for anyone to be able to help.

Bolton council, which I believe has done more than most councils in this respect, has just produced a report called "Goal 2000". One of its conclusions is that there is

"virtually no service provision specific to the needs of people with challenging behaviour."

That shows how far local authorities' current provision falls short of what is needed. I want carers and committed individuals to play a part in the direction of public funds, so that those funds reinforce the massive contribution made by informal carers and voluntary groups. I shall be interested to learn what mechanisms the Government can devise to achieve that. The Department of Employment has set up new training and enterprise councils to take charge of a £3,000 million training budget. The private sector will have two thirds of those councils, and will play a leading role in the direction of public spending. I hope that we can look to such models in this context.

I was amazed at the number of people who came up to me in Bolton during the general election and said that they could not cope any longer with their children--who, in some instances, were well into their twenties--and wanted help. After the election I called a meeting of those people, who then formed a handicap action group. I was astonished at their commitment. A report was produced stating their needs and explaining how far local authority provision fell short of what was required. Under the excellent chairmanship of Mr. John Seddon, they put forward proposals which have been largely accepted by the local authority and the health authority.

Bolton has been the subject of a number or reports ; it has been at the forefront of most of the thinking on care in the community. A report by the local district audit committee called for more co-operation between the local authority and the health authority, and we shall look closely at the Government's proposals in that regard.

I agree with the Opposition calls for more expenditure. We do need more money, but it must be spent much more in accordance with the wishes of patients and carers, and it must reinforce the £11 billion of voluntary care that is currently being provided, without being seen as a substitute for private care. Private and voluntary care is an excellent medium, and it should be helped and enhanced in every possible way by Government policy.

6.8 pm

Mrs. Alice Mahon (Halifax) : I intend to concentrate on the care of the elderly. Over the past 10 years we have witnessed the wholesale privatisation of care, at great and unnecessary cost to the taxpayer and with tragic results for many elderly people. My hon. Friend the Member for Wakefield (Mr. Hinchliffe) was right to draw attention to that.

It is no good the Minister or anyone else hiding behind clinical decisions. As hospitals have emptied beds for the elderly and mentally ill, consultants have had no choice

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but to go around the wards with lists of private accommodation. At the same time cuts have been made in social service budgets, and local authorities have not been able to make up the shortfall. Approximately £10 million was provided in 1980 for the care of the elderly in the private sector. It is now well over £10 million each year. It is no use the Government trying to justify their decision by using value for money arguments, because that is a massive waste of resources.

I criticise the private sector, and I admit to having a vested interest in the matter. As a Member of Parliament, as a councillor for five years before that and as a spokeswoman for social services I came into close contact with the elderly in many private homes. Many of those homes are very pretty, with chintzy furnishings and Laura Ashley decor, but that is only to attract people to them. The fact is that they offer little dignified care to the elderly. Most elderly people have no contract with the home, so their position is very insecure. I heard recently of an elderly person in my constituency having to be moved out of a private home, purely for cash reasons. There is no complaints procedure. There is no one to put forward their case if elderly people feel that they are being treated unfairly.

My other major complaint about private homes is that when old people apply for admission there is only a perfunctory evaluation of their financial assets. It has led to wholesale institutionalisation. The Public Accounts Committee reported that a quarter of those in care need not be in care. That is right. The Government were warned about that in the early 1980s when they deliberately moved towards the privatisation of care for the elderly.

I had to smile during the Euro-elections. I canvassed in an area where the number of private homes has gone up significantly. It is a Conservative ward. Nearly all those private homes were exhibiting Tory party stickers. I think that they were saying "Thank you" to the Conservative party for the lucrative cash handouts that they had received for caring for the elderly. However, some do not care properly for the elderly. Many of them employ low -paid, untrained staff, many of whom were YTS trainees. No occupational therapy is provided in most of the homes. Even in homes where occupational therapy is provided, the amount is small. Some homes do not provide a planned programme of orientation, but it is provided in local authority homes where the staff are trained to ensure that elderly people remain very much in touch with what is going on. The staff in local authority homes take training courses. I have yet to come across a private home that sends its staff on training courses.

Mr. Couchman : Is the hon. Lady saying that all is well with local authority old people's homes? As a councillor, I chaired the social services committee for five years and my experience was that local authority homes are among some of the most institutionalised establishments that can be found. They institutionalise old people in the same way as the large, long-stay hospitals institutionalise the mentally ill and the mentally handicapped. Does the hon. Lady not agree?

Mrs. Mahon : No, I do not. That has not been my experience. We have moved away from rigid, institutionalised care in large hospitals. My experience is that local

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authority homes can be monitored and that, if necessary, the management can be changed. That cannot be done in private homes. There is very little monitoring. Only two officers in my local authority are trying to monitor hundreds of places. That cannot be done properly.

Mr. Favell : Will the hon. Lady give way?

Mrs. Mahon : No. I should like to finish this point.

I have been told recently about a private home in my constituency where residents are put to bed at 6 o'clock. Some of them are drugged. It is a case of out of sight, out of mind. When I went to that home they told me that they dared not complain. There is a lack of control and accountability of private homes and it is impossible to monitor them.

Mr. Favell : I agree with the hon. Lady that the worst thing to do with the elderly or the mentally handicapped or mentally ill is to institutionalise them, but is it not true that we are learning all the time? Local authorities are learning and the private sector is learning. It is important to give the elderly plenty to do. Does she agree that sheltered accommodation should be provided for as long as possible? People are then able to cook for themselves, make their own beds and look after themselves generally. That is very much better for the elderly than providing them with a bedroom and then sticking them in an awful rectangular room where they all gaze into the middle of the room. There is no more certain recipe for misery. Whether it is local authority or private sector care, we must ensure that we provide sheltered accommodation for the elderly.

Mrs. Mahon : I wish that the hon. Gentleman had put that point to his Government about 10 years ago. Then the £10 billion which I believe has been wasted on the private sector could have been used to provide an intensive care package for the elderly, which would have meant that they did not have to go into care.

Institutionalised care destroys independence and murders the mind. Care in the private sector is often provided only for the money that it brings in. There is a great need for much more humane care of the elderly.

When the Minister referred to carers, families and friends playing a major role in the care of the elderly I thought that he had no idea of the size and seriousness of the problem. The Equal Opportunities Commission estimates that there are 1.25 million carers, most of them women, looking after the elderly and the disabled in the community, but the Carers Association believes that there are many more. There has been a huge growth in the number of elderly people. I have a vested interest, because my constituency contains a large number of elderly people and ranks third in the country. Therefore I have a great deal of experience of talking to carers.

There are now more women caring for elderly dependants than there are women caring for children. It is estimated that between the ages of 35 and 65, over 50 per cent. of all women can expect at some time to provide care for the elderly or the infirm. It is often provided at great cost to themselves. People who give up work to care for the elderly are immediately put at a financial disadvantage. They receive a pittance in benefits. Their benefits have been cut during the last few years, particularly last year. Many of the carers are elderly, too. An elderly couple in my constituency is trying to look after a violent, mentally ill son. He is twice as big as they are and he weighs more

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