The Secretary of State for Health (Mr. Kenneth Clarke) : With permission, Mr. Speaker, I wish to make a statement on the Government's proposals for the future organisation and funding of community care. I apologise for the fact that I have a fairly lengthy statement to make, but it is a complex matter which is difficult to abbreviate more than I have.
Community care is a policy to which successive Governments have been committed for almost 30 years. The key aim of the policy is to enable people to live as full and independent a life as is possible for them to do in the community for so long as they wish to do so. For many people, that means providing the services and support that they need to continue to live in reasonable comfort in their own homes for as long as possible. For others, who may have experienced long stays in hospital and have more intensive care needs, it means helping them to re-establish their lives away from large institutional settings. I am sure that the vast majority of people wish to live in or near their own homes until or unless age or disability make that impossible. It is the Government's purpose to help them and the people who care for them to achieve that aim. Success depends crucially on the availability of adequate services in the community.
The background to the developments that I am about to announce is one of tremendous growth in both resources and manpower for community care. To give the House some examples of the progress that has been made between 1979-80 and 1986-87--expenditure by the NHS on the community health services has risen by 40 per cent. in real terms and local government spending on the personal social services has grown by almost 27 per cent. Indeed, that local government figure is almost 39 per cent., if it is brought up to date.
The number of day centre and day hospital places for mentally handicapped people between 1979 and 1987 rose by 10,000. The number of home helps grew by 20 per cent. and the number of day centre places for elderly people by 18 per cent. The number of residential places for mentally ill people rose by more than a half, and places in day centres and day hospitals by a third. Between 1981 and 1986, the number of community psychiatric nurses doubled.
That growth in resources has been taking place alongside a dramatic change in the delivery of care and the movement of people out of hospitals and into community settings. Between 1980 and 1986, the number of children in mental handicap hospitals fell from 2,500 to fewer than 400, and the number of mentally handicapped adults in hospital fell by around 14,000, while the number in local authority, voluntary and private community based homes rose by 11,000. In additional, we have, through the benefit system, put huge additional resources into supporting people in private residential care and nursing homes. The amounts spent on supporting these people have increased from £10 million in 1979 to £878 million in 1988. None the less, I am sure that we all agree that progress has not been as even or as rapid as we should like. The rapid growth of residential and nursing home care has been unplanned and largely based on the availability of social security benefits. The Government recognised the need to see whether the arrangements for delivering
Column 972community care could be improved when we askd Sir Roy Griffiths in December 1986 to report on ways by which the better use of public funds for community care might be achieved.
We are indebted to Sir Roy for his report entitled "Community Care : Agenda for Action", which we published in March last year. The report has succeeded in stimulating valuable public debate. More than 280 organisations, professional bodies and members of the public, have sent us their varying views on it, many in support of the recommendations, but some favouring other options. We have taken full account of the wide range of views expressed, and considered a wide variety of options. Our conclusions are as follows.
We accept the distinction Sir Roy Griffiths makes between health and social care. Our proposals do not alter the functions or responsibilities of health services. The community health services will continue to play an essential part in meeting the medical and nursing needs of people outside hospital.
We are proposing to make important changes in the way in which non-health care is provided and, where necessary, funded at public expense. The great bulk of community care will continue, as now, to be provided by family, friends and neighbours. The majority of carers take on those responsibilities willingly, and I admire the dedicated and self-sacrificing way in which so many members of the public take on serious obligations to help care for elderly or disabled relatives and friends. Our proposals are aimed at strengthening support for those many unselfish people who care for people in need.
At present, people who are unable to support themselves and need help with social care can look to two separate sources of statutory help : to social security offices for payments towards the cost of places in residential care and nursing homes ; and to local authorities, for home care, day care and residential care services. We accept that these present arrangements are flawed, because they cannot ensure that priority is given towards supporting people at home where that is possible or desirable.
Social security payments for residential and nursing home care are subject to no assessment of individual needs for care. The public agencies have a financial incentive at the moment which no one ever intended to give to them, to rely as much as possible on the availability of social security for residential care. We do not believe that those present arrangements secure the best possible outcomes for people in need, or indeed, the best possible use of taxpayers' money.
We therefore accept Sir Roy's recommendation that those two sources of public funding should be brought together and allocated on the basis of a proper judgment of each individual's needs. By creating this unified source of funding for the full range of social care services, we can ensure that the objective of sustaining people in their own homes wherever possible be given the necessary priority. We propose to introduce a new funding structure for those seeking help from public funds for the cost of care. In future there should be a single budget to cover the costs of care whether in a person's own home or in a residential or nursing home. This will enable sensible decisions to be taken about the type of care that best meets an individual's needs and provides best use of public money. At the same time we will remove the perverse incentives in the present benefit system by making all claimants eligible to income
Column 973support and housing benefit on a similar basis, whether they are living in their own homes or in independent residential or nursing homes.
We have considered carefully which care authority should hold this new budget and take on the responsibility for the assessment of need and provision of care. Local authorities are already responsible for the full range of social care services and have a great deal of expertise in this area. We have concluded that the best way forward will be to build on local authorities' existing responsibilities. We accept Sir Roy Griffiths's proposal that local authorities should assume responsibility for the care element of public support for people in private and voluntary residential care and nursing homes, and for making the best use of those funds in relation to an assessment of people's individual needs and wishes. Collaboration between medical, nursing and social services agencies will be essential in assessing individual needs, and in designing suitable arrangements for care. We shall look to local authorities to ensure that suitable multidisciplinary assessment procedures are in place and to health authorities to make their contribution to those procedures.
We attach great importance to securing a smooth transition to this new structure, avoiding uncertainty for people currently living in homes and for their relatives. We therefore propose that the new arrangements for social security benefit entitlement will apply to people not already in residential or nursing home care after the date on which the new arrangements come into force.
Residents of homes who are in receipt of income support when the new system is introduced will therefore retain their entitlement to help through the existing system. People who are self-financing residents of registered homes when the new system is introduced will also be able to apply for income support under the existing arrangements if their funds become exhausted subsequently. My right hon. Friend the Secretary of State for Social Security is today announcing further details of these new arrangements.
We accept that further efforts will be needed to improve co-ordination between health and social services in the arrangement and delivery of services to individuals. We believe that the clarification of roles in our proposals will make it easier to achieve this.
The local authorities' responsibilities, in collaboration with others including doctors and other caring professions, will be to assess individuals' needs, design suitable care arrangements, and secure their delivery. It is not necessary for local authorities to provide all this service directly themselves and they should make maximum possible use of the voluntary, not-for-profit and commercial sectors so as to widen individuals' room for choice, increase the flexibility of services and stimulate innovation.
The Government have long urged local authority social services departments to act in an "enabling", and not just a "providing" capacity. Some authorities are already moving in that direction. To minimise disruption and to ensure that local authorities have every incentive to make use of the independent sector and offer people choice, we propose that they should continue to meet the full cost of accommodating people in local authorities' own homes, subject to their existing powers to make charges according to residents' ability to pay. My right hon. Friend is not therefore proposing to change the benefit rules for residents of these homes.
Column 974We believe that these new financial arrangements will give local authorities the necessary incentives to develop better services for people at home, and make greater use of independent providers. But it will be important that local authorities should have clear plans for the development of community care services, worked out in collaboration with health authorities and the independent sector. I shall expect all authorities to have such plans, and shall ensure that they are open to inspection by my social services inspectorate. I also propose to take powers to call for reports on local authorities' community care services.
Local authorities will need adequate resources for their new responsibilities. That means that we shall transfer to the local authorities the resources which the Government would otherwise have provided to finance care through social security payments to people in residential and nursing homes. The aggregate amount of transferred resources will allow for the projected growth in the number of people needing support. Resources will be needed by the local authorities in addition to carry out their new tasks of assessing individuals' needs, arranging appropriate care services for people at home, and buying residential and nursing home care.
We are confident that the proposed funding changes, by putting more emphasis on supporting people in their own homes, will provide both more suitable services closer to individuals' wishes and needs, and better value for money from public spending than under the existing arrangements. We shall be discussing the detailed financial implications with local authority representatives. The necessary decisions on the resources to be transferred will be taken in the public expenditure survey next year.
I have summarised our conclusions on the main proposals in Sir Roy Griffiths's report. They represent a major challenge for local authorities and social services departments. There are a number of associated issues on which the House will also expect me to make the Government's position clear.
First, we have been especially concerned to ensure that care for severely mentally ill people is properly managed. Here, as in other areas, we have concluded that the right course is to ensure that the existing responsibilities are discharged effectively. On the health side, I will ensure that discharges of seriously mentally ill people from hospital will take place only when adequate medical and social care is available for them outside hospital. More details of the initiatives we are taking here will be announced shortly. On the social care side, we have decided to create a new specific grant directed at encouraging local authorities to make their necessary contribution to services, in line with health authority plans and objectives. To achieve that, we have decided that the grant should be payable by health authorities, acting as my agents, on the basis of plans and targets put to them by the relevant local authorities. The details of this proposal will be worked out in discussion with health and local authority representatives.
Secondly, both Sir Roy Griffiths and Lady Wagner made recommendations about the registration and inspection of residential care and nursing homes. Local authorities will be asked to establish inspection and registration units, at arm's length from the management of their own services, which should be responsible for checking on standards in their own homes, and to involve independent outsiders in these arrangements. We have concluded that, for the present, existing statutory functions should remain unaltered.
Column 975Thirdly, we would expect general practitioners to ensure that social services departments are aware of their patients' needs for social care as recommended by Sir Roy Griffiths in his report. I have outlined our conclusions on the main issues. I am grateful to the House for its patience in sitting through a long and complicated statement. My right hon. and learned Friend the Secretary of State for Scotland and my right hon. Friend the Secretary of State for Wales are today announcing separately our conclusions of particular relevance to them. My right hon. Friend the Secretary of State for Northern Ireland will be doing the same early next week. We propose to spell out our proposals in more detail in a White Paper that we aim to publish in the autumn. It will be necessary to ensure that the necessary legislative framework is in place before implementation, which we propose should be in 1991.
Our proposals bring the policy of community care up to date, and will improve the way in which it is put into practice on the ground. Community care is no longer primarily about providing the alternative to long-stay hospital care. The vast majority of people needing care now have never been, nor expect to be, in such institutions. The policy aim now is to strike the right balance between home and day care on the one hand, and residential and nursing home care on the other, while reserving hospital care for those whose needs truly cannot be met elsewhere. The changes we propose will for the first time ensure that all public moneys are devoted to the primary objective of supporting people at home wherever possible. They provide a solid basis for the future, and are founded upon the principles of preserving individual independence and freedom of choice and of providing services in a sensitive and personal way. I believe that they deserve whole-hearted support, and commend them to the House.
Mr. Robin Cook (Livingston) : I begin with the two points in his statement on which we can unreservedly congratulate the Secretary of State. First, we welcome the fact that he has finally got round to saying anything about the Griffiths report. Will he confirm that Ministers have taken longer to think about their response to this report than Sir Roy took to write it? Even after all that time, the Secretary of State still has to ask the House to wait another four months for a White Paper to explain the meaning of today's statement.
Secondly, I congratulate the Secretary of State on persuading the Prime Minister that providing community care means swallowing her distaste for local government. This is a major achievement, which deserves full recognition. We welcome the Secretary of State's acceptance of Griffiths's central conclusion that the lead agency in community care must be the local authority, which belongs and is accountable to the community.
Why, then, has the right hon. and learned Gentleman rejected Griffiths's recommendation that residents of local authority homes should be entitled to the same financial support from central Government as residents in private homes? If he really believes that elderly people should be given the widest possible choice, why has he decided to deny them income support and housing benefit only if they choose a council home? Surely even the Secretary of State
Column 976will admit that, rather than widening choice, that narrows it, and does so simply to fit the Government's prejudice against local authorities.
Since the statement calls for greater co-ordination and collaboration between health authorities and local authorities, could the Secretary of State enlighten the House as to how that co-ordination and collaboration will be helped by his intention to boot council representatives off every health authority?
The Secretary of State was good enough to recognise that most care in the community will continue to be provided by family and friends. Does he not mean by that the nearest available female relative, often exhausted by providing constant nursing, with no training, with no break and usually with no help? The Secretary of State informed the House that he admires them. If he really admires them, why does the statement contain no mention of respite care to give them a break, or a single mention of care attendents to give them a night off? If he really admires them, why have the Government proposed to slap on an extra poll tax charge for taking in granny? If he really admires them, why does he not bring back national guidelines for home helps? What has he to say to the half-dozen councils-- all Conservative--whose provision of home helps is half the national average? Is that the standard of community care that is acceptable to the Conservative party?
The Secretary of State said that services should be sensitive to the needs and wishes of users. What will he do to encourage that? Will he begin by telling his colleagues on Bradford council not to proceed next Wednesday with the sale of a dozen old folks' homes without consulting the residents? Is that the sensitivity to the wishes of users that is acceptable to the Conservative party? Now that we have persuaded the right hon. and learned Gentleman to use the words "community care", could I tempt him to use the words "disabled persons Act"? Why did he not take this opportunity to implement section 7 of the Disabled Persons (Services, Consultation and Representation) Act 1986, which would have given patients discharged from mental health hospitals the right to an assessment of their needs? Is he aware that last week was the third anniversary of Royal Assent to that Act? How can he expect the House to believe in the Government's commitment to community care when they have yet to implement half that Act?
The biggest omission from the right hon. and learned Gentleman's statement was money. He knows that Sir Roy Griffiths recommended an annual grant for each local authority to fund its community care programme. Would the right hon. and learned Gentleman like to rummage through his notes in case he left out the passage announcing such a grant? Does he not appreciate that, without resources, the plans and the reports that he has announced today are mere window-dressing? Why does he not at least accept that local authorities should have the property fortunes that health authorities are making from the sale of mental hospitals? Should not the first charge on that money be the capital costs of new homes to house the patients put out so that the hospitals could be closed?
The right hon. and learned Gentleman began with a description of the Government's record on community care that oozed complacency from every sentence. It ignored the fact that the number of places at day centres for the elderly has fallen per thousand of the elderly population. It ignored the fact that the numbers
Column 977discharged from mental health hospitals are three times the growth in the number of day centre places. Those outside this place will ask how that description could be made by anyone who has noticed the dramatic growth in the number of mental health patients now living in hostels for the homeless, or the steady rise in the number of them in remand centres, or even the increase in the number sleeping rough behind the right hon. and learned Gentleman's ministerial office. The right hon. and learned Gentleman ended his statement by informing the House that his proposals will not be in place for another two years. Our pledge to those in need of community care is that, by then, no longer will he and his Government be in power.
Mr. Clarke : The hon. Member for Livingston (Mr. Cook) began by talking about the time that it has taken to produce our response. I cannot win on timing. For anything of which he disapproves, he accuses me of being too fast and a bull at a gate ; for anything of which he approves--despite his attempts to find disagreement--he accuses me of taking too long. It is easy for him ; he has only to see the words "local government" in a White Paper to ring NALGO--when it is not on strike--and ask what to say-- [An Hon. Member :-- "That is a poor joke."] It is a very good joke. The hon. Gentleman obviously takes footnotes from NUPE, as was shown by his questions. The truth is that the hon. Gentleman agrees with my proposals. We have taken considerable care, first in deciding exactly how to sharpen the responsibilities of local authorities ; secondly, how to transfer resources to them to enable them to do so ; and thirdly, how to ensure that we have some assurances that they will live up to those responsibilities and properly discharge their role. The hon. Gentleman knows that he approves of that policy.
The hon. Gentleman apparently dislikes the fact that we are not allowing a large increase in local authority provision of council homes. Indeed, we are not proposing any change to the existing arrangements for residents of local authority homes, and there is no case to do so. If the hon. Gentleman thinks that there is a need to change the arrangements artificially to stimulate a sudden upsurge in local authority provision, my answer is that my statement is a challenge to local government and gives it important new responsibilities. It probably would not be right for most councils to combine with that a growth in the management role of the day-to-day running of more and more homes. We have struck the right pattern, because more and more local authorities think of themselves as enablers, looking to other people to deliver the care.
The hon. Gentleman made some curious remarks about my reference to relatives and friends. He rightly said that many of them are female members of the family looking after their relatives. The whole point of my statement is that we are enabling local authorities to give more support to those people. The hon. Gentleman gave a list of provisions that they are likely to need, including respite care and care attendants. The whole point of transferring resources and of clarifying responsibilities is to make available the very kind of support that local authorities should be enabled to provide in the light of our policy. The hon. Gentleman's snide remarks were unintelligible to me. I shall not get into bashing Bradford council, which the hon. Gentleman also irrelevantly introduced into his
Column 978arguments. New control in Bradford is bringing great improvements to that authority and to its capacity to deliver enhanced care to the city's residents.
Section 7 of the Disabled Persons (Services, Consultation and Representation) Act 1986 is overtaken by my remarks today. Section 7 divides responsibility for mentally ill people between those who have been in hospital for six months or more and those who have not--and there is no logical basis for that arrangement. Of course I agree that care in the community policy for the mentally ill needs to be improved, and our proposal will ensure that pump-priming resources will be available to local authorities.
The key to those resources will be held by health authorities, which, as my agents, will release money when they are satisfied that the right local provisions are in place. That should reduce the number of patients who are rightly released from hospital into better provision, but who then leave that accommodation or become lost, are not followed up, and wind up in the unfortunate circumstances that the hon. Gentleman described.
As to money and resources, we are following Sir Roy Griffiths's recommendation to transfer resources and the care element of social security to local authority budgets--making allowance, as we will have to do, for anticipated growth and the new duties of local authorities. We have not followed Sir Roy's recommendation for a specific grant. The transfer of resources will take place, but the specific grant was a control mechanism suggested by Sir Roy. For my central Government Department to seek to use a specific grant to control directly the community care policies of all local authorities throughout the country would not be the right way of enabling those authorities to discharge their responsibilities.
That is why I prefer the route of community care programmes drawn up together with health authorities and voluntary bodies, of giving powers to my social services inspectorate, and of having the power to call for reports and to intervene when an individual authority poses a problem. The transfer of resources is in line with Sir Roy's recommendation. That transfer and the new responsibilities begin a new era in community care. It has always been right to pursue the policy of keeping people in their own homes for as long as they wish to remain there, and the implementation of that policy will now be greatly improved.
Sir David Price (Eastleigh) : Is my right hon. and learned Friend aware that the House is grateful to him for acknowledging the role of private carers in looking after the elderly and disabled in our midst? Is he aware also that if those carers decided to take industrial action, the statutory services could not cope? As my right hon. and learned Friend acknowledges the important role of the private carer, will he explain how he intends to "strengthen support" for the private carer? The hon. Member for Livingston (Mr. Cook) made a number of points that pertained directly to that aspect. Do the Government intend to increase the invalid care allowance, which would be of enormous help to people who give up work to look after a person who is insufficiently handicapped to be eligible for a disabled attendance allowance? Is my right hon. and learned Friend aware that there are more people out there needing help than have been acknowledged until now?
Mr. Clarke : I agree with my hon. Friend's final point, and I think that it is acknowledged now that the vast majority of care of the people in question is provided by dedicated friends and relatives. We are trying to tackle the situation of when it becomes increasingly difficult or near impossible for the family to cope. At present, they find it much easier to obtain social security, to enable them to move the relative into a nursing home, than to secure the additional support that might help them to keep that relative at home much longer. I refer to respite care, domestic help and the other provisions that local authorities should be enabled to provide.
The money for that is readily available, but is currently diverting people into residential care when perhaps that is not the best choice. Those resources will be placed in the hands of local authorities, who will use a lot of it to back up the carers and give the support that they require to carry on with their task--which they would do willingly, with the support of the statutory authorities. There is no change in the benefit arrangement for carers. That matter is for my right hon. Friend the Secretary of State for Social Security and it is not dealt with in the Griffiths report. However, there have been some advances. There has been a huge growth in the number of people receiving invalid care allowance since it was extended to married women, increasing elevenfold after the law was changed three years ago.
We are trying all the time to find other ways of helping carers, and we are encouraging the demonstration projects that are going on all over the country to show local authorities what is best practice in the provison of support.
Mr. Ronnie Fearn (Southport) : We welcome the statement, and, indeed, the fact that social services departments will now be the lead authority : we have asked for that for a long time in our discussions with Sir Roy Griffiths.
Does the Secretary of State accept, however, that the GPs now have a considerable role to play, and that the GP lists should be smaller? Does he agree that training is needed for social services departments? They have called for it through their directors, and it will certainly be an important aspect of the arrangements. Hon. Members have already mentioned the role of carers. Can the Secretary of State specify one or two measures to help them? I am connected with the Association of Carers, which will not be too sure, from a reading of the statement, what is to happen. Perhaps the Secretary of State for Social Services could enlighten us. It appears that there will be rather a dearth of housing for those who are sent out--I will not say "thrown out"--of institutions. Clearly local authorities must play a major role. Will the Secretary of State direct in any way that they should receive more finance for the purpose?
Mr. Clarke : A high proportion of referrals to social services departments--of people in need of community care--come from general practitioners at present, and I accept that GPs have an extremely important role to play. They will be able to perform that role if they take advantage of one of the elements in the new contract : we shall pay them a much higher fee if they carry out an annual social assessment of all their patients over the age of 75.
I agree that small lists will help GPs to carry out their new duties. None of my proposals will increase the average
Column 980size of lists ; they have been getting smaller ever since the Government came to office, and I confidently expect them to continue to do so.
I agree entirely that we must continue to strengthen training of social workers and local authority employees. Specific grants are already available--for example, to increase the amount of training for social workers caring for the elderly.
I gave some examples to my hon. Friend the Member for Eastleigh (Sir D. Price) a moment ago of the kind of assistance that carers can expect from local authorities, which are being given their new responsibility in the transfer of resources precisely so that they can step in and help people to obtain the support that they require to live in or near their homes.
I note what the hon. Gentleman said about housing, but I honestly do not think that housing finance is remotely related to what I am talking about today, and it is not a matter on which I can announce any new policy.
Dame Jill Knight (Birmingham, Edgbaston) : I welcome what my right hon. and learned Friend has said about the improvement in the arrangements for the discharge of mental patients, whose plight has been worrying many Conservative Members.
May I ask my right hon. and learned Friend to consider two factors that make it very much more difficult for private residential homes to fulfil their important task? First, patients in such homes are not eligible for ordinary NHS ancillary treatment : that is a serious problem. Secondly, payment to such people to meet their bills is all too often not passed on to the managers of the homes, who are experiencing severe losses.
Mr. Clarke : I am grateful for what my hon. Friend has said about the worrying problem of mentally ill patients, who nowadays are increasingly treated and cared for outside rather than inside hospitals. As I have said, my hon. Friend the Under-Secretary of State for Health will be making a further statement in the form of a written answer tomorrow, setting out more details of our NHS policy towards such patients. Lest anyone should speculate further along the lines of press reports, let me add that that will not include a moratorium on the discharge of patients from hospitals, or anything of that nature. [ Hon. Members :-- "Why not?"] Well, some may want it. It will strengthen the policy of care in the community for those who ought to be cared for in the community and will ensure that the policy works. I am afraid I have forgotten my hon. Friend's other point.
Mr. Clarke : I am grateful to my hon. Friend. In my experience, people who are living in private residential and nursing homes are not deprived of all rights to NHS ancillary care, but I agree that the practice varies widely from place to place. If I may, I shall either write to my hon. Friend or will answer a parliamentary question, if she cares to table one, setting out the basis on which those who live in private homes are entitled to NHS treatment, thus aligning them with other citizens. It is a matter that often gives rise to local worries.
As for my hon. Friend's point about social security, various difficulties can arise when people get social security payments to pay for their stay in a nursing home, including
Column 981the fact--particularly when they are first admitted--that large sums of money can sometimes be handed over to someone to pay for the treatment, and owners sometimes say that it does not reach them. I know that my right hon. Friend the Secretary of State for Social Security is aware of that. He will have heard my hon. Friend's points, as he is in his place. I know that he is considering the matter and that he will keep it actively under review.
Mr. Frank Field (Birkenhead) : I thank the Secretary of State for his statement, but does he not agree that what he has said this afternoon could mean everything or nothing, depending on the level of funding? As for his most welcome statement that people should remain in their own homes or in their children's homes, if that is at all possible, what is the projected increase in expenditure from the total budget which would ensure that that objective is kept to over the next five years? To take him back to the important point that has just been made by the hon. Member for Birmingham, Edgbaston (Dame J. Knight), will he assure the House that from now on no one will be expelled from a long-stay mental hospital, only to find himself a dosser?
Mr. Clarke : On the hon. Gentleman's first point, decisions on resources can only be made in the public expenditure round next year. [ An Hon. Member :-- "It may not be forthcoming."] No. Most Departments of State and the Treasury are concerned about the public expenditure round this year. There is no point in expecting us to come to final decisions on a part of the public expenditure round for 1991 at this stage. However, the question of resources is important, so that everyone can plan. What my statement contained was a very clear, explicit statement binding the Government to the principles that we shall adopt in working out the right transfer of resources. When that transfer of resources takes place, the final figure will emerge in the public expenditure round next year.
I entirely share the hon. Gentleman's desire that no mentally ill patient should be discharged from hospital and touch is then lost with that patient, or care breaks down, so that he or she winds up in undesirable circumstances. Therefore I intend to ensure that National Health Service hospitals do not discharge patients until they are satisfied that proper arrangements have been made.
Mr. Clarke : It would not be realistic for every patient's case to be referred to the Department of Health so that the Department of Health can be satisfied. The practice has much improved, although there are places where it does not work now. In the past, there were some dreadfully bad examples of failure. Hospitals are no longer pushing people out, knowing that they will get into difficulties. The difficulty is that they were pushed out into what appeared to be adequate facilities. Then they left, went away and touch was lost with them.
We are ensuring that responsibility is clearly placed on the local authority, but a specific grant will be available which will be released by the health authority when it sees that local authority plans are there to keep in touch with patients and to provide them with the social care that they need. I very much share the desire that all of us have that there should be a big reduction in the number of incidents whereby mentally ill people fall into dreadful and destitute circumstances.
Mr. Nicholas Winterton (Macclesfield) : Will my right hon. and learned Friend assure the House that the National Health Service will continue to have responsibility not only for the treatment of the mentally ill, the mentally handicapped and the elderly, but also for the care of the mentally ill? How can he give the House an assurance that the social services of this country are competent or qualified to deal with the problems relating to the mentally ill?
Can my right hon. and learned Friend give the House an assurance that in his view there is a continuing need for long-stay hospital care for the mentally ill, particularly those suffering from schizophrenia? Despite what he said in his statement this afternoon, how will he ensure that mentally ill people will not end up in prison--as was discovered in an inquiry carried out by the Social Services Select Committee--in doss houses, in totally inadequate accommodation, on park benches and under the archways of such places as Waterloo station? Will he ensure that health authorities do not concern themselves more with the realisation of assets than with the care of people who require their help?
Mr. Clarke : I am entirely satisfied, in the light of my experience, that health authorities are concerned with the care of mentally ill patients in their charge and not with asset management, as my hon. Friend implied. Of course that must continue. Nothing that I have said today in any way reduces the responsibility of the National Health Service for hospital services for the mentally ill and the community care services, which have been so greatly expanded in recent years by community care units. The number of psychiatric nurses has doubled in five years in the 1980s and their number needs to increase further. Of course I accept the need for long-stay care in hospital, as that will always be required for those who suffer from acute illness or bouts of acute illness. However, the balance of provision between hospital care and community care is greatly changed. It has been changing for 20 years and it will continue to change. We are concentrating on ensuring the success of community care for those who ought not to be treated in hospital.
We have to avoid the scandals that my hon. Friend has described. I wish that some of the television expose s of those scandals were accompanied by expose s of some of the scandals that used to exist in the long-stay mental institutions which we have closed, which were nightmarish institutions. We do not wish to go back to them. We now have the opportunity to link local authorities with health authorities, giving the health authorities the key to unlock the money for the specific grant that will pump-prime new and improved provision of social care for patients for whom the Health Service is trying to provide medical care in the community.
Mr. Alfred Morris (Manchester, Wythenshawe) : How does the Secretary of State square what he said about appropriate care for the mentally ill with the closure this Friday of a 24-bed hospital ward for the mentally ill in south Manchester, which, in the words of their consultant, means that his patients will have to wander the streets with nothing to do and nowhere to go? Will he stop that closure? Moreover, how does he reconcile what he said with the insistence by local authority leaders of all political persuasions that, due to lack of resources, they can no
Column 983longer meet their legal duties under the Chronically Sick and Disabled Persons Act 1970 which, as he knows, is all about community care?
Mr. Clarke : I know that South Manchester district health authority is the centre of enormous controversy about its services and their provision. It is financed on the same basis as any other health authority. If it wishes to make a closure that is contested it is referred to us and is approved by a Minister only if we are satisfied that there is a good health care case for doing so. We should leave South Manchester district health authority to discharge its responsibilities in the way it judges best. Half the Members of Parliament representing Manchester regard everything there as a political decision, but we are satisfied to approach them as health care decisions. I am quite satisfied that South Manchester district health authority is responsible for arranging its own services. If there is a contested closure, we shall consider it in the usual way. Local authorities have had an enormous increase in resources-- [Hon. Members : -- "Where?"]--on personal social services. Local authority spending on personal social services has gone up by almost 39 per cent. above inflation in the lifetime of this Government. The last time that I was in Stockport, which is near Manchester, I was shown a letter by the director of social services explaining that he could not care for a patient because he needed another £1,500 million to bring his services up to the standard required. Frankly, many local authorities can discharge their responsibilities on present resources, continue to improve them and will look upon today's statement as a great challenge to enable them to improve them further.
Mr. Ray Whitney (Wycombe) : I congratulate my right hon. and learned Friend on his long-awaited statement, which brings together a complex network of community care services. Given the uneven level of provision of personal social services and properly managed residential care homes by certain local authorities, will my right hon. and learned Friend in implementing his proposals take careful account of the need to stablish an effective national monitoring mechanism? In that way, the funds, which will undoubtedly continue to increase, will be properly used and the best national standards obtained throughout the country.
Mr. Clarke : I endorse the excellent objectives that my hon. Friend sets for us in monitoring local authority performance. As I said, all local authorities will have to produce community care plans in collaboration with health authorities and local voluntary bodies. We will, of course, consider those plans.
We have not gone down the specific grant route of trying to control all the plans, but are very much using the inspectorate route. My social services inspectorate will have an increased ability to step in and inquire into the delivery of services. I shall have increased powers to order reports and inquiries. Our inspectorate is producing advice on the management of local authority homes, which should give a clear guide to those local authorities that are not achieving adequate standards. This should ensure that, if they follow that guide, the standards of most will be brought nearer the standards of the best.
Mr. John McAllion (Dundee, East) : I deplore the fact that there has been no separate statement for Scotland and that Scottish Members must await a written reply to a planted question on today's Order Paper.
Will the right hon. and learned Gentleman explain why he has ignored Sir Roy Griffiths's recommendation that the public finance of residential home care should be the same whether it is in the public or the private sector? Does not the right hon. and learned Gentleman accept that, by announcing his intention to discriminate against the financing of local authority homes, he throws into utter confusion the planned provision of care in many areas such as Dundee, where a new major residential home is being built?
Mr. Clarke : My right hon. and learned Friend the Secretary of State for Scotland has been involved in the production of the Government policy that I announced today. It is entirely proper for him to produce a written statement setting out particular Scottish aspects of the policy, just as my right hon. Friend the Secretary of State for Social Security is producing a written statement on the social security implications.
The Gentleman's second point shows that he has misunderstood what I said. There is no change in what I am proposing for the financing of residents of local authority homes. If anything, the discrimination against them is greater under the system that we are replacing. At present, there is an incentive to put people in private residential homes instead of assessing the possibilities of the local authority making other provisions for them. Local authorities will find that, if there is any discrimination in the provision, it will be lessened by my proposals, not increased.
Mr. James Couchman (Gillingham) : I am grateful to my right hon. and learned Friend for his statement. As a former chairman of social services and of a health authority, I know only too well the gaps and overlaps that exist. Clarification of responsibility will be welcome to all those who have followed community care matters for a long time.
What will happen to the funds that have been released by health authorities when people have been discharged from long-stay hospitals and that form a kind of dowry to those who now look after them? What will happen to the joint funding money that has been passed from the Health Service to social services as an enabling fund? What plans does my right hon. and learned Friend have for increasing the level of day activity for those who have been discharged from long-stay hospitals where day activity has been provided on site?
Mr. Clarke : I am grateful for my hon. Friend's opening remarks. He has considerable expertise which is relevant to both sides of the local authority and health authority fence. Joint funding will continue. We are considering whether we can improve its effectiveness and the way in which it is applied and used. The White Paper that we will publish in the autumn will provide more details.
The amount of day activity is increasing. The provision of an adequate level of day activity for mentally ill people is one of those matters that should definitely be addressed in the community care plan, when it is produced by local authorities in collaboration with health authorities. In future, it should be much easier not only to carry on increasing the level of day activity but to ensure that,
Column 985between them, the authorities know exactly what is required, so that plans are drawn up and they know where day activity is provided.
Mrs. Margaret Ewing (Moray) : The Secretary of State has touched briefly on training. Does he accept that if we are to marry the assessment of need with the provision of service, there will be a clear requirement for a vast number of additional trained, qualified and professional social workers in field work and day care? Has he made any assessment of a budget for the provision of additional training for such people? Does he intend, unlike his right hon. and learned Friend the Secretary of State for Scotland, to ensure that people who suffer from degenerative mental illnesses, such as Alzheimer's disease, will be exempt from the community charge, which has placed an added burden on those who undertake care in the community at this stage?
Mr. Clarke : Social services is a labour-intensive activity, so the continued growth in the provision of personal social services is bound to lead to a growth in the number of staff employed. However, I am not setting a target, and we should not look for growth in the administrative staff as opposed to those delivering care. I recognise the need for training, and we already have some specific grants designed to encourage an increased level of training in care for the elderly. We shall continue to look at the case for any new specific grant, if that is required. I am sure that one of the first actions of local authorities with the new resources transferred to them from the Department of Social Security will be to consider how they will now be able to finance training to bring their staff to the required level of skill.
Mr. Jerry Hayes (Harlow) : Does my right hon. and learned Friend agree that the frail, the elderly and the most vulnerable will welcome his statement? For the first time, they will have clear guidance on health care packages, backed with cash. However, will he be vigilant in ensuring that local authorities, which will be vested with vast resources, spend those resources specifically on community care and that the resources are not abused?
Mr. Clarke : I welcome my hon. Friend's remarks about the frail, the elderly and the vulnerable, who are meant to be the point of the policy and who will be the beneficiaries of it. I am glad that my hon. Friend has concentrated on that, rather than on the interests of particular groups inside the local authority world, as some Opposition Members appear to be doing. It is important that we stimulate a high level of performance by local authorities. They now have a great opportunity and it is up to them to deliver a good standard of care. I have therefore already stressed the drawing up of the new plans, the involvement of health authorities in them, and the role I expect my social services inspectorate to play. It will be necessary to ensure that some local authorities raise their present standards and use the new resources to catch up with the best practice elsewhere.
Mr. Michael Foot (Blaeunau Gwent) : As it is almost impossible to exaggerate the agonies and anxieties of individual families and the individuals concerned with this question, and as those anxieties are bound to be intensified in a period of transition, will the right hon. and learned Gentleman tell us whether he has had any consultation with the people who work in the service, including the
Column 986Royal College of Nursing? When I asked the right hon. and learned Gentleman a similar question about his general health care plans, he passed it away with a sneer, but he should have learnt better by now. Should he not consult the people who do fine work in this respect, even finer than in the rest of the service, if that is possible? In the transitional period and even over a longer period, will the Secretary of State and his Department retain, in one form or another, control over the reassessments that will take place of when people will be discharged into the community generally? The assurance for the whole system is bound to depend on those reassessments. The right hon. and learned Gentleman must do his best to give firm guarantees to the people concerned.