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Mr. Andrew Rowe (Mid-Kent) : I cannot believe that it has escaped the hon. Gentleman's attention that, during the past decade, and in the past 40 years, there has been an enormous growth in the number of people who have disposable incomes and who have had them for most of their working lives. They are accustomed to making choices in the market place about the kind of care that they want. It would be entirely in keeping with that choice that there should be a considerable growth of a mixed economy in the provision of care, as there already has been in the provision of residential care.
Mr. Cook : The hon. Gentleman says that many people with an income are obliged to buy in the private sector what they cannot obtain from the public sector. Since the hon. Gentleman's constituency is in Kent I shall describe a situation that faces some of his constituents. His local authority is in the bottom 20 for provision of home helps to people over 75, and it provides the lowest number of meals per person to those over 75.
Mr. Rowe rose--
It is hardly surprising in those circumstances, when there is dire, desperate and inadequate public sector provision, that so many constituents are forced to turn to the private sector.
That brings me to the Minister's observations about the increase in the provision of home helps and of domiciliary services. There has undoubtedly been an increase. There are also dramatic variations in provision across the country that ought to be of interest to the Minister. The top 20 social services authorities provide more than 40 hours of home help service per person over 75. Virtually all of them are Labour authorities.
I agree that none of those authorities would be complacent about provision. Every one would accept that there is a case for further provision and that they are not meeting needs in their area, but at least they are in the top 20. They all provide more than double the number of hours of home help service that are provided by authorities in the bottom 20, all of whom provide less than 20 hours per person to those over 75. I am proud to say that none of those local authorities in the bottom 20 are in majority Labour control. The issue is not the Minister's barren ideological obsession with whether services are contracted out or are with a private provider but whether the services are being provided at all. My hon. Friend the Member for Newham, South (Mr. Spearing) mentioned the inadequacy of home help provision in Newham, where the number of hours of home help provided per person over 75 is 38. The neighbouring borough to Newham is Conservative-controlled Redbridge, where the average number of hours of home help per person over 75 is 16--less than half that of the neighbouring borough.
Are there so few old people in Barnet that it can get by by providing one fifth the number of hours of home help provided in Greenwich? Are old people in East Sussex so wealthy that East Sussex can get by with a quarter of the services provided in Cleveland? There is the same variation in the provision of meals for people over 75 in Kent. Can Kent get by with one tenth of the provision of meals per person over 75 as is provided in Lewisham, which is only half an hour's drive away? The variations that those figures reveal have nothing to do with variations in need,
Column 48but everything to do with the political priorities of the people in charge. Throughout the country, Labour authorities are committed to meeting those needs, but the services that they provide may be put at risk by the political dogma foreshadowed in the White Paper. The Government's worrying double standards on residential homes were revealed in the Secretary of State's statement in July and confirmed by the Minister's speech. The Secretary of State takes pride in saying that he has delivered on 80 per cent. of Griffiths's recommendations. Typically, the two major departures from Griffiths relate to money. The first is arrangements for people in residential care. The Government's proposals are not the same as Griffiths's, despite the Minister's congratulations on a cogent and worthwhile report.
Griffiths recommended that there should be a level playing field between the public and private sectors, which is what one would expect from an author committed to a free market in which people can exercise choice. Instead, Ministers are offering a rigged market in which one choice is off limits. One will receive social security support only if one chooses private provision. One will be lucky to receive local authority provision because, inevitably, Labour and Conservative-controlled authorities will be obliged to steer people towards the sector that enables them to maximise revenue and protect their fixed budgets. On this playing field, the public sector will be playing up hill.
I note in the synopsis of the White Paper a delphic line that reads :
"Explanation of the rationale for this."
I look forward to reading that. I do not know how Ministers propose to wrap it up, which may be a cause of the delay. We are already aware of one reason for the delay--to force local authorities out of direct provision. If anyone doubts that, he should consider what is happening in local authorities where the Conservatives already have their hands on that direct provision. In Bradford, they are selling old folks' homes, not necessarily to be used as such once they are sold. Since the publication of the Secretary of State's statement in July, the authority in Wirral has divested itself of all old folks' homes.
In those circumstances, what happens to the rights of the users of those homes? What about the choice of residents who live in them? What guarantee do they have that they will be allowed to continue to exercise their choice to stay in a local authority home?
The truth is that there is a mixed market in residential care, and that no one in the public sector is arguing against it. Indeed, precious few people in the private sector are arguing against it. The only voice urging retreat by public sector provision is that of Ministers. That dogma matches the prejudice with which Ministers are currently booting local authority representatives off the health authorities at the very time when community care requires greater co-operation between the two.
Column 49"Inspectors are setting standards for the private sector which are not adhered to in the public sector, especially in residential care homes."
Perhaps the hon. Gentleman will take that on board.
Mr. Cook : The hon. Gentleman should be on this side of the Chamber. The Government propose to leave registration inspection in the hands of local authorities. The Labour party proposes that registration inspection should be carried out by a national agency and not left with local authorities, but that is a debate that the hon. Gentleman can have with his hon. Friends and not Labour Members.
Local authorities are being invited to make long-term dispositions about residential care homes on the basis of the rigged market that will be introduced in 1991. The next Government will remove the absurd discrimination against the public sector. We shall restore to local authorities the right to compete fairly and the ability to be direct providers of residential care.
That brings me to the Secretary of State's second major departure from Griffiths. Griffiths recommended a specific community care grant to meet half the total expenditure of local authorities on community care. No specific grant was included in the Secretary of State's statement to the House. I was astonished when the Minister said that the Government had not yet made up their mind about that. It is perfectly clear from the Secretary of State's statement on 12 July that he had made up his mind. I asked a specific question about this issue, to which the Secretary of State replied :
"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 We have not followed Sir Roy's recommendation for a specific grant."--[ Official Report, 12 July 1989 ; Vol. 156, c. 982.]
If the Minister is saying that the Secretary of State is having second thoughts, that is most welcome, but I should like to tempt the Secretary of State in his second thoughts to go beyond the specific minor element to which he referred--the transfer of the present social security provision to those in residential care. If that is the only commitment to money being diverted to local authorities and a specific grant, I warn hon. Members that we are not talking about large sums. We are talking not about the £1 billion that is currently given to those in residential care who are on social security, but about only the care element of funds that the Department of Social Security would otherwise pay out on persons admitted for the first time to residential care after April 1991.
The increase last year in DSS expenditure on residential care was less than £200 million. The Minister has not told us how much of that is the care element, but if we assume that it is about one third, we are talking about a transfer from DSS funds to local authorities of less than £100 million--perhaps £750,000 for every social services authority in England and Wales. We are not talking about sufficient grants to meet 50 per cent. of their community care expenditure. Local authorities are worried that they will not be receiving enough even to carry out the function of substituting for the DSS and maintaining people in residential care.
It is not enough for the Minister to dismiss the intervention of my hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody) as Dickensian. The point that she made about the under-funding of those who are currently on social security in residential care is well
Column 50documented. A study carried out in Oxford identified almost one third of those residents having a shortfall in excess of £30 a week. A firm of accountants, on behalf of the British Medical Association, is studying that picture.
There is no mystery about it--the gap dates from 1985, when the Department of Health and Social Security changed the rules, no longer met the full fee of the homes and residential care and annually uprated only a flat charge, which in every year since 1985 has gone up by less than the rate of inflation. Tens of thousands of elderly people are driven frantic with worry because of a shortfall between what they receive in benefit and what is required to keep the roof over their heads. The nightmare for local authorities is that, if and when they get this new money transferred from the DSS, it will entirely vanish on topping up the shortfall that already occurs on existing provision, never mind fresh provision.
That brings me to the key question. If the Under-Secretary of State wishes to choose a question to which to reply from the multiple choice questions, this is the one that I would most prefer him to tackle. A new duty has been placed on local authorities to sponsor elderly and disabled persons who are admitted to residential care. Along with that, there is the duty to assess whether they are appropriately admitted to residential care. In this new system, if the local authority carries out the assessment and decides that residential care is appropriate, will it then be obliged to find a place and will it be guaranteed the resources to meet the cost of that place, or will applicants be told, "Yes, you are entitled to residential care and you pass the assessment for residential care but, sorry, we have hit our cash limits and we cannot afford to place you in residential care"?
The worrying feature is that we are moving from a system in which cash from the DSS is awarded to the individual on individual entitlement to a system that will be based on a fixed budget and will therefore be cash- limited. It is difficult not to conclude that the elaborate rhetoric of a new direction in community care conceals the fact that the Treasury has now got what it has long been looking for--a device to cap the bounding social security expenditure on residential care. The device will consist of sitting back and letting local authorities take the strain or, as Chris Heginbotham of the King's Fund expressed it rather bluntly, but tellingly, there is a real danger that local authorities will be "politically stuffed". That brings me to the critical question of why there is no specific grant for the transfer of resources. As we understand it, the transfer of resources will be buried in the revenue support grant, where they will be so small that even the Secretary of State will require his best pair of ornithologist's binoculars to spot it. Certainly no one else will be capable of seeing what is going on, and that, of course, is what local authorities suspect is the intention behind not ring-fencing this transfer of resources.
The Minister asked about the voluntary organisations that I consulted. Every one of them pleaded for the transfer of resources to be ring-fenced so that it could be separately identified. The Minister keeps referring to the importance of the private sector. The joint care committee, which represents the commercial sector, is terrified about what will happen if the transfer is not ring-fenced, because it is worried that local authorities will not have the resources to meet the claims of the claimants currently in their homes.
Column 51I raised the matter with the Secretary of State in July. In responding to my intervention, he said that the separate specific grant proposed by Griffiths was intended as a control menchanism-- the implication was that local authorities should be pleased that he was not imposing this control mechanism on them. Possibly the most remarkable voice in support of a specific separate grant is that of local authorities. They are willing to accept the deal of a specific grant for specific services. That is a control mechanism that they are confident they can meet. They want it also because it will be a control mechanism on the Secretary of State as well. A specific grant would make it clear to everyone how much he was putting into community care and who was responsible if it was not enough. the person dodging the control mechanism is the Secretary of State ; it is not the local authorities.
The Minister's comment on the carers of those in need of care was welcome and generous. However, the House should recognise that the bulk of care in the community is met by informal carers, by which--let us be blunt about it --we mean the nearest female relative, time after time. It is impossible not to salute the dedication and sacrifice of those carers. The Minister of State went to the AMA conference the day after I did, and no doubt found as I did that every delegate to that conference had been deeply moved at the plenary session when a number of carers had been specifically selected by Tessa Jowell to talk about their experiences and needs. They included one woman for whom that was the first hour in two years in which she had been out of the house and away from the person for whom she was caring. The Minister is right to say that we cannot be pious in deriving a warm glow of satisfaction from contemplating the devotion of those carers, but the response of the House in contemplating that dedication and devotion should be shame--shame that we provide so little help to them, that we do not provide any training for them and that we provide little respite care and minimal relief for them. There are undoubtedly a number of pertinent questions that can be asked about the Government's intentions. One set relates to how the Government intend meeting the need of those carers for an income of their own. I am glad that the Minister for Social Security is with us, because the way in which this Parliament has treated the benefit rights of carers is a disgrace. If the carer lives with somebody who claims social security, it is almost certain that, by definition, that person was one of those getting higher social security levels, based on allowances and extra payments for heating, diet and other needs, all of which were abolished in April 1988. Therefore it is likely that such a carer now finds himself or herself stuck in a household on transitional protection, with a frozen income for the past three years. If the carer was on social security in April 1988, she would have found herself in April 1988 in the only group on long-term supplementary benefit which got no premium on transfer to transitional protection, and therefore she would have lost the equivalent of £5 a week.
I was deeply moved a couple of months ago when I read an article by a woman who gave up work four years ago to nurse her terminally ill sister. She explained how she got out of the house only twice a week. At the end of those four years of constant nursing and after her sister died, she
Column 52applied for unemployment benefit because her invalid care allowance had expired. When she applied for benefit, she was told that she did not qualify because, as a result of the Social Security Act 1988, credits for ICA no longer counted towards unemployment benefit.
Mr. Cook : As my hon. Friend says, it was a kick in the teeth. The woman's emotions and reactions to that were greatly exacerbated when the person behind the counter, no doubt well-meaning, but essentially tactless, said that caring for a relative was not a proper job.
Mr. Frank Field : Does my hon. Friend agree that the position is even worse, because no carers get credits for unemployment benefit? Therefore, when the person for whom they care dies and they claim benefit they are told that they do not qualify for any national insurance benefit. The Government say how important it is to support the carers, but does my hon. Friend agree from experience of his surgeries that about six months after the person for whom they have cared has died, many carers often have a breakdown, such is the pressure on them? If the Government were serious about supporting carers in their move back into work, the very least they could do today would be to announce that all carers would qualify for benefit when they cease to be carers.
Mr. Cook : I agree absolutely with my hon. Friend. All the medical surveys that have been carried out show that not only those who are in need of care are infirm or disabled, but the people who care for them are less healthy than the rest of the population.
I stress that however much we improve the service to carers and whatever solution we find to the serious problem they face in obtaining independent income, it would be an immense mistake for any hon. Member to imagine that we shall be able to palm off the growing number of those in need of care on to a growing number of carers. Most people over the age of 85 have children --if that is the right term--who are now in their early sixties and who are on the verge of needing domiciliary support. There are not enough younger relatives to go round. Already, 29 per cent. of single women between the age of 45 and 64 provide full-time care for disabled relatives. In the real world that percentage cannot be increased. Other Ministers, especially the Secretary of State for Employment, have other plans for these women and want them to step into the breach caused by the declining numbers of school leavers.
The harsh reality is that individual solutions in private families cannot match the growing need for care in the community. It will take collective provision by public agencies for the community. That will not be achieved by a Government who persist in regarding local authorities as whipping boys and every increase in public expenditure as a defeat and who, when faced with a social need, see only a market opportunity. Those are the real reasons why Ministers are having such difficulty writing the White Paper after 18 months and why all the signs are that when the White Paper appears it will not match the challenge that we face. They are part of the reason why the public outside this place are increasingly impatient to be rid of the Government.
Column 535.22 pm
Sir Geoffrey Pattie (Chertsey and Walton) : I followed closely what the hon. Member for Livingston (Mr. Cook) was saying and I had some sympathy with his point about carers, because I am most concerned in case there is any belief in Government circles that the voluntary sector can in some way, in totality, take over the responsibilities which have hitherto been the purview of the state.
In 1971 my wife was involved in establishing an emergency social health scheme in the Brixton area of south London. After it had been going a few years and a partnership had been developed with the local authority, it had five full-time paid employees, who were paid for largely by the local authority. There were also about 80 volunteers. Without the five full-time employees, it would have been impossible to keep the 80 volunteers in the field. I would be happy to be reassured, but I am concerned that there is a belief that the 80 could be extended and the five full-time employees could be taken away so that the entire scheme--which is replicated throughout the country--could be run on a completely voluntary basis. Quite frankly, it cannot.
We seek reassurance from the Government that they will look at the importance of funding some paid employees in local schemes to act as false multipliers to make it possible for the considerable amount of voluntary good will which exists to be utilised. They must not regard volunteers as a substitute for paid effort.
I know that many people want to speak in the debate, so I shall be brief ; but there are some points that require further elucidation and clarification from the Government. It would be extremely helpful if, when replying to the debate, the Minister could tell us when the Government intend to transfer the management and staff of long-stay mentally handicapped hospitals to social services departments. There is a considerable gap on this subject and we should like to hear about it.
There is also much concern about what the care packages will consist of. There is a problem between what constitutes a care cost and what a housing cost. In my own part of the country, one of the specialities of the North West Surrey health district is respite care breaks. There is a great deal of demand from individuals and carers for such respite care. In order not to disadvantage the individuals, they would need to be able to pay not only for their respite care, which is a care cost, but for the rent on their homes, plus rates, heating and water, which are housing costs. They should also pay something towards the hotel charges incurred by the providers of respite care, which is a housing cost. Therefore, the formula for calculating care costs must include provision for the housing element ; otherwise, there would simply not be enough to pay for the service.
Mr. Chris Heginbotham, who has been mentioned in this debate, has spoken in favour of the desirability of setting up various forms of trusts to help to administer housing needs in areas where there is a considerable degree of pressure. In my part of north-west Surrey we must have sufficient capital, revenue reserves and resources provided otherwise we shall be in great difficulty when following through some of the excellent initiatives that we have. There is much that is good in what the Government have been proposing ; now we want further clarification on some of the points that I have raised.
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Mr. Jack Ashley (Stoke-on-Trent, South) : I shall try to deal in a few moments with a few of the points made by the right hon. Member for Chertsey and Walton (Sir G. Pattie), but shall begin by saying that the Minister of State is a pretty dab hand at putting a gloss on the policies he presents--that is, when he gets round to doing so. I was disappointed that he took so long to get round to community care. The Government have had the Griffiths report for a long time, as my hon. Friend the Member for Livingston (Mr. Cook) has constantly mentioned.
Today, the Minister of State is making friendly overtures to those people who need community care, but I was not that impressed by the substance of his speech. Community care is one of the greatest social problems of our age, affecting old and disabled people. I would have thought that the Government would have given the subject a much higher priority and dealt with it more quickly.
Despite the vagueness of the new proposals mentioned by the Secretary of State in April and filled out a bit today by the Minister, they show that a new financial burden may be added to those shouldered by people who receive community care. Many people are fearful that, if local authority care is to be privatised, it may mean that the Government will replace free provision with means-tested care. That is a point of great importance to disabled and old people, because the consequences would be devastating. If that fear were justified, it would mean that thousands of elderly and disabled people would gradually lose their savings, and nothing could be more important to them than that. They might even have to sell off their houses as their resources melted away in payment for essential care services. I hope that the Under-Secretary will be able to give a categorical assurance that the Government will not privatise community care. I would welcome that. If he cannot, I shall take that, too, as a statement of Government policy. If the Government privatise community care and charge for it, that will be scandalous ; it will be the equivalent of selling it like cigarettes or detergents.
The Minister of State expressed good will to people who receive community care. I shall tell him where Government policy is wrong. The fundamental shortcoming of the Government's new policy is its assumption that the acknowledged inadequacies of community care can be remedied by shuffling responsibilities, not by increasing resources. The truth is that we need new polices and new money, yet we do not seem to be getting them. Indeed, the level of finance may even be reduced. It may leak away because of the Department's refusal to make specific allocations.
On 12 July, the Secretary of State said that he had not gone down the specific grant route but would use the inspectorate route. Today we heard the Minister of State say what the inspectorate would do. He has been led up the garden path if he thinks that it is a substitute for specific grants. He said that the inspectorate would "offer advice". What is the point of that? Intransigent local authorities which are not prepared to allocate funds for community care will not be impressed in the least by advice from any quarter.
We must have specific allocations by the Government for realistic and genuine community care.
Column 55One of the problems facing Ministers is that specific grants would enable people to identify the true cause of poor services--the Government's inadequate funding. Without specific grants, blame can be diverted to local authorities, which may well be why the Minister has rejected such grants.
Local authorities are under great pressure to divert funds to badly needed housing or to repairing decaying school buildings. That could be tempting to some impecunious local authorities--and to some mean ones. It would devastate old people if the cash were diverted in that way.
Few things are more insulting to disabled people than being patronised or refused consultation, or denied someone to represent them. I know that these things can be and sometimes are done on an ad hoc basis, but disabled people want such consultations as a statutory right. That is very important. Improved community care for disabled people will develop only from consultation with them and their representatives when that is a statutory right, and I hope that the Minister will be able to say today that the Government will implement sections 1, 2, 3, and 7 of the Disabled Persons (Services Consultation and Representation) Act 1986. If he does not, that will show that, despite having quoted Tessa Jowell's view of caring in the community, the Minister is not prepared to go as far as disabled people want him to.
The mentally handicapped and mentally ill are of special concern because of the appalling way in which many of them have been shunted into an unprepared and often indifferent community. Hon. Members on both sides have made that point strongly. An eloquent Conservative Member demanded recently improvements. These matters concern all hon. Members, and I do not believe that the policies spelled out by the Minister will deal with them substantially. I hope that the Under-Secretary will be able to enlighten us more about what the Government intend to do to keep these people off the streets, out of the prisons and out of the cemeteries.
The Minister of State spoke at some length about carers and I was glad to hear him say that they should have top priority. Many of them bear enormous and unfair burdens. Carers are more overworked, worn out and exploited than workers in any sweatshop in the east end ever were. They are the martyred millions ; 6 million of them have had their lives pushed out of kilter because of their affection for relatives. The Minister said that they had been given £1 million more, but they have saved billions of pounds by the care which they have devoted to people in need. It is not possible to solve their problems with £1 million or even more--they need much more cash and they must be given the money. It is imperative that they get it. They must be recognised, consulted and supported. They need respite care, specifically allocated financial support and involvement in the creation of new care packages for their dependent relatives. When the Government provide those, we shall be on our way to proper community care for Britain's disabled people.
Column 56heard from the Deputy Prime Minister in Blackpool that the Government have become a listening Government, and I shall take them at their word. In the interests of brevity I intend briefly to put to the Government some of the issues that I hope will feature in the White Paper. Inevitably I shall cover some ground which has already been covered by others.
I want to take up a point mentioned by the right hon. Member for Stoke-on- Trent, South (Mr. Ashley)--the recognition that some people need permanent asylum : I use the word in the proper technical sense. The House will recall that the Social Services Select Committee produced a report in the session 1984-85 which dealt with the mentally ill and the mentally handicapped. We were concerned about the speed with which profoundly mentally handicapped people were being turned out of long-stay institutions without adequate provision. In theory, there were plans for their care but in practice they were not being carried out.
I remind the House of what we said at the time :
"While the disabilities of long-stay patients may well be heightened by institutional care, the simple facts are that there is little prospect of major change for the better for many mentally disabled people The concept of asylum has nothing inherently to do with large or isolated institutions. Asylum can be provided in a physical and psychological sense in the middle of a normal residential community : traditionally indeed, in the midst of a busy church. We must face the fact that some people need asylum." I repeat our conclusion that some people need asylum.
We also need to take into account the demographic facts upon which my hon. and learned Friend the Minister touched. We must recognise, as the Royal College of Nursing has said, that among those over 75 the rate of various forms of dementia requiring 24-hour nursing care is currently running at between 21 and 22 per cent. The college says that there is no reason to suppose that that percentage will drop. In real terms, by simply extrapolating demographic trends, we see that by the end of the century we must make provision for between 80,000 and 100,000 more dependent people with dementia. We are talking about nursing care. It is not fair to ask ordinary care attenders or social workers to cope with that. That is my first point--the need for asylum.
Secondly, there is a need to quantify the number of clients with whom this public policy is trying to cope. I remind the House of the wise words of a famous Scottish physicist, the late Lord Kelvin, who said :
"When you can measure what you are speaking of, and express it in numbers, you know that of which you are discussing. But when you cannot measure it, and express it in numbers, your knowledge is of a very meagre and unsatisfactory kind."
It is time that we made the message a little less meagre and less unsatisfactory. I hope that the White Paper will attempt to quantify it.
The task has been made infinitely easier by the reports of the Office of Population Censuses and Surveys on the number of disabled people in our midst. Extrapolation of the demographic trends and percentages such as those that I have quoted from the Royal College of Nursing on the elderly can give us a reasonable estimate of the number of people with whom we shall have to cope. I can tell the House that there are far more such people out there needing support than are recognised in official statistics.
My third point follows from that. It is that we must have better resourcing of care in the community. We all agree that if we are to make public policy more effective,
Column 57it must be properly resourced. That means that it must be more generously and more effectively resourced. That is the message of Griffiths, of the Audit Commission and of every organisation in the health care business that submitted evidence to us. No mention has yet been made in this debate of the telling report from the Audit Commission. In the simple language of the King's Fund Institute : "More and better-used resources will be required."
Does my hon. and learned Friend the Minister and the Treasury agree?
If the local authorities are to be the vehicle for these more and better- used resources, it is imperative that the contributions of central Government should be in the form of specific grants and should be ring- fenced. I think that every hon. Member who has spoken in the debate has made that plea, and I should like to reinforce it. Whatever earlier hesitations he had, I trust that the Minister, having listened to the debate, will accept that argument in his White Paper. It should appeal to the Treasury and certainly to the Audit Commission.
My next point is about the need for an inspectorate. The proposal for local authorities to make arrangements for independent care facilities to be inspected by them is welcome. Nevertheless, some major organisations have argued for national standards covering both the private and public sectors. Here central Government must play their part as the procurers and enforcers of standards. The social services inspectorate will have powers to monitor community care plans, but unless it is given wider powers its recommendations can be ignored by local authorities--as they currently are.
I plead with the Minister to beef up the social services inspectorate. If he is worried about that being a revolutionary advent, I remind him that under the first Elizabethan poor law, which, as the House will recall, was administered by the parishes, the Privy Council had a duty to monitor the effectiveness of the parishes in implementing care in the community as it was conceived in those days. Therefore, there is good precedent behind my argument. Finally, may I return to the old theme with which I have burdened the House in the past and which I have noticed other hon. Members have taken up--the importance of private carers? In so doing I declare a personal interest. Far more dependent people are being cared for at home than are being cared for in all the hospitals, institutions and rest homes whether statutory, charitable or private in the kingdom. Therefore, the first priority of any more active policy for care in the community must be to improve the lot of private carers. In his July statement, the Minister praised that concept and my hon. and learned Friend the Minister of State did the same today.
Are the Government and the House aware that two thirds of live-in carers receive no help at all from any service? Some of them may be caring 24 hours a day for very dependent relatives and may be working round the clock with no support. Caring for the doubly incontinent is no gentle pastime and looking after a dotty old relative is demanding and exhausting. That fact alone puts into perspective the role of the carer in our society. From its own experience, the House will know that carers come in all shapes and sizes and that they cover the entire age spectrum. Many elderly people are themselves carers. That fact must be emphasised and, given the demographic forecast, the number will increase.
Column 58While the personal circumstances in each case may vary greatly, the common factor is that most carers have consciously chosen, or accepted, the role of looking after their dependent relatives because they love them. For that reason they do not want to hand over the job to anyone else. However, caring for someone who is heavily dependent is continuous, tiring, stressful and restrictive. It can impose serious strains upon other relationships in a family.
We should think of the effect on other children in the same family that comes from looking after a severely mentally handicapped child. There is no 40-hour week in the caring game. Outside help at key times on both a regular and a one-off basis can make the difference between a total breakdown and a successful and loving partnership between the carer and the cared for.
I hope that we can all agree that carers need more backup, regular support and emergency assurances. They especially need sound professional support if they are to fulfil their mission as carers and still have any hope of even a modicum of a personal life of their own. I invite the Minister to spell out in his White Paper how the community can support the carers more effectively. That is essential if we are to make a success of any improved national policy for care in the community. I and I suspect other hon. Members will judge the validity of the White Paper by the extent to which the Minister succeeds in doing just that.
Mr. Ronnie Fearn (Southport) : Although I welcome once again the opportunity to debate this subject, I thought that this important issue was to come before us quite soon and that during the recess we would see the White Paper. However, that was not to be. Like everyone else, I naturally assumed that, as the Government had scheduled community care as the business for today, the purpose would be to discuss some concrete proposals. From what the Minister said, I understand that the White Paper is now expected in early November. If that is so, I doubt whether what is said in the debate will have time to make a great deal of difference to the content of the White Paper.
The matter is extremely urgent, as previous debates have shown. The lack of care in individual cases in some areas and in certain sections of the community service has led to an intolerable level of neglect. Social services departments are presently working at crisis level. I say that from experience of my own authority of Sefton. They are responding with short- term solutions. Many long-term strategies are abandoned because of the shortages of funds and grave doubts about what the future holds.
I know that community care is a complex issue that requires thorough investigation, and I should be a little happier about the delay if I thought that it was due to Ministers conducting an in-depth study to ascertain what the true needs of the community are, in terms of care for the elderly, the handicapped, the disabled and the mentally ill, and then devising plans as to how best the needs can be met. However, I fear that the delay has more to do with the conflict in policy and ideology between the Prime Minister and her many advisers and to the narrow terms of reference within which the proposals for community care are now to be drawn up.
Column 59I am referring to the fanaticism with which some members of the Government approach any service that is remotely connected with the welfare state and the need that they see to reduce public spending while increasing support for the private sector. Such thinking is often coupled with the view that local government can be tolerated only if it has its hands tied firmly behind its back.
It is clear that the recommendation by Roy Griffiths that local government should act as the lead agency for community care services was accepted only reluctantly by the Government. We must now ensure that local authorities receive the resources that they need to fulfil this role, not only financially but in terms of manpower and training. I was pleased to hear the Minister say that there would be a full commitment to training. We must take care that local government does not become the Government's whipping boy. I take that view not because, I am soft on local government--far from it--but because, if that were to happen, many people in need of community services would not receive them.
We all know that a policy of care in the community is not a cheap option, but we do not know what will be the true cost of that policy. There is no adequate means to assess the many different forms of care, and I hope that some investigations are carried out to rectify this. What is certain is that the present level of resources is not enough. Too many people are out in the cold and too many have been allowed to slip through the net. I fear for the future. We have little knowledge about the allocation of funds to local government except the few hints given to us by the Secretary of State in his statement on 12 July, which in effect amounted to a cash-limited system.
We were also told that funds would not be earmarked. This will make it difficult to identify the amount allocated for community care services at national and local level. This raises a number of issues that I hope that the Minister will address. Given that there is already a great shortage in the amount of money required, will he guarantee extra resources to meet the demands not only of providing for the numbers who need support but of ensuring the type of support that is needed? The requirements and costs of care for the elderly, the handicapped, the disabled, and the mentally ill are different, and I hope that the proposals will allow for assessments of funding for the needs of each client group.
It is expensive to provide constant 24-hour care for those suffering from senile dementia, the numbers of which increase every day. This point has been mentioned already, but it needs to be mentioned again. When local authorities are forced to make choices between services, such a community care group will be neglected. The poorer authorities, where often those in the most need live, will be the hardest hit in any cash-limiting exercise.
The Government's attempt to put pressure on local authorities to use the independent sector by refusing to fund people in local authority homes will have devastating consequences. The provision of private and voluntary homes varies considerably across the country. It is not viable for the voluntary or private sectors to set up all those homes in some inner-city, rural or suburban areas. Some people will be cared for in local government homes out of necessity and others out of choice. Neither should be discriminated against.
Column 60We support the provision of personal care packages, which would involve a pluralist approach to community care. My party has long called for the Government to act as an enabler--I was pleased to hear the Minister say this as well--rather than a universal provider. We are adamant that some public provision must remain as an option in community care services. It is intolerable that, even in the present circumstances, local authorities are being forced to sell off their residential homes to ensure that there are adequate standards of care. In the interests of choice and as a means of last resort, the individual client and carer must be given access to public provision.
The public sector has not generally provided care for the more vulnerable members of society, and the voluntary sector should not be expected to take too many contracted-out services. If it does, it is inevitable that its services will change in character and the community will lose the benefits of the flexibility, innovation and new initiatives that many voluntary organisations now provide. There is not and cannot be any obligation on the independent sector to make provision for any form of community care, and if it closes down its operations in an area without public provision, it will be difficult and expensive for the local authority to restart its residential care provision. Once again, the more vulnerable and the disadvantaged will suffer the most.
I said earlier that community care is a complex issue. Unless one has experience of it or is advised by those with some experience on the ground, one will never grasp all its complications and implications. I have much to learn, but the Secretary of State has even more. After his statement on 12 July, I asked him about housing within community care and whether he would direct that local authorities would receive more finance for this purpose. While I accept that the solution does not entirely lie with the Department of Health, the Secretary of State's reply--
"but I honestly do not think that housing finance is remotely related to what I am talking about today"--[ Official Report, 12 July 1989 ; Vol. 156, c. 984.]--
leaves me with little hope of a co-ordinated community care policy from the Government.
Does the Secretary of State not know that many community care projects involve housing and capital finance? These include the provision of housing for those with special needs to live independently, ordinary housing for handicapped people to be trained for independent living, sheltered accommodation for the elderly, hostel provision for the more vulnerable and special units to provide short-term respite care for the carers. I could go on, but I hope that I have made my point and that the White Paper offers some proposals for ensuring some provision for capital finance for community care projects.
I shall look with interest at the proposals in the White Paper that lay out the respective responsibilities of the health authorities, family practitioner committees and local government. For instance, will it make clear who is responsible for a patient who is discharged from hospital with certain needs but who is assessed by the local authority in a way that does not meet those needs? Who will provide the care? Will it be the health authority, the local authority or the general practitioner? Above all, who will make the decision? This is critical to the whole matter. Will there be a single point of access for clients and carers or will they, as they do now, have to negotiate a mammoth maze before reaching their objective?