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Mr. James Couchman (Gillingham) : As I am Parliamentary Private Secretary to my right hon. Friend the Secretary of State for Social Security, I shall obviously not comment about benefits or money during my speech on this important subject.
As I am a former chairman of a health authority and a social services committee, I have long been involved with care in the community. I have been worried by the ambivalence of responsibility of the Health Service and social services departments, particularly in relation to the mentally ill and the mentally handicapped. Like my hon. Friends the Members for Eastleigh (Sir D. Price) and for Macclesfield (Mr. Winterton), I was a member of the Select Committee which, in 1983 and 1984, considered care in the community in an in-depth study which ranged from here to San Francisco. During our deliberations and investigations we saw the worst and the best of care for the mentally ill and mentally handicapped.
In America, we saw the ghastly St. Elizabeth's hospital outside Washington, and an extremely old-fashioned place in Nebraska where the mentally handicapped were cared for. We saw soup kitchens in San Francisco and the hostels where people who had been
de-institutionalised were decanted, in that wealthy city. One of the best programmes that we saw during the year was for mentally handicapped people in Nebraska. There was a most progressive scheme for the mentally handicapped within a factory which gives them real work to do, and makes one-to-one care in residential homes available. That was available and being made good use of, and people with severe handicaps were able to have a worthwhile quality of life in the community.
During our deliberations, my hon. Friend the Member for Macclesfield obviously came to certain conclusions which he has expressed in the House on a number of occasions. It is clear that he would prefer to keep long- stay hospitals--the old asylums. In many respects, I sympathise with his worry about people being decanted into the community for whom the community can never be a real place to live. Among the mentally handicapped it is quite clear that the autistic represent a special problem. It is most unlikely that they will ever easily be able to live in the community, and I speak with knowledge on this, as I have an autistic brother-in-law.
I welcome my hon. Friend's statement on 12 July--particularly his assurances with regard to the closures of long-stay hospitals. He said that they will not be closed and that patients will not be discharged into the community until proper and appropriate social and medical provision has been made. That is most important. If we have learnt nothing else over the past 20 years, since the
de-institutionalisation and decanting of schizophrenics at the onset of neuroleptic drug treatment, we must have learnt that these people must be cared for properly in the community.
Closure of long-stay hospitals is not easy. I remember the early meetings about closing down Darenth park hospital in north Kent some 12 to 14 years ago. Last year, the last patient left Darenth park. That is the sort of time scale that we are talking about. The creation and provision of appropriate residential and day care facilities for people takes a great deal of providing. We must ensure that those facilities presently available on long-stay hospital sites are bettered when people are moved into the community.
Column 79I welcome the fact that local authorities have been given a lead role by my right hon. Friend in seeking to clear the line of responsibility. I ask what powers they will have to ensure co- operation on a number of fronts by health authorities. I am particularly worried about the level of expertise within local authority social services departments. Seebohm took us away from specialisation towards generalised social working practice. It is only quite recently that some social services departments have decided that they should go in, once again, for specialised workers, particularly in the areas of mental illness and handicap. I ask my hon. Friend to tell us what discussions he has had with the Association of Directors of Social Services and the Central Council for the Education and Training of Social Workers, with regard to the future lead role that local authorities will have. We have heard much about the training of social workers and that is going to be terribly important. It will also be important to train at lower levels than social worker level. Too often, people in the care of the social services departments are being looked after by very young, inexperienced people. Training is essential at that level too. I am not certain that the present qualifications for social workers will fit the bill of my hon. Friend's vision of community care in the future. Perhaps my hon. Friend will say what further thoughts he has had over the summer about these important matters.
My hon. Friend the Member for Macclesfield stressed the number of schizophrenics who return to hospital. Over a period of years, they do so on a revolving door basis. Will that revolving door remain when the present responsibilities are removed? Will local authorities be able to readmit schizophrenics to a hospital appropriate to their needs?
I add my reservations about local authorities being their own monitoring and inspecting agencies for the provision of that important care facility, which will affect many people. An extension of the hospital advisory service may be appropriate, but there must be a national scheme to monitor local authority provision of care. 7.20 pm
Mr. Dafydd Wigley (Caernarfon) : A debate on community care is of much importance to use in Wales, not only because of the Welsh contribution to the development of the welfare state by people such as Lloyd George, Aneurin Bevan, Jim Griffiths and, more recently, the all-Wales initiative for mentally handicapped people, but because of our interest in the community dimension--the emphasis and value placed on the community.
I could not disagree more with the Prime Minister when she suggested that people do not live in a community, that there is no such thing as society, that we are all individuals and families. I strongly believe that the community is a vital dimension. It has been relevant to the sharing of problems in Wales, which is probably part of our Christian-Socialist tradition.
The sharing of a burden, whether it be problems faced by physically disabled people, the aged and infirm or mentally handicapped or mentally ill people, cannot be left only to friends and families ; if it is, the burden falls
Column 80unfairly, usually on those least equipped to cope and often particularly on women. What about those who have no friends or families to help them?
I recall several cases that have come to my attention recently, such as the wheelchair-bound person in his mid-forties who had a degenerative condition. He lived by himself and had to contemplate going to bed at 5 pm because he could not get assistance to set his splints. The only possibility was to get a volunteer to help, which underlines the need for more community-based nursing services. Another young man, in his forties, had a history of psychiatric illness. He lived in a flat in the community and discharged his social worker. He died from an overdose of drugs and his body was not found for three weeks, which underlines the need to consider who is in charge of such cases and who is the defined key worker. A case came to my attention in the past week of a mother of a handicapped child whose husband had died. She had had her invalid care allowance withdrawn at a time when she most needed that support. In another case, a stroke victim's wife dearly wanted to have him home, but he was too heavy for her to handle, she was elderly and the domiciliary nursing services insufficient to enable him to live the remainder of his days at home. Those are only examples, but hon. Members can give further examples to show why we must pay greater attention to community care and ensure that facilities are available for those who need them.
In the past, perhaps too much emphasis has been placed on institutional care. I understand the points made by hon. Members about discharging people from long-stay hospitals without adequate services being provided, but in this debate I would rather concentrate on how we can ensure that people are not drawn into long-stay institutional care in the first place. We must ensure that that is done coherently, by providing the community-based services that are so needed. If those services were available, many people would not need to be incarcerated in institutional care. Inevitably, some people will always need such care, but many do not, which is why we must pay greater attention to community services.
In recent years there has been massive growth in private residential care. The explosion in demand has been created partly by the Government, through the social security system that they have adopted. The system has directed elderly people to residential care irrespective of whether it is what they want or best need. It is undoubtedly right that Parliament should be considering the workings of the system to ensure three things : first, the flexible provision of care based on individual need with emphasis, where possible, on enabling the individual to choose ; to facilitate continued independent living as a valid choice ; and to provide proper services that make that practical, irrespective of the individual's ability to pay or otherwise.
Secondly, we must use public resources in the most effective manner to provide the most appropriate care for the individual in the light of the individual's needs. In many cases it may be less expensive to provide domiciliary services--home help, community nursing and domiciliary physiotherapy--than to provide a place in a private residential home. The decision must be taken, however, not because it is cheaper to do that but because it is right for the individual to make that choice.
Column 81Thirdly, we should be considering the efficient working of the system to allow effective assessment of individual need, the right of advocacy to enable the individual's wishes to be articulated and respected, the general availability of community-based services in all areas and the resources to ensure that there is growth in services in line with the inevitable demographic growth in demand. We need a certainty of provision to give clients the confidence, the security, that they are entitled to expect.
Those are the essentials of any new system towards which we may be moving and are the criteria by which we should be judging the Government's response to not only the Griffiths report but the Audit Commission report, the Firth report and the Wagner report in particular. I hope that today's debate will take those other reports into account.
The Government took much time to respond to the Griffiths report and many questions remain unanswered. I should like to highlight a number of the uncertainties, while welcoming any genuine move to greater personal choice and freedom and greater emphasis on community-based care. The first and overwhelming worry is finance. Many hon. Members have spoken of the need to ensure that the finance given to local authorities is ring-fenced and used for its intended purposes. The Government intend to approach the new policy from a cash-limited perspective, and I am worried about that. The present system is demand-led. People who cannot afford to pay for residential care can get help from the social security system without any cash limit on the global sums that are available, although there may be cash limits on individual sums. The Secretary of State suggested that the new system may be constrained and defined by a budgeted pool of money. On 12 July, he said :
"decisions on resources can only be made in the public expenditure round".- -[ Official Report, 12 July 1989 ; Vol. 156, c. 985.] That is a warning of things to come. From time to time, shortages of finance will make life extremely difficult for people. The second worry is that the social worker's role may be compromised. He will have to have one eye on limited resources and the other on how to get the best deal for the client. Social services departments will be in the difficult position of trying adequately to monitor the services they provide while having to take cash- limited decisions.
For that reason we must consider the minimum general standards that are acceptable. We must assess not only quality but quantity. Paragraph 6.2 of the Griffiths report is right :
"Local authority social services authorities should be responsible for identifying people with community care needs in their area." It should be a statutory responsibility for local authorities to know what the needs are and to ensure that they respond to them. I am worried also about the possible effect of privatisation and competition on the delivery of services. I wonder whether voluntary bodies such as Crossroads will be a part of such a competitive world. That has not been their nature in the past. People involved in them may not want to be a part of a fundamentally different approach. I should like to draw the Minister's attention to the issue of uncertainty. What will be the position of a widow who sells her home and goes into a private residential home? She may get £30,000 from the sale of her home, which can keep her going for two or three years, but then
Column 82she drops below the threshold. At present, she would automatically get help from the welfare state. Under the new proposals, presumably her position will have to be assessed. When that happens, is she likely to be returned to the community? If so, she will think twice about going into a residential home in the first place. She may find herself in some uncertainty.
In summary, we need a system that identifies and assesses all the needs. We need an individual and personal plan tailored to the needs of each person. We need a generality of services in all areas, rural and urban, and an independent monitoring system. We need finance that is ring-fenced and not cash-limited. We need a crash recruitment and training programme for people to carry out this vital work. 7.31 pm
Mr. David Nicholson (Taunton) : As both my parents, who are in their mid-70s but fortunately are in good health, live on the island of Ynys Mo n next to the constituency of the hon. Member for Caernarfon (Mr. Wigley), I listened to his speech with not entirely uninterested pleasure.
I agree with the point made by my hon. Friend the Member for Eastleigh (Sir D. Price), and reiterated by hon. Members on both sides of the House, that these services need to be resourced more generously and effectively. I listened with considerable interest to the points made about carers, especially those made by the hon. Member for Birkenhead (Mr. Field), who speaks with such authority on these matters. Like my hon. Friends, I will be interested to hear the Government's response to those points and I will study the hon. Gentleman's speech in detail.
There are two large hospitals in my constituency--Tone Vale hospital, which deals with the mentally ill, and Sandhill Park hospital, which deals with the mentally handicapped. We all appreciate the extremes to which placements in long-stay institutions can go. In recent months, we have seen on television the dreadful scenes on the Greek island of Leros. As some Opposition Members have said, in previous years pregnant single young women and other members of families whose relatives have got tired of them were easily shunted into these establishments. I agree with my hon. Friend the Member for Macclesfield (Mr. Winterton) that we must be careful how we go about closing such hospitals.
I welcome the commitment made by my right hon. and learned Friend the Secretary of State, which was reiterated at least three times on 12 July-- in columns 985 and 990 of Hansard and in reply to me in column 991 of Hansard --that he will ensure that NHS hospitals do not discharge patients until he is satisfied that proper arrangements have been made. I welcome my right hon. and learned Friend's assurances that
"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."--[ Official Report, 12 July 1989 ; Vol. 156, c. 987.]
My local health authority, Somerset, is making progress and its detailed proposals will be produced shortly. I welcome the inter-agency work between the Health Service, social services and the voluntary and private sectors, which are all playing their part. In the north of the county--you will have some knowledge of this, Mr. Deputy Speaker, since it affects services in your
Column 83constituency--the number of beds in the Mendip hospital has been reduced to 124, with considerable development of community services. Those of us in the remainder of the county will need to monitor these developments closely. Tone Vale hospital in my constituency has reduced the number of beds from 504 to 420 since 1987. Day services have increased by 40 per cent. and community mental health teams have become operational. The intention is to continue to develop community-based services throughout the county, with the objective of closing the large mental hospitals.
I have had the opportunity of studying the excellently terse briefing from the National Schizophrenia Fellowship. My hon. Friend the Member for Macclesfield has referred to the impressive and startling 1986 admissions figure--90 per cent. of schizophrenic admissions were readmissions after relapse. The National Schizophrenia Fellowship points out that withholding ministerial approval for hospital closures shuts the stable door after the horse has bolted, because most beds have gone. There should be recognition of that point. The fellowship referred also to the reply given to my hon. Friend the Member for Cheltenham (Mr. Irving) on 13 April 1988 in column 174 of Hansard on the number of community psychiatric nurses in 1986. Eight district health authorities had none, 17 had five or fewer and the best staffed, Leicestershire, had 43. That echoes the point that we constantly make about the NHS--there are considerable variations in services, equipment and efficiency. Indeed, the December 1986 report by the Audit Commission states : "A very uneven pattern of local authority services has developed, with the care that people receive as much dependent upon where they live as on what they need. In well over half of local authorities, expenditure on services for mentally ill people is less than £1 per head of population even though one in ten people each year consult their general practitioner about a mental health problem, and one in a hundred is referred to the specialist psychiatric services". This problem was brought home to me by a visit that I had two weeks ago from a constituent. The notes that she gave me should sound a note of caution when authorities consider putting patients into the community without ensuring that services are provided for them. I realise however that, on the whole, the position in my area is satisfactory. This lady's son was a former schizophrenic patient of Rampton secure hospital. Four years ago, he returned to Tone Vale hospital and two years ago was released. His parents bought him a house, and this was successful in giving him independence. All seemed to go well. He went back to Tone Vale once or twice for a few days and then returned home.
About five weeks before my constituent came to see me, he announced to his parents that as he was so well he had decided to "cut back" his medication- -this often happens in these cases. A few days later, he went off in his car to the south-east. When he returned, his parents noted that he was "much more disturbed". They advised him to go into hospital as an informal patient, but he would not. The parents asked the medical services at Tone Vale to assess whether he needed to be sectioned and were asked three times by the GP, "Do you want him sectioned?" The
Column 84decision whether he should be taken in was, apparently, to be left to them. Surely that is a decision for experts in the medical and social services.
A few days afterwards, the son smashed the windows in the house, strewed pills everywhere, upset furniture, left and drove away to another part of the south-east, where he severely upset other relatives and appeared to be extremely disturbed. At this stage, in the car were a crossbow, three arrows and two Stanley knives. I should point out that his mother emphasised to me that he had never actually been violent, but there was an element of threat there. She continued :
"We feel that nobody listens to parents. We see tell-tale signs of illness and feel that if our son had been persuaded into hospital three weeks ago he would certainly be more stable by now." He was eventually taken into hospital and I believe that he is going to be sectioned.
Such loss of control over a former patient was, first, bad for the patient because he will require far more care and will face more difficulties in future as a result. Secondly, it was bad for the parents who had been through an extremely tense time because of the pressures placed on them. Thirdly, particularly given the weird weapons in the car, it was a considerable source of worry, provoked alarm and could have posed a threat to the wider community if anything had gone wrong.
The Minister must take care to ensure that our resources are properly used. We must ensure that these services are properly resourced. I agree with my hon. Friend the Member for Hendon, South (Mr. Marshall) that, despite our current difficulties, only a Conservative Government can ensure the economic success which will achieve that goal. The Labour party talk about resources, but when it was in power it failed dismally to provide those resources. I welcome the debate which has now started and the forthcoming appearance of the White Paper so that those resources can be properly and efficiently used in our society.
Mr. William McKelvey (Kilmarnock and Loudoun) : Thank you, Mr. Deputy Speaker, for giving me the opportunity once again to speak in the debate about the Griffiths report. If my memory serves me right, this is the third recent occasion on which the House has had the opportunity to discuss the report. The previous debates were initiated by the Opposition. I have to register my disappointment, as I did in the two earlier debates, that the Government are dragging their heels in implementing some aspects of this report.
We have not agreed to everything outlined by Griffiths, but I certainly think that we can all agree on our disappointment that there is no real movement by the Government. Some progress has been made, inasmuch as the Government have at last initiated the debate on the Griffiths report. However, it is disappointing that no White Paper is available for this debate. I was naive enough to go to the Vote Office to ask for a copy of the White Paper in case it contained points which I might want to raise in this debate.
I wish to cover two aspects which I have covered before. I do not want to be repetitive, but they are extremely important. Several Members have talked about the growth industry. Certainly in my area of Ayrshire the fastest growth industry involves residential homes. It has slowed
Column 85down somewhat because the last anticipated increase in fees was not given by the Government. Nevertheless, it has not reached saturation point as yet and the plans show that some people still think that it would be profitable to have a residential home in Ayrshire. The fact that it has a coastline and many large, comfortable, mansion-type houses which are easily adapted to residential homes probably means that it lends itself to such speculation.
A great many of the residential homes are extremely well run, although some of them could, perhaps, be better run. It is for that reason that many hon. Members on both sides of the House have clearly shown that, if we are to proceed evenly with an expansion and extension of residential homes for the elderly in the private and public sectors, we must have an inspectorate that watches both sectors from the constitutional point of view. It would be impossible and hopeless to have an inspectorate for each sector.
When I raised this matter in an Adjournment debate, a Scottish Office Minister assured me that he would respond by letter to the point I raised. Sadly, I am still waiting for his response. The argument remains one which we should underline. It is not sufficient to leave local authorities to look after or inspect their own establishments. There are weaknesses in doing that, one of which I have outlined previously : people in homes are often afraid to complain because they fear that they may be turned out. If that happened they would not have sufficient finances to go to a private home and would face extreme difficulties.
Another difficulty is the plight of the carer. We have heard pious statements from hon. Members from all parties. I am as guilty as anyone of making pious statements about the role of the carer. However, no Members of Parliament could fail to be moved by the horror stories about the plight of individual carers which are told to them by constituents who come to their surgeries. As a young Member of Parliament 10 years ago, I used to be extremely concerned when I heard of cases and I sometimes thought that they lacked credibility. I could not believe that people were in positions where everything seemed to be so desperately wrong for them. Since then I have been to see some of these people and I have in my constituency an active carer who knows the business inside out. As a result of my experiences and much of the guidance that she has given me, I believe that there is an indisputable case for carers' problems to be scrutinised by the House in this debate.
We have raised with consecutive Ministers the problems faced by carers, particularly those related to their financial means. If an invalid care allowance is paid only to those who deserve to be paid, surely there is a case to be made that invalid care allowance should be a free benefit and not one which is calculated together with other benefits and, therefore, at the end of the day, proves to be worthless.
Elisabeth Reid, who is my mentor in these matters and works for carers, dropped me a note. Her lines are cryptic. She says : "Willie, you'd better read again the Griffiths Report'. It frightens me! It is yet another money- shuffling exercise between Departments."
The Minister said nothing today to dispel that woman's fears. It does appear to be a money-shuffling exercise. The Minister could have said from the Dispatch Box--perhaps if will be said in the wind-up speech--that however we
Column 86move about the resources and finances for caring in the community, if we give local authorities the responsibility to look after and link together all the strands of caring in the community, we must protect that money by ring fencing. If not, it will be used for all other sorts of, perhaps good, causes. The money must be protected so that the local authority is accountable to its people. This will show that the Government actually mean what they say and ensure that the money so desperately needed in those areas is actually put up front. In an intervention, my hon. Friend the Member for Monklands, West (Mr. Clarke) made a pertinent point about the disabled. It is all right to make fine statements and it is good for the Government if a couple of lines appear in the press, but it does not bear examination if money is not put in with the legislation as it is passed. Certainly, we ask for a guarantee that the money will not only be put up front and be adequate, but will be ring fenced so that it is protected.
The Griffiths report calls for the setting up of a system of registration and inspection of residential homes. It should be underlined that, whether in the public or private sector, the rules and regulations must be the same. One matter that concerns me about the Griffiths report is that it advocates the establishment of a new group of community carers to assist the professional care workers with tasks such as shopping and home help duties. The voluntary sector plays an important part in that. I hope that the Government are not attempting to direct young people into this work-- young people who, through no fault of their own, cannot find work, especially in areas such as the one I represent. We do not want some form of home help on the cheap, and we will not tolerate it. I should be interested to hear the Minister's comments on my suspicions. The thrust of the Griffiths report is the strengthening of community care and the extension of consumer choice, which we all welcome. Of course we want elderly people to have some choice. My hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody) spoke eloquently and passionately of the carer-- usually the nearest available woman relative--who is forced into looking after that relative by her conscience and by circumstances. I have learnt through talking to such people that when the person to whom they have devoted many years of their life dies, their first feeling is one of overwhelming relief because at last they can enjoy some release from unrelenting drudgery. That feeling is immediately followed by an overwhelming sense of grief, and of guilt for having felt the relief in the first place.
If we are to have a system for looking after people in the community and if the onus continues to be thrust on those who want to keep their relatives at home, we cannot solve that problem by pious remarks in the House. The real solution lies in an established plan backed up with the necessary finance. The Government managed to pull £1 billion out of the air to sort out some of the anomalies of the poll tax in England. Let us hope that they will pull out whatever amount is needed to solve the problems of those who need care and of those who care for them in the community.
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Mr. Andrew Mitchell (Gedling) : I have no doubt that this is one of the most important debates in which it has been my good fortune to be called to speak, because it is about one of our most challenging social issues. As a civilised society, we have an opportunity to put in place a structure that can make a real contribution and a tremendous difference to the quality of life of some of our most vulnerable constituents. We all know that too often there is confusion between all the different agencies and bodies involved, and that confusion allows people to slip quietly through the net. The Audit Commission's report of 1986 has already been mentioned tonight, but it sums up the problems that existed and still exist in the service--problems of continual waste of scarce resources, with care and support either lacking entirely or being inappropriate to the needs of some of the most disadvantaged people in society as well as to those of the relatives who look after them. I shall return to those relatives later in my speech.
The Health Service already owes a great debt to Sir Roy Griffiths for his earlier managerial reforms, which I had the interesting experience of seeing implemented when I was a member of a health authority. His second major report confirmed that too often good intention is married to a system that is ill-suited to delivering community care and insufficiently accountable. That is no reflection on the professionals who deliver the care : they are saddled with the system. Nor is it to suggest that there has been anything other than a steep increase in the necessary funding. In recent years there has been a real increase of almost 40 per cent. in expenditure by both the NHS on community-based services and by local authorities on personal social services.
I hope that the White Paper will contain a blueprint for excellent management of community care coupled with clear accountability for its delivery on the ground and efficiency in that delivery. I am sure that there will be a role for the Audit Commission in that, too. We need to be absolutely clear about several key principles and requirements. The first is that community care must be based on a clear response to the needs of the individual and their family. The individual and their family must have a major say in how to meet those needs. There must be clear and open regulation of standards and quality of care, and I look forward to an enhancement of the role of the social services inspectorate. While a national policy sets the framework, it is for one single and local entity to take responsibility for the services available and for their delivery. Within that framework, we must make a real contribution to improving the ability of those who wish to continue to live in their own homes and environment to do so. That is partly a housing matter, of course. We need continued growth in the development of sheltered homes for the elderly and of bought sheltered housing, such as Bridge Housing in my constituency, which can offer great security to older people without penalising their capital. This is not a trouble-free area, as escalating service charges have shown, but I know that my hon. Friend the Member for Fylde (Mr. Jack) has done much good work in this area by promoting a proper code of practice.
Column 88However, if we are to enable elderly people to continue to live in their own homes, we must enable more assistance to be given to those who provide the lion's share of community care--friends, family and those who live next door. Too often, the presence of a willing daughter or daughter-in-law is taken for granted instead of being built on and supported as a cornerstone of the needs of the family. We especially need to support and strengthen the ability to cope of the vast army of volunteers who shoulder these responsibilities. Supporting people in their own homes is not only a policy which runs with the grain of basic human desires : it is also in tune with demographic realities. By the year 2000 there will be over 70 per cent. more people aged 85 and over than there are today. All too frequently in the past, elderly people have been shoved in a home because the local authority lacked the money to provide the help that they needed to continue living in their own homes.
If responsibility for all this is to rest with one authority, as it must, the Government are right to reach the conclusion that local authorities are best placed to take on that responsibility. That presents an opportunity and a challenge. We must ensure that the cry of inadequate funding is not allowed as a camouflage for failure ; but equally, inadequate resources would merely saddle the local authority with the problem rather than giving them the means with which to effect a solution.
I recently re-read the report to his committee of the director of social services in Nottinghamshire on the Secretary of State's statement to this House on 12 July. His report is constructive and encouraging and, I am sure, bodes well for the future.
If local authorities are to succeed, it is essential that they see themselves principally as enablers, not as providers of local services, because, just as it is a caricature of local authority homes to say that they are bureaucratic and unfeeling places for elderly people, so it is a caricature of private sector homes to see them as motivated by profit and greed. I believe that local authorities will genuinely find their tasks easier to fulfil if they set out whenever possible to be enablers of community care and not to take upon themselves its provision. The safeguards which they and we require rest in effective monitoring and regulation, and I endorse everything said on both sides of the House about the need for a separate national body to carry that out.
There is inevitably concern about the interface between health authorities and social services, the break point of responsibility for someone who is released from full-time medical care. At present, the customer is presented with a kaleidoscope of people who may be responsible for helping them : the GP, the hospital, the social services, community services or the voluntary sector. We must ensure that there are clear lines of responsibility. Naturally an effective partnership between all those groups is essential, but a clear lead must be given.
I hope that the White Paper will properly recognise the role of the GP in determining the right level of community care in conjunction with the local authority. After all, the GP receives the notes when a patient is discharged from hospital. He is involved in the service of health as well as of ill health. We need to enshrine the role of the GP.
The parish priest can make a contribution as the eyes and ears of the community as he goes about his pastoral work. He should see it as part of his role to act as an early-warning system for developing difficulties ; many
Column 89priests already do. I pay tribute to the Bishop of Southwell, who has recognised the role that his priests can play in this important area.
The support services for people who can continue in their own homes include a galaxy of helpers--home helps, meals on wheels, day care services, twilight nursing and incontinence services ; but we often hear stories of district nurses ending up having to do the shopping. Do we not need to build up a much simpler "general health" or sitting service by which a low- skilled level of assistance can be supplied? It could be less specialised and provided at much lower cost but could give the extra specific support that is needed by the client. I have talked mainly about the care of the elderly, but I should like to end by speaking about the care of the mentally ill. Some of the speeches in the debate have demonstrated a misunderstanding of our policy of closing some of the dreadful old asylums and placing people back in the community. All too often there is genuine public misunderstanding about that matter. Some people believe that community care is no care at all and is a cheap option, but nothing could be further from the truth.
In saying that, I draw on the experience of the health authority in Nottingham which looks after many of my constituents. It is closing some of the appalling Victorian asylums. The policy is working extremely well, precisely because the funding is matched to the speed at which the asylums are being emptied. The policy is not a cheap option. I continually follow up cases where it looks as though someone has fallen through the net. I regularly discover, as the authority confirms again and again, that it has lost track of none of the people who moved into the community.
What some hon. Members have been describing is the failure of the working of the policy but not failure of the policy itself. That is extremely important. Twelve people who were in Saxondale have gone to Broomhill house in Gedling village in my constituency. It is well staffed and people have been given what they never had in the asylums--a much better quality of life. There is day care support nearby and the policy is working extremely well. Hon. Members should go to see some of these old asylums. If they do, they will realise that people have a much better quality of life outside if they are properly supervised and looked after.
I am not, of course, being disparaging in any way about the service provided by the people who work in the old asylums. I spent half a day in an asylum in my constituency and I have no doubt that many of the people who work there are saints who must deal every day with appallingly difficult human problems. The money obtained from selling such dreadful places will provide the health care that my constituents want in the next decade and into the next century. The release of those assets will make possible far better, modern, up-to-date and brand new health facilities.
I welcome the Government's response to Griffiths and I welcome this important debate. I look forward with keen interest to the White Paper.
Rev. Martin Smyth (Belfast, South) : I am privileged to follow the hon. Member for Gedling (Mr. Mitchell) and should like to take up two of the points that he made. I am not convinced by his deduction about policy and systems.
Column 90In audits we discover that it is the systems that are important, not the working of them. I am not sure that the policy has always been right. I confirm the hon. Gentleman's view about the use of parish ministers. However, I regret to say that regularly the professionals in the field look askance at the clergyman who appears to interfere in the care of their patients or clients.
I wish to underscore the hon. Gentleman's point about the place of the doctor. In the suggestions before us the doctor is expected to communicate with the social services about his patients who require back-up help. He is not required to do so, but it is important to place a requirement upon the doctor because doctors are regularly out of touch even with what is available from the social services. I was fascinated by the comment of the hon. Member for Kilmarnock and Loudoun (Mr. McKelvey), who said that he had taken part in three debates on the Griffiths report. Many hon. Members also comment on the fact that we have still not seen a White Paper. I was reminded of the old cinema serials which have been replaced by the modern soap operas. We watched them and were left in suspense, but the next part of the serial left us wondering why we bothered to turn on at all. I trust that when we receive the White Paper there will be no sense of disillusionment but that the input from the debates will have sharpened the Government's perspective. The Government have heard hon. Members from all parts of the House expressing deep concern and raising specific issues.
The Minister spoke about being in Coventry during the recent social services conference. I am sure that, like me, he discovered there a deep concern about the avalanche of legislation that is coming forth and about the lack of facilities and training. The Children Bill will come on line and we will have a Bill based on Griffiths. There is a deep feeling, especially among social service workers, that they are not adequately prepared to meet such change at such a rate. Specific attention should be given to the training and preparation of workers in the field.
The pressure of time makes it impossible to cover everything but I suggest that the implementation of the Disabled Persons (Services, Consultation and Representation) Act 1986 and the corresponding Northern Ireland legislation of 1988 would go a long way towards meeting a great many needs. I call into question the Government's intention about the implementation of the various sections. For example, at a recent meeting of the all-party disablement group, the Minister with responsibility for social services and the disabled was committed to the concept of advocacy. Will the Government fully examine the implications of sections 1, 2 and 3 as a means of putting that concept into practice? How do they propose to make the services fully accountable to disabled people? How do they propose to consult disabled people about their community care needs? Will the Department fully examine those three sections as a means of ensuring user accountability?
At that meeting, it appeared that section 7, which deals with people's discharge from hospital was to be the next priority for implementation. However, the Secretary of State later contradicted that, because in parliamentary answers the Government have said that they are still in discussions with local authority associations on section 7. Is there a time limit on those discussions about the implementing of the sections? If they were implemented,
Column 91we would be on the road to providing the framework of legislation that is required to provide care in the community.
We must be careful when talking about resources. Most areas appeared satisfied to a degree, but when one probes one discovers problems. One area is convinced that it has a fine spectrum, and has its workers out in the field. However, it sees difficulties because of the soaring cost of land and property.
When I challenged the need for an inspectorate, especially in Northern Ireland, I had a telephone call from a constituent of my right hon. Friend the Member for Lagan Valley (Mr. Molyneaux) who asked me to visit his home. It was a small residential home with six people and it was ideal. It was not a large mansion-type institution but a home. That man said to me, "I am not by any means wealthy, but I am comfortable and I take £140 a week from the residents." We must be careful about setting national standards for finance which will raise the overall cost and not meet the real needs of the people. We must examine more carefully the place and role of an inspectorate for national standards of care so that local authorities or whoever is charged with this will not just minimise it to suit its own position. However, if we consulted people, particularly the carers and those requiring care, we would discover that they would benefit by more personalised care in their own homes rather than being in a home or an institution.
Has enough attention been given, difficult though it might be to implement, to giving respite care not in an institution but in the residence of the person in need? All of us know that, especially as people get older, they can be disoriented if taken out of their familiar surroundings. It would be better for them to have respite care in their homes. In that context, I pay tribute to the work of bodies such as Extra Care, which have gone a long way to providing personal attention for those who desperately require it.
How will the Government's stated intention of shifting the financial aspects of community care in nursing and residential homes from the social security budget to the health budget work? What will be the effect on residents and nurses in private homes? In that context, I support the cry for ring fencing. We were recently informed of a local authority that used the funds that it had been given to implement an aspect of the Griffiths report to pay the wages of the road menders. I do not doubt that the roads might need mending, and that those involved might need payment, but that was not a proper use of the funds.
Mr. Peter Thurnham (Bolton, North-East) : I welcome the debate. I am sorry that Labour Members were hoping to have the White Paper before it, because I see it as proof of a listening Government who want to hear, on the first day back, what we would like to see in the White Paper. This is an excellent opportunity for us to tell the Government what we want to see in it.
I agree with all my colleagues who have said that we need substantially more resources. I call on my hon. Friend the Minister not to be shy, and to ask the Treasury for more money, because more money will be needed. The issue is how that money should be used, and there are
Column 92differences about that between the Government and the Opposition. The hon. Member for Livingston (Mr. Cook) implied that if there were a Labour Government and all local authorities were Labour, everything would be simple and fine, but we know that if we go down that road we shall have the IMF cuts. We should remember the remark attributed to a former head of the DHSS : "If you are not confused about community care, it shows that you are not thinking clearly."
To understand why that is so, one should read the excellent speech of my hon. Friend the Member for Eastleigh (Sir D. Price), who went to the heart of the matter when he said that the essential ingredient is love by carers. We have over 1 million unpaid carers, two thirds of whom have no help at all, and whose care could be valued at upwards of £10 billion if it were paid for. They are dealing with a vast bureaucracy of social service workers--200,000 of them--who are mostly paid to do a job from nine to five and whose motives, by definition, are different from those of the unpaid carers who are doing this work through love. Here we have the essence of the conflict and of the Government's difficulty in seeing that the extra money that is desperately needed is channelled to help carers and the disabled rather than to swell this vast army of workers.
I shall illustrate the point with two examples that have recently come to my attention. Today I received a letter dated 9 October from the Association of Directors of Social Services, briefing hon. Members on today's debate. The letter says about assessment : "The way in which individual consumers are assessed for community care services is crucial. We seek clarification on the statutory requirements being placed on local authorities It is important, for example to know whether a consumer who has been assessed as requiring certain services has a legal entitlement to expect all those services within a given timescale. If so, how will the funding be guaranteed? If not, what right of appeal should exist?"
That is how the bureaucracy looks on the responsibilities placed on it by statute.
Let us compare that with the remarks made by Mrs. Pat Nelson at a Barnardo's conference held in Liverpool a few weeks ago, which was attended by Princess Diana. Mrs. Nelson is the mother of six, three natural children and three adopted Down's children. She said that the children had taught her what is really important in life : "Courage, honesty, truth, love and relationships. They don't ask What is your job? How much do you earn? What sort of car do you drive?' They ask Can I trust you? Do you love me? Will you always be there for me?' "
That can be compared with the example from the Association of Directors of Social Services. There is a complete difference in approach and the Government's difficulty is in seeing that the extra resources that are needed go where they are needed and not just into the bureaucracy.
I am a supporter of the Disabled Persons (Services, Consultation and Representation) Act 1986, which is a great credit to the hon. Member for Monklands, West (Mr. Clarke). That Act will not go away, and it is disappointing that the Government have not given it a better response. However, I see the difficulty, because the Act is oriented on local authorities. This is where we must pin down the local authorities' responsibilities. We must ring-fence the local authorities--although not by money because it is a mistake to think that if local authorities are given more money, that means more care--so that we can give them the extra responsibilities that are called for in the
Column 931986 Act without leaving them with responsibility for additional provision. The money should be directed more to voluntary groups such as Crossroads.
More money is needed. My hon. Friend the Minister should not be shy. He should tell the Treasury that £10 billion is needed. It will not be needed straight away, because there will have to be time to pin down local authorities to what they should be doing rather than what they are pretending to be doing. Time is needed to build up voluntary groups such as Crossroads. I am pleased that Crossroads now has agreement to start a scheme in Bolton because it provides care for 12,000 people and has another 7,000 on its waiting lists. There are tens of thousands more in areas where it does not have schemes. Such groups should be built up and that is where the money should go.
I am a voluntary unpaid carer and chairman of the newly formed Conservative Disability Group. I hope that the White Paper will allow more money and more say for the voluntary groups and, immediately, more respite care for the carers.
Mr. David Hinchliffe (Wakefield) : It is clear from the debate that, although the Government have been in power for 10 years, they have yet to develop a coherent strategy in their policy on community care, particularly in relation to the elderly. In everything that they do, the Government have only one policy--economic. That is the kernel of tonight's debate. What has been said tonight, and what has been said before in the Chamber about community care, shows that the Government see their central challenge as how to free the market, in domiciliary as well as residential care, and how to reduce the huge £1 billion per annum Exchequer grant going to private residential care. I shall break the consensus that we have had so far and comment on a fundamental question that has not yet been touched on. It is whether the market is an effective mechanism to determine the nature and quality of care for vulnerable and dependent people. That question must be addressed in the context of the way in which the Government intend to respond to the Griffiths' report. No one doubts that the private sector has played a part in the provision of care, and will continue to do so under every Government. Is it appropriate that the bulk of care provision should be left to the private sector, with the market determining the extent, the nature and, especially, the models of care that are being provided? I do not think it is. A number of problems stem from the market approach and I shall mention some of them. First, it is an unplanned approach. We have heard much about the way in which services have or have not developed over the past 10 years, but I am concerned especially about the clear bias towards institutional care, with that being the easiest area for the market to develop.
The Government have landed themselves with a huge albatross around their neck, that of institutional care. They have allowed that sector to develop because they have institutional tunnel vision. They should be aware of the huge range of options that is available. Residential care, however, is the easiest option when one has in mind a business proposition.
Business expansion means institutional expansion. We increasingly see intimate private homes being taken over and expanded so that they become large institutions.