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The hon. Member for Glasgow, Cathcart (Mr. Maxton) referred to prevention when he spoke about sport. The Health Minister is also responsible for sport in Scotland. He wears two hats. I repeat the point made earlier in this short debate, that over the century the greatest contributors to better and healthier living have been improved housing, water supplies and working and environmental conditions. In that context, and without straying beyond the parameters of the debate, I hope that the Minister will recognise that there are slightly wider social obligations, in terms of broader Government social policy. Much of that resides with the Secretary of State for Social Security. We shall go on to one aspect of that later. Those obligations must be borne in mind as well as worthwhile and valuable initiatives such as the Minister outlined.Like the two other smoking sinners, and as the third member of that triumvirate in the House, and with national no-smoking day almost upon us, such is the extent to which I am moved by the Minister that I shall have a real go this year to kick the habit once and for all.
Mr. Michael Forsyth : I am delighted that, even before the new clause has been accepted by the House, we have at least one convert in the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy). If the House accepts the new clause and amendments, when we lay down regulations to establish the new health boards in Scotland responsible for health education, the hon. Gentleman will be able to give us a full report on the progress that he has made in the intervening period.
The hon. Gentleman was kind enough to raise the matter in Committee when I was considering the report that we had received from Touche Ross and the advisory council. The hon. Gentleman said that the Secretary of State was taking more powers. The new clause and amendments do not give the Secretary of State more powers. They enable him to delegate his powers to new bodies. In that sense, the new clause does not increase the Secretary of State's powers but merely allows him to set up bodies that will act as his agents. That is the constitutional position of the health boards. I pointed that out when we first discussed competitive tendering in Scotland.
Mr. Maxton : Perhaps the Minister will tell the House in what other circumstances he expects the Secretary of State to use the power to delegate responsibilities. For what reasons would he do so?
Mr. Forsyth : If the hon. Gentleman is patient, I shall come back to the point that he raised. I was simply responding to the points raised by the hon. Member for Ross, Cromarty and Skye.
The hon. Member for Ross, Cromarty and Skye also said that housing, water supplies and so on were important for public health. I agree, but he will recognise that both those areas are the responsibility of local government, not central Government. There is certainly much room for improvement in both areas and in local government. No doubt people will take the opportunity in respect of water supplies on 3 May.
The hon. Member for Glasgow, Cathcart (Mr. Maxton) raised several points. He asked why there was no reference in the new clause and amendments to health education and why they were widely drawn. To be
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perfectly honest, when we were contemplating what steps we might take it struck me as remarkable that the Secretary of State for Scotland could not delegate his powers to new bodies that he might constitute, as my right hon. and learned Friend the Secretary of State for Health can south of the border. We discussed the matter in Committee and it seemed appropriate that we should give the Secretary of State those powers.I am surprised that the hon. Member for Aberdeen, North (Mr. Hughes) thinks that there is some Machiavellian plot involved in my moving the new clause. There is nothing sinister or underhand going on. The powers in the new clause and amendments mean that the Secretary of State would have to come to the House to make regulations which would be subject to negative resolution. Therefore, the House would have every opportunity to consider the arrangements in respect of this new health education body.
The hon. Member for Cathcart was suspicious and, in line with the hon. Member for Aberdeen, North, suggested that this was all part of putting the management executive, which we have established in the NHS, on a statutory basis. We do not require these changes in the law to establish the management executive. We have been able to do so. Mr. Cruickshank, the chief executive of the NHS, is a civil servant, not a political appointee. I was distressed to hear what the hon. Member for Aberdeen, North said. I take it that he was not speaking for his Front Bench when he suggested that members of the management executive, who are being recruited to get the best possible deal for the patient, would not enjoy job security under a Labour Government. In that respect they would share the fate of many thousands of fellow Scots, if that is what he sought to imply.
Mr. Robert Hughes : We must get this exactly right. What is the status of the new executive body? Will the individuals be appointed under normal Civil Service terms and conditions? If so, that is another matter. However, if they are to be appointed on individual binding contracts with high salaries, we need to be told. There is a big difference.
Mr. Forsyth : The hon. Gentleman is absolutely right. The appointment of people on fixed-term contracts which are performance related is different. It is also desirable and important. The chief executive of the Health Service certainly is appointed on that basis, as are the general managers of the health boards. That is a great step forward and I am sure that the hon. Gentleman will welcome accountability of those whose function it is to hold the Health Service accountable for the targets which are set in the interests of patients.
Mr. Maxton : All of us would be interested to know exactly who the Minister has in mind for these jobs. The newspapers have said that the chief medical officer for Scotland will be one person on the executive. Who will the others be? I appreciate the Minister's remark about Mr. Cruickshank because he was appointed against the Minister's wishes. The Minister wanted Mr. Laurence Peterken from the Greater Glasgow health board. Is not this a back door through which the Minister can put Mr. Peterken on the executive?
Mr. Forsyth : What the hon. Gentleman says is completely untrue. The appointment of the chief executive
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was made in the normal way, on a recommendation from the Civil Service Commission, and was approved by Ministers. The hon. Gentleman should not make such comments unless he is sure of his facts. He is wrong.The management executive has nothing whatever to do with the new clause. It has come into the debate only because the hon. Member for Aberdeen, North asked me to give an assurance that we do not intend to create a special health board, which is the management executive. I am happy to give him that undertaking which I hope means that we can now leave the matter behind us and look forward to a better managed, better run Health Service. I know that Opposition Members are opposed to that--
Mr. Robert Hughes : Will the Minister give way?
Mr. Forsyth : In a moment. The Official Report will show that the hon. Member for Cathcart said that we cannot run the NHS like a business, and a business is run in a businesslike manner. A Health Service run in that way will be better able to meet the needs of the patients and those who send us to the House.
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Mr. Robert Hughes : The Minister should not be allowed to get away with the statement that Labour Members do not want the Health Service run in a businesslike manner. It is utterly untrue. In all the years I have been involved in the Health Service, whether as a councillor, a member of the regional hospital board or a Minister, we have always been anxious to ensure that it is run properly and we get value for money. That is different from what is happening now. The Health Service is being run not on businesslike methods, but to put business the way of the Minister's friends. The way that it has been prostituted for his political ideals is a disgrace.
Mr. Forsyth : If the hon. Gentleman is arguing that the Labour Government ran the Health Service well, he will forgive me for pointing out that they presided over a cut in the hospital building programme and a cut in nurses' pay of more than a quarter. The contrast with our record could not be clearer. He may not wish me to go over what is certainly ancient history, because it is so long since we had a Labour Government, but perhaps I may remind him of the Labour party's attitude to the appointment of business men to take charge of Health Service management. It opposed that on the grounds that business men were not appropriate. Yet business methods and a businesslike way of running the Health Service are in the interests of patients.
Mr. Martin Flannery (Sheffield, Hillsborough) rose
Mr. Robert Hughes rose --
Mr. Forsyth : I have been good in giving way and I should make progress, but I give way to the hon. Member for Aberdeen, North.
Mr. Hughes : The Minister should be reminded that the Labour Government set up a special commission to look into nurses' pay. That was done thoroughly. I remember a business man in Aberdeen who was appointed by one of the Minister's predecessors to be vice chairman of the then North- East of Scotland regional hospital board with a
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view to making it more business-efficient. He became chairman of the finance committee. Within a year he said, "What are those so-and-sos who used to be friends of mine doing to my Health Service?" Business men who are appointed know what is happening. The Health Service is not being run properly in the interests of patients, and the Minister should stop pretending that it is.Mr. Forsyth : If the hon. Gentleman is saying that everything is not perfect in the Health Service, I agree. That is why we are introducing the Bill and providing for the service to be run in a more businesslike way. If he thinks that it is any consolation to nurses that when his colleagues were in government they set up a commission into nurses' pay, he does not live in the real world. The Labour Government cut nurses' pay by a quarter whereas we have increased it by--
Mr. Deputy Speaker : Order. This is a long way from the new clause before the House. I hope that the Minister will return to it.
Mr. Forsyth : I apologise, Mr. Deputy Speaker, if to speak of the good news in the Health Service is to stray from the new clause. The hon. Member for Cathcart asked about the "Good Hearted Glasgow" campaign. I appreciate his kind comments about it. It is a good example of a health board being involved in health promotion and doing it extremely well. That sort of campaign would not be threatened in any way by the creation of a new body with national responsibilities for health promotion, as he claimed. We intend to have a national policy statement about health education for which the new body will be responsible. The health boards will work with the new body to achieve that. We particularly want to place more emphasis on the prevention of coronary heart disease. The campaign in Glasgow and that in my own constituency, which is run by the Forth Valley health board, are excellent examples of what can be done in that area.
Mr. Tom Clarke (Monklands, West) : Since this seems to be a rather rushed affair, and since the Under-Secretary has referred to the important subject of health education, will he tell the House what consultations he or the Secretary of State have had with people responsible for health education at the moment?
Mr. Forsyth : I do not think that the hon. Gentleman was here at the beginning of our deliberations and he therefore missed what I had to tell the House--
Mr. Forsyth : I am surprised, because I told the House that we had asked Touche Ross to carry out a review of health education policy in Scotland. The company spoke to nearly all the interested parties in health education and produced a report which is now in the Library. I commend it to the hon. Gentleman. It sets out Touche Ross's recommendations, which reflect the views that were given as it went around Scotland speaking to interested groups. The report recommends the establishment of a special body, although not of the kind that we are discussing. Having commissioned those reports, we should proceed with all due speed to ensure that the body is up and running by 1 April next year.
My hon. Friend the Member for Tayside, North (Mr. Walker), who is no longer in the Chamber, raised a
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number of important issues. As the hon. Member for Ross, Cromarty and Skye said, we should give him and my hon. Friend credit for having raised the matter in Committee.The hon. Member for Moray (Mrs. Ewing) asked me about the detailed nature of the body, who would be appointed and other such matters. Assuming that the amendments are passed, that will be decided by the House. There will be an opportunity to discuss the issue in the House, if the hon. Lady cares to ensure that, because the new clause provides for powers to make regulations which will be subject to negative resolution. I have no doubt that we will get a great deal of advice now that we have made our policy clear.
The hon. Lady also highlighted the importance of health education in schools, and I entirely agree. We shall expect the new body to strengthen links with education authorities and schools. When I was Education Minister I was particularly conscious of the great work that is being done in our schools, particularly on drugs and AIDS, and all credit is due to the education authorities involved in that. The hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) asked me about independence-- [Interruption.] Not the kind of independence with which the hon. Member for Moray is concerned. That seems to be becoming less fashionable, if recent polls are to be believed. The hon. Member for Roxburgh and Berwickshire asked me about the independence of this body. It will be active as the agent of the Secretary of State. I agree that there are times when it is helpful for Ministers to be distanced from some of the campaign that is necessary on a health education fund, for the reasons that the hon. Gentleman outlined. There will be a national policy statement and it will be the job of the board to give effect to it and obviously that will be at arm's length.
I heard what the hon. Gentleman said about the nature of the board, and the composition of chairman and members, and I shall ensure that people with the talent and ability to provide the best possible service will be recruited to the body--as we have done with all the health boards.
The hon. Member for Roxburgh and Berwickshire also asked me about resources that will be deployed. If he looks at the Touche Ross report in the Library, he will see that credit is given for the increasing resources that have been provided. The report points out that this area may have been under-resourced in the past. That was a problem not of funding but of structure. We are determined to commit resources to health education because it is one of our priorities. The hon. Member for Glasgow, Maryhill (Mrs. Fyfe) asked me about women appointees. I think that we have done extremely well in appointing women to health boards--not because they are women, but because they had the talent and expertise required--and they have done extremely well. The hon. Lady also asked me about funding for drug abuse. She will know that we have made available considerable additional resources to deal with the problems of drug abuse and AIDS. In the space of a little more than a year we have doubled resources. I hope that the hon. Lady will recognise the progress that has been made.
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I sense that, having given those assurances to Opposition Members, there may be some support across the House for our proposals. The strengthening of health education is a key link in achieving our objectives for a better health service and better health care in Scotland. I hope that I have been able to persuade the House to support the new clauses.Mr. Tom Clarke : I do not think that the Minister should be surprised if some hon. Members feel that we should take up some of his remarks, albeit briefly.
The Under-Secretary of State said that he was not sure whether I had been listening to his remarks about the Touche Ross report, but I do not think that he was listening to my intervention. I clearly asked whether people involved in health education had been consulted. He gave no evidence that they had been consulted on the conclusions and the recommendations of the report. Therefore, there is a great temptation for Opposition Members-- perhaps because of the Minister's speech--to have greater doubts about the new clause.
In all honesty, perhaps the only redeeming feature is that the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy), who was positive at all times in Committee, made some contribution to the new clause. I hope that he and the House will not mind when I say that the Opposition--having heard the Under- Secretary's particularly vague explanation in response to my hon. Friend the Member for Aberdeen, North (Mr. Hughes), who asked a direct question about the legislative purpose of the boards--will judge the Government's real intentions when we deal with the regulations.
I am not convinced that the new clause represents the answer that all hon. Members would wish for in creating a broad strategy for the Health Service in Scotland, and for the major thrust necessary to deal with heart disease, respiratory conditions and the problem of an earlier mortality rate than elsewhere in the United Kingdom. The Minister did not convince us that much time had been devoted to real consultations on health education. I hope he will not mind if I return to the painful subject of what was once the responsibility of the Scottish Film Council. I think he is now able to distinguish that organisation from the Scottish film library. It works closely with the health education unit, which deserves to be congratulated on the way that it has promoted the campaign against AIDS and drugs. The Opposition want to be absolutely certain that the quality of those campaigns will not be diminished but will increase. We are not convinced, by any stretch of the imagination, by the Minister's arguments. Some of us are worried, in view of his speech, that there he was, sitting on the roof of St. Andrew's house feeding the vultures and coming up with even more crazy ideas about what he will do with the Scottish Health Service.
Notwithstanding the Minister's weak arguments, we shall not oppose the new clause. However, we shall look carefully at the regulations that will be laid before the House.
Question put and agreed to.
Clause read a Second time, and added to the Bill.
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New Clause 1
Preserved right to income support
(1) The Secretary of State shall, in respect of every person specified in Section 40 and who is in receipt of Income Support on the date on which Parts III and IV come into force :
(a) determine whether the appropriate amount of income support for that category of residential or nursing care is adequate to meet the charges levied by the residential care home or nursing home ; and where it is inadequate establish the difference between the appropriate amount of income support and the charge ; and (b) pay to that person an additional amount of income support representing the figure determined in accordance with paragraph (a) above except that no such payment shall be made in respect of any proportion of a charge which an adjudication officer considers to be unreasonable, having regard to the nature of the premises and of the services provided ; and
(c) by means of annual adjustments, maintain the value of the amount described in paragraph (b) above by reference to an index reflecting the average movement of charges made by proprietors of relevant premises.
(2) In this section :
"relevant premises" has the same meaning as in section 40. "appropriate amount of income support" has the same meaning as in paragraph 5, 6 and 7 of Schedule 4 to the Income Support General Regulations 1987.'.-- [Mr. Robin Cook.]
Brought up, and read the First time.
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Mr. Robin Cook (Livingston) : I beg to move, That the clause be read a Second time.
Before I turn to the substance of the new clause, I intend to make two comments on why the Opposition have chosen this as the first of the Opposition new clauses to be considered on Report. The Opposition deliberately chose a community care topic to be debated first. The Bill is the response, such as it is, of Ministers to the Griffiths report on community care and their response to the explosion in the numbers of the very elderly which, during the next decade, will be a major challenge to the health and social services.
The clauses on community care are to be found at the very end of the Bill. We were anxious from the moment that we saw the Bill that those clauses should not be ignored. It is a measure of the success of our strategy in Committee--a success that has been much appreciated by voluntary organisations--that we were able to pace our Committee debates in such a way that four days were spent on debating those clauses. We were equally determined that community care and the needs of the elderly should not be forgotten on Report. It was partly for that reason that we chose to debate new clause 1 at the start of our debates on Report.
I am sure that it has not escaped Ministers' attention that there is a second reason for the Opposition having chosen first to debate new clause 1 : this is an issue which unites both sides of the House. I stand at the Dispatch Box under the novel burden of speaking to a new clause that has attracted the signatures of more than 30 Conservative Members. I respect their support, in return for which I shall seek to be as non-partisan as it is possible for me to be. I may have to compensate later tonight for that non-partisan spirit, but on this occasion I shall endeavour to curb my enthusiasm.
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It is understandable that so many Conservative Members should want to support our attempt to provide justice for the people who are referred to in the new clause. Ironically, Conservative Members represent more social security claimants than do Opposition Members. They represent constituencies in parts of the country that tend to have more private residential care homes. I doubt whether there is a single Conservative Member who does not know of at least one constituent in his or her constituency who falls into the trap that is addressed by the new clause. The trap catches elderly residents who entered private residential care homes or private nursing homes after being assured by the Department of Social Security that it would meet the charges through income support. Now, however, they find that they are being short-changed on income support and that they have no means of bridging the gap.During the last two months I have seen and heard of so many such cases that it is difficult for me to select only one for the purposes of illustration. However, I shall share with the House the experience of Mrs. Renninson, who appeared with me at a press conference last week. Mrs. Renninson's father experienced a stroke at the age of 86 and had to go into residential care. He was admitted to a home that was able to cope with his needs. However, from the moment that he entered the home he faced the familiar problem that the charges increased faster than the increase in income support. Four years later, at the age of 90, he was put out of the home by the owners. Seven weeks later he died. The discontinuance of familiar surroundings is one notorious way in which death among elderly people can be precipitated. However, we cannot tell whether in this case death was associated with a change in surroundings ; we can only make a reasonable presumption.
When Mrs. Renninson spoke to the press conference she said that she felt that it was a mercy that death occurred after her father's second stroke because he really did not know what was happening to him. As I listened to Mrs. Renninson, I thought how amazingly reasonable and calm she was, despite all that she had been through. I am bound to ask how we, as a legislature, can have permitted circumstances in which elderly men and women--too confused and too disoriented to know what is happening to them-- are evicted from residential care homes because the benefit that they receive, in the name of this House, is not sufficient to keep a roof over their head.
That case occurred in the constituency of the Minister for Health, who is responsible for community care. In fairness to the Minister, Mrs. Renninson told me that she appreciated the support that she received from the Minister during the years throughout which she struggled to meet the fees at the home. As Mrs. Renninson expressed it to me, the Minister had written many letters of support to her, but unfortunately she was trapped because of the way in which the regulations are framed.
The new clause provides the House with an opportunity to change the regulations. It would help many people who are in the same position as Mrs. Renninson's father. Study after study throughout the past two years has confirmed that the present level of income support for those in private residential care is hopelessly inadequate to meet the fees. Only last month, Counsel and Care for the Elderly published its latest survey which showed that, of the homes it had investigated, only one in three charges fees that are within the income support limits. When it looked at homes
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in the London area, out of the 132 homes that it surveyed only seven charged fees that were within the income support limits. The British Federation of Care Home Proprietors says that the average shortfall is £40 a week. The Independent Hospitals Association says that the average shortfall is £60 a week. That shortfall is calculated on the basis of typical weekly expenditure per resident. It makes no allowance for capital borrowing and it allows only £14 a week for the food of each resident. When I referred to that figure in Committee, perhaps in an unfortunately partisan spirit I asked how many Conservative Members could feed themselves for a week on £14. In the non-partisan spirit in which I move the new clause, I ask my hon. Friends how many of them could feed themselves for a week on £14.Lest it be thought that the shortfall that the figures represent includes an excessive and unreasonable profit for the homes, let me consider the case of those residential care homes in the private sector that do not seek to make a profit. The National Federation of Housing Associations has made a survey of 500 homes. All of them are provided by voluntary organisations or housing associations. All of them are organisations that the Government seek to foster. In none of these cases is a profit, excessive or otherwise, being made. Few of the 500 homes came up with charges within the limits for income support. In most cases they were £30 above the limit, and, in one fifth of cases, more than £60 above the limit.
Counsel and Care for the Elderly has sent to a number of hon. Members examples of the cases in respect of which it has been asked for assistance. I should like to refer to two or three of them. The first demonstrates beyond any argument how even organisations that do not seek to make a profit cannot run their homes within the limits set by the Department of Social Security. Let me cite the case of Mrs. B, aged 95. In 1985 Mrs. B moved into a voluntary nursing home run by an order of Roman Catholic nuns. Over the past five years the nuns have been faced with escalating costs, and the fees of this non-profit-making home are now £275 per week. Mrs. B is therefore unable to meet the full charge out of her income support. Her daughter is retired and is unable to make up the shortfall. Six charity funds have now been persuaded to make long-term grants, leaving the retired daughter to make what is described as a manageable contribution to top up the social security. This is a home run by nuns--people who patently do not seek to make an excessive or unreasonable profit, people who have themselves taken vows of poverty, yet who, within the limits set by the Department of Social Security, cannot make ends meet. I should like the House to note how many charities had to be approached in order that the gap might be bridged.
Let me refer to another case history that has been supplied by Counsel and Care for the Elderly. It relates to a woman of 92 who has been in a private nursing home in Sussex for four years. She is confused and requires heavy physical care. The fees of the home have increased steadily, and there is now a shortfall of £90 per week. As in the other case, this lady's only daughter is retired. Nevertheless, she contributed her entire state pension to try to meet the amount by which income support fell short of the fee. That situation cannot be maintained for long. Currently,
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Counsel and Care for the Elderly is negotiating with 10 separate charities to meet the top-up. It says that if all 10 can help, Mrs. V will be able to remain in the home.What makes many of these cases so perverse is that they involve elderly people who were placed in private residential care by NHS hospitals desperately anxious to recover the beds that were being occupied. Time and again those people, having been placed in that care, are left in an impossible financial situation. Just before coming to the Chamber I received, by fax, from the National Association of Citizens Advice Bureaux, details of the latest case. It involves an elderly lady who is in need of full-time nursing. She is incontinent and is unable even to feed herself. She has been in a private nursing home for a number of years. The home has now asked her son to remove her because it is no longer prepared to tolerate the loss that it sustains by way of the difference between income support and the fee that it charges. The irony is that neither the son nor the lady herself was responsible for her being in the nursing home in the first place ; a local NHS hospital put her there without consulting the son because it wanted access to the bed that she was occupying.
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As this matter was debated by the Select Committee, we have the advantage of the Committee's report, which came out last week. It confirms every point that was put to Ministers in the Standing Committee on the Bill. In particular--and I found this startling--the report confirms that the Government themselves admit that income support levels do not meet the needs of many of those in private residential care. It quotes Ministers as having said that 58 per cent. of people in private residential care in receipt of income support are paying fees that are within income support limits. Therefore, even on the basis of the Government's own figures, two out of five of those in private residential care are faced with fees that are outside income support limits.
I have to say to the Secretary of State for Social Security, whose presence for this debate I welcome, that, given his knowledge that 42 per cent. of those people are now faced with charges that exceed income support levels, it is impossible to believe that the uprating this year or last year turned on a careful calculation of what it would take to meet a reasonable fee.
As the House will be aware, the uprating that was announced last autumn will take effect next month. I remember the figure particularly well--it is £10--as at that time I was shadowing also the Minister who will reply to this debate. I can tell the House how the right hon. Gentleman arrived at that figure. He did not do so by measuring the fees and by doing a careful calculation of what was needed ; it just happens that £10 is the round figure nearest to 5.4 per cent. of the £190 that was the previous limit for care in private nursing homes. This is the standard application of the uprating, across social security, to these levels, although that uprating is hopelessly out of touch.
Last year, for instance, private nursing homes had to meet the cost of the nurses' pay award. This year they have to meet the additional burden of high interest rates. These place a particularly heavy burden on those homes that borrowed in order to get into business. The Select Committee's report quotes the Minister as having said that it was never intended that fees should be met in full. In other words, it was never intended, and apparently never
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claimed, that income support levels should be measured against the fees of homes. I put it to the Secretary of State and to the Minister of State that, as a simple statement, that is just not true. The original basis on which income support was made available to people moving into private residential care was that of the regulations on board and lodgings, under which local social security officers were empowered to meet the full reasonable cost of accommodation. There is no suggestion there that it was not intended that those payments should not meet the full cost of private residential care. Let me put to the Secretary of State what, in a sense, is a more important consideration : that statement not only is not true in history but is a novel principle in social security law. The whole function of income support is to meet the full subsistence needs of those in receipt of it. After all, they are broke. They have no other means of subsistence. If it were otherwise, those other means would be deducted from the income support entitlement. That prompts a question to which a straight answer from the Secretary of State would be appreciated by many people : if he and the Minister of State are now saying that it is not their intention that the full reasonable charges of these homes should be met through income support, who is it intended should make up the balance? Who should absorb the shortfall? Will it be the homes? Are they expected to make a loss as a condition of accepting as residents people who are on income support? I can tell the Secretary of State what their response will be. Indeed, there are two possible responses.Mr. Andrew Bowden (Brighton, Kemptown) : As the hon. Gentleman will know, I put my name to the new clause. I put this question to him in good faith so that I may be able to think through the point that he is making. I am sure he agrees that, under the old system, there was gross exploitation by a proportion of nursing home owners, in the sense that they increased their rates knowing that the individuals concerned would have only to apply to the DHSS, as it then was, to have the shortfall automatically made up. We are now in a new situation. I understand completely the points that the hon. Gentleman is making. However, I ask him quite genuinely how he thinks this problem should be overcome. It seems to me that there are two possible solutions : either there should be a blanket increase in all levels, or either the DHSS or the social services departments of county councils should be allowed to assess cases and make a proportionate increase to meet the costs. Which is the best path to go down--or does the hon. Gentleman have an alternative?
Mr. Cook : The hon. Gentleman makes a rich intervention and it will take me a little time to respond to it. On his point about the genesis of the situation, I do not wish to introduce a partisan note, but if it were possible for us to go back to 1980, we would not have wished to start out on the path that the Government followed. We would have preferred the large sums that were made available through the social security budget for private residential care to be channelled into local authority residential care, which would have meant that we would not now face our present difficulty.
Ministers made the deliberate decision to subsidise the expansion of private residential care through social security provision. The resultant expansion cannot have
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come as a surprise to them, because the policy was intended to achieve that expansion. I accept the point made by the hon. Member for Brighton, Kemptown (Mr. Bowden) ; indeed, the Opposition criticised the consequences. Some homes came into existence at that time with, let us be frank, an eye to the main chance, to take advantage of the new bonanza.I would not necessarily criticise the 1985 system to introduce flat-rate payments for people in private residential care, although I believe that they should have been subject to regional variation. I criticise the fact that, since 1985, those flat-rate payments have been uprated in such a meagre and unrealistic way that they have precipitated a major crisis among those in receipt of those allowances.
To follow the point raised by the hon. Member for Kemptown, and letting all that go as water under the bridge, how do we get out--if that is not a hopelessly mixed metaphor? Perhaps I should say, how do we get up-river from where we are? As the hon. Gentleman said, there are two alternatives. The alternative proposed in my new clause, to which the hon. Gentleman has added his name, is that we should oblige the Department of Social Security to carry out a realistic evaluation of what charges are reasonable. The new clause gives protection and gives the Department the right to refuse to make payments where the charge is unreasonable and to pay the money to the resident. I am not immediately attracted to the alternative of empowering local authorities to top up the amounts. Every other clause on community care imposes additional burdens and liabilities on local authorities. The Opposition doubt whether those local authorities will achieve the necessary finance to discharge them. I should be hesitant about passing on to those local authorities the additional expenditure of meeting that top-up. I can warn the hon. Member for Kemptown about the immediate and predictable consequences of such a change : the Secretary of State for Social Security would never uprate those limits again and the burden would fall on local authorities. That is why I chose the path followed by the new clause. I hope that I have responded to the points raised by the hon. Member for Kemptown without jeopardising his support for that approach. To return to my previous remarks, I was posing to the Secretary of State this question : who does he expect to meet the top-up payment if Ministers no longer intend to meet the full bill? Is it the home? Is it expected to absorb a loss? If so, the home can make two responses. First, it can reduce the facilities that can be made available to people on income support, and that is already happening. A study carried out last year by a firm of financial analysts discovered that only 11 per cent. of homes providing private residential care were willing to provide single rooms for residents on income support. Virtually 90 per cent. now provide only shared accommodation for such residents. Those homes have drawn to our attention the fact that two-tier accommodation is emerging in the private residential sector. The National Association of Citizens Advice Bureaux refers in its briefing to many hon. Members to its information that there are homes where residents on income support receive inferior meals compared with other residents. I cannot believe that any hon. Member would knowingly wish to have a public policy that resulted in that tasteless, undignified and damaging discrimination.
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The second response that a home can make is simply to go bankrupt, and a number of homes are contemplating making that response. In Standing Committee, the Minister of State was good enough to say that she was tremendously impressed by the work of the Anchor Housing Association for the Elderly. I do not know whether she has had an opportunity to study the Select Committee's report, but it contains the evidence that that association provided to the Select Committee. The Anchor Housing Association said that its shortfall was £30 a week per resident and pointed out that in 1988-89 the association lost £250,000 on its residential care schemes, which, as the association said, was"a loss it cannot, as a charity, continue to sustain".
If it is not the homes that have to absorb the top-up amounts, will it be the relatives? I put it to the Secretary of State, who knows social security law as well as any other Member, that the liability to pay the fees is a liability on the resident, not on the relatives. In any event, often those relatives are elderly. We are talking about residents of private residential care homes who are in their 90s. It is in the nature of people of that age that their sons and daughters are themselves retired. As hon. Members will have seen from the briefing circulated to them, NACAB knows of at least one retired pensioner couple, in Cheshire, who have been obliged to take part-time employment solely to pay the top-up on the fee charged for their mother's accommodation.
Sir Dudley Smith (Warwick and Leamington) : Does the hon. Gentleman agree that one of the tragedies of the problem is that, however severely incapacitated, the elderly person may live on for 10 or more years? I know of someone who lived on for 17 years. Even if the relatives have reasonable funds, they can soon be dissipated and they could be in penury.
Mr. Cook : The hon. Gentleman makes a fair, although infelicitously expressed, point. There is no doubt that one of the great stresses felt by relatives with an elderly parent in this position is that they have no idea how long it will continue, so they have no idea whether they will have any savings left. They do not even know whether their savings will last long enough to keep their relative in private residential care. When their savings are gone, who will meet their liabilities when they in turn require private residential care?
I come to the last possibility in terms of who fills the gap. Are the residents expected to make up the balance? If so, how? By definition, they are people who have no income of their own, except for the £10 a week that they are allowed for personal expenses. Although it is contrary to social security law, many of these residents do not receive even that miserable personal allowance ; it goes to fill the gap on the fee, leaving those residents with no money for telephone calls home, stamps and toiletries and even, for some, no money to purchase the incontinence pads that they need but now cannot obtain on prescription.
Ministers have a wonderful phrase to describe what will happen to people in those circumstances under the Bill. It is said that they will have "preserved rights". There is no security in having preserved rights that will leave people unable to afford toothpaste or incontinence pads. The
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reality is that for "preserved rights" we should read "excluded rights". The only provision in the Bill that affects those people is clause 40, which is in the Bill with only one purpose--to exclude those people presently in private residential care from the new arrangements to take effect from April 1991.There is a real danger that those people will become the forgotten people. Local authorities will have no powers to make the top-up, the Department of Health will have no duty towards them and the Department of Social Security, which plainly regards them as imposing irritating costs on the social security budget, wants to be shot of them as fast as possible.
I hope that the House will not be bought off by the formula that the Minister of State put to the Committee when we debated this matter. The Minister drew attention to clause 40 on the basis that "there is scope for making a regulation power to provide for people who otherwise would be homeless or suffer severe hardship in the ultimate circumstances."--[ Official Report, Standing Committee E, 13 February 1990 ; c. 866.]
In other words, it would be possible to contemplate regulations that would protect the position of those people at the moment of eviction.
That proposal does not address what happens in the years leading up to the moment of eviction. We are talking about people in their 80s or 90s. We cannot ask them to sleep easily in their beds on the basis that there may be regulations to cater for them at the point of eviction when the home finally boots them out. Moreover, such a regulation would be entirely pointless because the bizarre result of clause 39 and clause 40, read together, is that if the home evicts a resident and that resident qualifies for assessment by the local authority, qualifies under assessment as being eligible for residential care and is placed by that local authority in another residential care home, he becomes a new resident under the Bill at that point and will qualify for top-up.
We are creating a ludicrous message to send out from this House to the owners of private residential care homes. We are saying to them, "If you are reasonable, if you absorb the loss, and if you do not evict the residents, we shall not help. But if you are unreasonable and evict that resident, we shall intervene and meet the bill." I cannot think of a more confused or hopelessly limited response to the problem.
The truth is that that response is intended not to meet the problem but to defuse the political pressure to solve the problem. I urge the House not to be defused. I can guarantee Conservative Members plenty of opportunities for partisan votes in our proceedings on the Bill. They will have the opportunity to redeem themselves in the eyes of the hon. Member for Derby, North (Mr. Knight) before the night is out. I beg them to vote not to please the hon. Member for Derby, North on new clause 1, but to assist their constituents. I commend the new clause to the House.
Miss Ann Widdecombe (Maidstone) : I am grateful for the opportunity to take part in the debate, which concerns the most vulnerable of our constituents. The Government are to be congratulated on their recognition that the present position is unsatisfactory. If they had not recognised that, they would not have brought about the courageous and welcome changes in their implementation of the Griffiths report and in the Bill. However, in saying that the proposals will relate only to elderly residents who come into private residential homes in future, the
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Government have eliminated from their wise and humane reforms all who are currently in such homes and who are having to suffer the unsatisfactory position that has led the Government to make changes in respect of future residents.The hon. Member for Livingston (Mr. Cook) has quoted several of his constituents and I suspect that we shall hear many specific cases tonight. I have raised the issue on many occasions, as has my hon. Friend the Member for Romsey and Waterside (Mr. Colvin), who deserves the thanks of the House for the persistence with which he has raised the matter over the past year. We have raised the topic in Adjournment debates, in Consolidated Fund debates, in the inquiry held by the Select Committee on Social Services and in many other convenient fora. I record my gratitude to my hon. Friend the Under-Secretary of State for Social Security for her many letters to me in response to a particular problem with one of my constituents. That problem is not solved and cannot be solved under the present circumstances. Although I have quoted the case of Florence Smith so frequently that she has become almost a byword to describe such a situation, I have many other cases.
It is a question not only of the problems of our immediately suffering constituents, but of the effect that lack of recognition of the problem to the point of being unwilling to solve it will have on future provision for the elderly. It has been estimated that we need to provide about 40 new beds a week if we are to be able to take care of the ever-increasing number of elderly people by the end of the century. That means that there must be an incentive, and not a disincentive, to the homes to expand and to build them in the first place.
There have been two principal reasons for the immense distortion between the charges being levied by the reasonable homes--I set aside for the moment the unreasonable homes--and the level of income support. First, there has been an immense rise in interest rates which means that any home that has new property attached to it, or is a new property itself, is having to pay immense sums to service the capital investment. The owners have to pass on those sums, which is not greed or unscrupulous profiteering, but basic business sense such as the Government normally applaud. Secondly, there was a welcome and wholly justifiable rise in the pay of nurses the year before last, when the average rise was 15 per cent. Once again, that charge has to be passed on in our nursing homes.
It is significant that some of the homes that have managed to depress their charges artificially are those where the proprietor is herself a qualified nurse and can, therefore, take on many of the duties that would normally fall to other staff. However, if she is also to take on more residents--as she must if we are to meet our target for caring for the elderly--she will be unable to carry that burden indefinitely. That means that she will have to employ qualified staff at an ever-increasing cost, which also has to be passed on.
Other distortions have been caused by regional variations. An established home with no new building in the north-west, for example, may be able to cope and set a charge within the level payable under income support, but there is no way that that can be done in areas where property is vastly more expensive, such as the south-east, and where the home is new. It is not insignificant that
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