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10 pm

Mr. Roger Gale (North Thanet): I am grateful for the opportunity to raise an issue that is of considerable concern to a number of my elderly constituents and, for different reasons, to those who run residential homes as businesses.

When I was elected to Parliament in 1983 I first came into close contact with residential and nursing homes, of which Herne Bay and Thanet have a large number. I was impressed by the standards of care and dedication in some and quite appalled by the lack of care, trained staff and attention in others. The phrase "granny farming" was used revoltingly but graphically to describe some of those establishments. It was that exploitation of the elderly that led me and a number of colleagues to press for changes in the legislation.

The Registered Homes Act 1984 did a great deal to weed out the villains and to generate real considerable investment in improved facilities and fire precautions and in the numbers and training of staff employed per resident. The inspection of licensing procedures was tightened considerably, and I hope and believe that we all saw a real and dramatic improvement in the living standards of the many elderly people in north Thanet who for a variety of reasons either chose or found it necessary to live in retirement homes.

The programme of improvement in facilities and investment continued through the 1980s and in the early part of this decade. Then came community care and care in the community. The concept of community care is absolutely correct. In the past I have met many elderly constituents who perhaps having lost their partner and because of advancing years and frailty have been compelled, against their will, to move from a home that means everything to them and contains all their memories of family happiness into a residential nursing home. That kind of move is traumatic and sometimes avoidable, and experience suggests that it often precipitates death. With support from the right team of professionals, who can provide care and help daily, and with the benefits of care and repair schemes, which maintain the fabric of homes, many elderly people are now able to end their days in a manner and in the surroundings that they wish. That is an estimable achievement and it is right that it has been brought about through considerable investment on the part of the Government and local authorities. Community care is not a cheap option. As with most projects, there is a downside in community care, and it is to that that I now wish to turn.

My own support for community care was founded in the fond belief that it would extend the choice available to elderly people. I believed that by providing support from within the community in the form of home aid where necessary, home help and meals, those who were previously left without an option would be re-enfranchised.

I did not expect--nor, I believe, did many others in the House--that community care would, through the imposition of rigid eligibility criteria, often deny the elderly the right to choose of their own volition to move

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into a residential home and to receive support to enable them to do so. It was inevitable that the introduction of community care would have an impact on residential and nursing homes. Clearly, if we are to keep more people in the community in their own homes, there will be fewer people to occupy the capacity of residential and retirement homes. It was therefore self-evident that, as surplus capacity was generated, some homes would close.

I must express considerable unease at the manner in which the Government first introduced high standards of residential care and stimulated considerable investment--often of borrowed money--in good facilities, only to move the goalposts and deny those businesses the clients on which they are dependent. While all business ventures are at risk, that has for some been a harsh adjustment.

The imposition of contracts for residential places has not merely exerted a downward pressure on costs, which is clearly desirable for the taxpayer, but has in some cases meant charges that do not meet the costs of servicing investment or payment for food and staff--that way lies bankruptcy. Equally, the placement by the authorities of a few clients in a number of homes has meant that more are struggling than is perhaps necessary. If no one home is able to enjoy the critical mass necessary to survive financially, we may expect a further wave of bankruptcies. There is a concern that, perversely, we may be left with insufficient places to meet the demand.

The funding of clients for community care in their own homes or in residential care is a bone of contention. Until now, funding has been ring-fenced, but, as money becomes tighter, so the option of community care, which was never intended to be cheaper, becomes more desirable, and the criteria for residential care are likely to become more, not less, rigid. That will have a still greater impact on freedom of choice.

It has also become clear that, while social services departments may decree that adaptations to homes, approved by occupational therapists, are necessary, and while architects may draw up plans, turning those promised adaptations into reality can take an eternity. Local authorities simply do not have, or are not making available, the necessary funding for even those minor works to be carried out. The ends may have been decreed, but far too often the means are not forthcoming.

There are built into the system hidden costs that are not sufficiently well recognised. When those in residential care become ill--frequently in winter--they are generally cared for within the home. When similarly afflicted, those living alone in their own homes tend to gravitate immediately to hospital upon GP referral. Those who, like my hon. Friend the Minister, are looking for an explanation for the sudden rise in hospital accident and emergency admissions over the past couple of years, might look no further than that for the cause.

I had to spend three weeks of days and nights visiting the excellent Queen Elizabeth the Queen Mother hospital in Margate last Christmas. That hospital was overworked and bursting at the seams with elderly patients suffering from the sort of chest infections, influenza and seasonal diseases that one might expect. I do not believe that, a few years ago, that number of patients would have been admitted in that way.

The entire system was congested as valiant nursing and medical staff battled around the clock to tend to patients who might otherwise have been looked after in residential

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care. The cost, not simply in terms of pounds, shillings and pence, but in terms of cancelled, much-needed but non-acute operations, has been--and I fear this winter again will be--enormous. We shall face full wards, empty operating theatres and lengthening waiting lists. A senior health service employee told me that hospitals are being used as social hotels, which cannot be right.

One further aspect of community care gives me growing cause for concern. In Kent, and I suspect elsewhere, about two thirds of domiciliary care is contracted out to independent providers. I have no quarrel with Kent county council staff, who are, I understand, fully trained and screened before being let loose on their elderly charges. But some of the independent providers also undoubtedly offer an excellent service and a high standard of care. I am assured that the social services department runs a check on its contracts with those firms.

What is clear, however, is that the domiciliary care business is unregulated. There is no system in place to ensure that each and every domiciliary carer is fully and professionally qualified, or that they have been security screened. Yet those people are in positions of great trust, deal with a potentially vulnerable section of the community and, by the very nature of their jobs, have access to people's homes.

I do not seek to cast aspersions on the characters of the many people working in this field, who are totally honest, hard-working and dedicated. However, it worries me that, although we have gone to great lengths, through the Registered Homes Act 1984, to regulate the residential end of the market, we have allowed the freelance care agency to develop by default, without checks and balances built into the system. That is a circumstance that is wide open to abuse. It is in the interest not only of the clients, but of the carers who might otherwise face unsubstantiated allegations, that the problem is addressed and remedied as a matter of urgency.

I believe that a good concept is at risk of failing in the realisation. Unfair burdens and judgments are being placed on care managers who, without medical qualifications, might find themselves charged with the implementation of a rigid set of criteria for admission to residential homes, perhaps against their own better judgment and instincts.

Good residential home proprietors capable of providing a caring home are being denied clients who wish to use their services. Some of those elderly clients--the very people whom community care was designed most to benefit--are being denied the choice to opt for the security of a residential home, and are instead compelled to while away the gaps between hurried domiciliary visits in isolation and sometimes in distress.

I urge my hon. Friend to take on board my comments, which are born of my day-to-day experience as a constituency Member of Parliament, I hope that he will seek to fine-tune the community care system, so that real freedom of choice is restored.

10.11 pm

The Parliamentary Under-Secretary of State for Health (Mr. Simon Burns): I congratulate my hon. Friend the Member for North Thanet (Mr. Gale) on his success in securing this debate on community care in Margate and Herne Bay. I am pleased to have the opportunity to respond to several important issues that he

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raised. From correspondence with my hon. Friend, I am fully aware of his concerns on a number of points, and I intend to try to deal with all of them this evening.

First, I want to put the issue into the context of private sector and local authority provision of community care. Last week in the Budget, my right hon. and learned Friend the Chancellor of the Exchequer announced next year's settlement for local government. We have kept our commitment to fund community care fairly, and have provided Kent county council with an additional £9.7 million, earmarked for spending on its new community care responsibilities next year. The total resources provided for social services in Kent next year will be more than £218 million.

That is a huge amount, which needs to be put into context. It is more than three times as much as Kent county council's net spending on social services 10 years ago, and more than double the resources available at the start of this decade, in 1990-91. What other department of the council can boast increases on that scale? Those increases bear testament to the Government's intention to fund social care appropriately. It is now up to Kent county council to ensure that those massive increases in resources are used efficiently and effectively for the benefit of those who need the help of social services and community care in the county.

In deciding to continue with a special transitional grant in 1997-98, I was aware of the representations made by many care home owners from around the country, and by my hon. Friend in his correspondence earlier last month. They showed that care home owners have little confidence in some local authorities' willingness to choose the independent sector's good-quality, cost-effective services in preference to their own more expensive in-house provision.

As a Government, we believe in a flourishing independent care sector. I am not yet fully convinced that that has been established in both residential and domiciliary care markets. For that reason, we are again attaching two conditions to the special grant. The first states that it must be spent on community care services. The second requires local authorities to spend 85 per cent. of the grant in the independent sector. That has become known as the "85 per cent. condition", and was extended for a fifth year by my right hon. and learned Friend the Chancellor last week.

To ensure that it is satisfied by additional expenditure in the independent sector, the condition has a cumulative effect. Each year, local authorities must show that their community care expenditure in the independent sector in that year is in addition to the amounts required to meet the condition for the past years. In 1997-98, the cumulative effect will be applied to the past three years. In Kent, the county council will be required to spend a minimum of £49 million in the independent sector. I hope that those measures will reassure care home owners throughout that county.

Many local authorities have already proved that they can purchase reliable, good-quality, cost-effective services in the independent sector at a lower cost than their own in-house provision. They are able to place people in residential care homes that are cheaper than their in-house provision. They are also able to purchase

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domiciliary care from the independent sector at less cost than their own home care services. Yet many local authorities continue to limit the purchase of services from the independent sector to the requirement of the independent sector condition of the special transitional grant.

In its report "Balancing the Care Equation: Progress with Community Care", the Audit Commission drew attention to the accounting practices of local authorities making a false separation of those funds from their own historic base budget for community care services. It said:

Some local authorities could make substantial savings if they used more of their historic community care budget to purchase services from the independent sector. Local authorities should use their budget to purchase community care services to meet the needs of their local communities irrespective of sector, not according to their historic budgetary arrangements. They need to see their role as that of enablers rather than providers of those services.

We have compared costs of in-house and private provision. Kent county council has advised us that the cost to a prospective resident of an in-house placement is £272, and that an independent sector place purchased by Kent county council averages about £230. A place in the independent sector is therefore about £42 cheaper. Sadly, that difference in cost is greater than in other parts of the country. It clearly shows the scope for substantial savings by some local authorities.

Where the comparison of quality is the same--the independent sector is often better--people who are self-funding will choose their residential care home taking cost as a main factor. Local authorities need to make a similar judgment between providing in-house services at a higher cost and purchasing good-quality care at a lower cost from the independent sector.

Local authorities insist on perpetuating their own services regardless of cost that could achieve significant savings for their communities if they also made more effective use of independent sector domiciliary services. They are often used only as a stop-gap to provide the services that local authorities find it difficult to operate. If the independent sector has proved its reliability in achieving savings for local authorities in difficult cases, could not more savings be made by allowing the independent sector to compete for more of the core service provision?

As my hon. Friend said, the choice as to whether a person should remain at home with a domiciliary care package or be put in a residential care home depends on assessments. The latter are critical to determining what is in the best interests of the individual. The whole point of the community care policy is that people should be allowed the dignity and quality of life that come with remaining in their own home for as long as possible--obviously with the support services that they require. When that is not feasible, for a variety of reasons, they should be placed in the residential home of their choice.

It is as a result of the community care reforms that people now have more choice of services tailored to their needs. But that choice is effective only if it provides the

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care that people really need. That is why assessment is at the heart of our community care reforms; local authorities decide in the light of local needs and priorities how to meet people's assessed needs. In making this crucial assessment, local authorities should involve any other appropriate professionals, including health professionals, so that a complete picture of a person's needs can be built up before any decision is taken.

The assessment process ensures that people's needs come first and that the services they receive are carefully tailored to them--that is critical. If the real needs are not being met, resources are wasted. Equally, if needs are being met in ways not appropriate to the case in question, devoting resources to that case may deny other people the help they need.

The choice we want to give people must therefore be matched to the assessment of the individual case. It is one of the successes of the reforms that many people have been enabled to stay at home, with the relevant services, instead of having to be admitted to inappropriate residential or nursing care because of a lack of care packages to meet their real needs in the community.

That also makes good sense economically, given that day centre placement costs £24 a day, and a visit from a home care worker or a care manager costs £6 and £18 an hour respectively. The combination and frequency of these will often mean that the care package costs considerably less than the residential care placement, at £230 a week.

The reforms have opened up the use of more innovative care packages, which have enriched the lives of those needing help and allowed them to receive the care they need, when feasible, in their own home.

My hon. Friend also mentioned the fact that domiciliary care is currently unregulated--an extremely important point, because there are at present no checks on all residential care workers. But, as my hon. Friend will be aware, the Burgner report recently produced a consultation document for my right hon. Friend the Secretary of State for Health recommending further regulation of domiciliary care, to ensure the highest possible standards and the best quality of care for those who need it.

My hon. Friend will be pleased to learn that, although the consultation process is still under way, as an interim measure the Secretary of State has accepted that advice from the Burgner report, and we shall seek to introduce legislation, at the right time, as part of a wider package of regulations to safeguard the people who rely on

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domiciliary care. Because they are the most vulnerable and frail members of society, they need the best possible care, with the maximum number of checks and regulations to ensure that they get what they are entitled to. In an unregulated market, there may be problems with quality of care and other ancillary matters. I trust that my hon. Friend will be reassured by the Secretary of State's decision.

I have sought during this short debate to show that, when community care was introduced in 1993, we understood that it would take about 10 years to bed down the system and iron out some of the problems that would inevitably arise in introducing a new way of looking after the elderly, the frail and the vulnerable in our society. We are now beginning our fourth year, and great strides have been made in raising standards, protecting the independent sector and ensuring that the elderly and others in community care receive the best possible standards of care to which they are entitled.

For that reason, I am pleased that the Chancellor announced in his Budget statement additional resources next year of £335 million for community care, which shows our commitment to providing high-class services for those people. Our commitment to a flourishing independent sector is also clear, as we are continuing the special transitional grant and the independent sector condition in order to protect the independent sector and allow it to continue to flourish while providing a valuable service for the elderly, as it has over the past decade or so. That needs to be matched by the commitment of local authorities like Kent to obtain full value for money, irrespective of sector, in providing those services.

I look forward to local authorities and the independent sector working in partnership to achieve those aims, because, as my hon. Friend amply demonstrated this evening, the highest-quality provision of care for the most vulnerable and frail in our society must be paramount. They have the right to choose whether to live in their own homes, where that is feasible, with a package of care and support, or to live in residential care. It is important to ensure that they are allowed the dignity to live their later years with maximum care, which they so rightly deserve.

My hon. Friend has, for a long time, been a champion on behalf of his constituents in seeking centres of excellence and the right provision of the highest quality of care. I am extremely grateful to him for bringing before the House such an important and sensitive subject.

Question put and agreed to.

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