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Mr. Burstow: I am grateful to the Minister for that reply. I hope that it will help some of his Back Benchers, who may have been misled by some of the comments earlier in the debate. It is helpful to know that the comprehensive spending review will consider all the royal commission's recommendations, and will thus consider the possibility of providing personal care free at the point of use, based on assessed need. That is important and it is useful to hear it from the Minister.
The Select Committee on Health considered some of those matters, as well as the interface between health and social care, and received some forthright submissions. I quote one of them:
"NHS services are provided to all on the basis of clinical need regardless of ability to pay, whereas local authority services are subject to charges. A particular problem of the caring regime is that many packages of care include elements from health and social services (for example, community nursing from health; home care
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- from social services). Sometimes the difference in the nature of the tasks performed is not clear to the user, and they resent paying for one and not the other. The situation is particularly acute in nursing homes, where a proportion of people are placed by the NHS, free of charge, but the bulk are either local authority placements or self-funders who may have to pay or contribute towards all costs, including nursing costs."
When quizzed by the Committee, even the then Secretary of State for Health had to admit that he could not offer clear definitions of health and social care. It is anomalous for the same type of nursing care to be provided free by the NHS in NHS settings--or paid for by the NHS in nursing homes--but to be charged for in nursing homes. There could be two people sitting next to one another, one of whom could be paying for care while the other received it free.
The Coughlan case has already been mentioned. It brought into sharp relief the way in which the previous Conservative Government redefined the role of the NHS as a provider of acute care, by drawing its boundaries more tightly--dumping and decanting people into nursing and residential homes and shedding responsibility for their care. That is rationing by stealth, as the Royal College of Nursing quite rightly described it.
When asked to explain their continuing care criteria, several health authorities listed tasks that they excluded from NHS care--such as artificial feeding, pain control, care of the dying and catheter care. Seven in 10 older people admitted to nursing homes in England and Wales come from acute hospitals. As other hon. Members have pointed out, those people have chronic, complicated medical and social needs, and multiple problems. However, many of them arrive at nursing homes with inadequate documentation--sometimes with no medical information whatever. Through no fault of their own, those people have drawn the short straw of sickness and dependency.
The courts have made it clear that when nursing care is the principal need, the place in which it is provided is irrelevant--it should be paid for by the NHS. As the RCN revealed today, 90 per cent. of health authorities have illegal arrangements for assessing and meeting the continuing care needs of their patients. I realise that Ministers dispute those figures; perhaps the Minister will comment on the matter in his winding-up speech. Furthermore, I hope that he will commission his own review and publish it, so that the House can debate it.
In February, a national audit of nursing home placements for older people in England and Wales was published, although it did not receive much press attention. It is a technical but important document. It was commissioned by the clinical audit unit of the NHS. It found that one third of all people placed in nursing homes were inappropriately placed; that is about 63,000 people who are so dependent that their principal need is nursing care--63,000 people who should not be paying, who have been let down by the system and who are not receiving the care to which they are entitled.
Even the former Secretary of State had to acknowledge to members of the Health Committee that
The RCN survey suggests that nine out of 10 health authorities are currently breaking the law. If that is the case, given that the Minister said, in a Health Select Committee meeting in July, that the Government were looking at issuing fresh guidance, I hope that today he can tell the House when that fresh guidance will be published. We need to know soon where the line is to be drawn, because practitioners do not know where to draw it, and it is a lottery whether one gets free nursing care; it depends on where one lives. That position cannot be acceptable; it should not be allowed to persist.
The Government are moving at a snail's pace on other matters, too. Care standards in residential and domiciliary care will remain unchanged during this Parliament, and nothing is proposed in respect of day care and day centres.
I hope that when the Government introduce legislation, we shall, as the hon. Member for Runnymede and Weybridge (Mr. Hammond) said, see the regulations for domiciliary care and for residential care alongside the Bill so that those matters may be debated together. However, it is worth bearing in mind the fact that, although the Centre for Policy on Ageing--which carried out for the Government 10 months of detailed work and consultation on residential care standards--presented its new standards to Ministers in January 1999, it was another eight months before the Department of Health published them for further consultation. As a result, a comprehensive set of standards for all regulated services is unlikely to be completed until 2002. As is clearly stated in the impact assessment attached to the document "Fit for the Future?", that is the year when the regulations will start to come into effect. I am sure that the Minister would have put his pen through that statement if it was not the case. I look forward to his telling us that that is wrong, and that the document will be reprinted.
Reports such as those in the Express earlier this year show why action is needed now. The Express found evidence that residents in one care home were
As has been said, there are beacons of good practice. The star scheme that was described by the hon. Member for Blackpool, North and Fleetwood (Mrs. Humble) may be a very good way to proceed. Those places that follow good practice need to be recognised and acknowledged. However, there are still too many care homes where care has been reduced to little more than life support.
Why must elderly people wait for the Government to legislate for new commissions for care standards? Why not use the existing inspection and registration system,
patchy and inconsistent though it may be, to start to drive up standards? Why must we wait another two years to tackle some of the issues of control, quality and choice? I hope that the Government will stop the dither and delay in that respect.
Dither and delay characterise issues of charging policy, too. It is a further damning indictment of the Conservatives' record in that respect that they failed for 10 years or more to commission any serious work on the impact of local charging policies on the provision of social services. The Government therefore inherited a chaotic picture of charging methods, ambiguous Department of Health guidelines and confused local procedures.
The confusion remains. Local authorities set their own rules, driven by Government funding plans that assume that councils will recoup at least 9 per cent. of what they spend on social care. The variations are enormous. In a recent report, the Audit Commission found that Tower Hamlets recouped 1.1 per cent., whereas Slough recouped 1.5 per cent. Social care charges are a complete and utter lottery. They distort local priorities and fail to meet need. What will the Government do to get things moving? We have heard that there will be further consultation about how a level playing field is to be provided. When will that level playing field be a reality?
The tone and substance of the Secretary of State's speech had more in common with the note of dissent in the royal commission's report than with the majority recommendations, although the note of dissent was not written by two people who agreed with each another on everything. In fact, there was a note of dissent to the note of dissent.
In the kite flying of the past nine months, far too much attention has been paid to the views of the dissenters, and not enough to the majority recommendations. I believe that the dissenters lost the plot during the inquiry, because they were more concerned about cost than social justice and failed to grasp the paradigm shift inherent in the majority's proposals.
In reaching our view about the best way forward, we as Liberal Democrats have set three goals for a reformed system of long-term care. First, the system must promote independence and dignity. The central goal of policy on long-term care should be to ensure the greatest possible opportunity for people to lead the life that they want. Services should be directed to and by older people.
"nursing care is something that people have expected would be provided free by the National Health Service . . . so in the eyes of many people I guess to say that all nursing care should be provided free is not an extension of what most people see as the principles of the National Health Service."
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We have heard from the Secretary of State that the Government are promising to align social services eligibility criteria with the eligibility criteria for continuing care in the NHS. The findings of the RCN about how the NHS is shirking its responsibilities cause me great concern, and I am sure that many people outside the House will be worried that an alignment of the two will level down, not up, the standards of care that people may expect.
"put to bed against their will and woken as early as 4.30 am to get ready for breakfast; not properly cleaned even though they regularly soiled themselves; left to sit for hours without activities and woken at two hour intervals during the night to be taken to the toilet because they are not given incontinence pads."
The Express made it clear that there was no deliberate abuse at the care home that it investigated, but no one could describe what it found as anything but unacceptable and appalling.
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