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Mr. Letwin: The hon. Gentleman used the words "intergenerational equity", but I am unsure what he meant. Did he mean that people now living should pay collectively for those who now need long-term care;
or that a person, during the course of his or her lifetime, should pay, effectively, for their own long-term care and that of their generation?
Mr. Burstow: In their evidence to the Health Select Committee, the Government said that many people felt that there was a clear contract between the state and themselves--that they were paying towards not only their own care but future care. I believe that we need a system that reflects the fact that we, as a community, are a wealthy nation, that we can afford to pay for long-term care, and that one generation should be able and willing to afford the costs of care for their elders. That is really what this is about.
All the kite flying that I was talking about obscures some key aspects of what the majority on the commission proposed--first, that a clear distinction should be drawn between living costs, housing costs and personal care; and secondly, that a national care commission should be set up to set standards and oversee the system. We have heard that the Government will consider all those questions, and we welcome the fact that the Minister has clarified that, but hon. Members and people outside the House still do not know what the Government's stance will be in six or seven months, when they publish their White Paper.
We therefore want to know whether the Government will seriously consider, and give high priority to, the commission's proposals on personal care, including nursing care free at the point of delivery after a rigorous assessment of needs. Do the Government understand that such a change would honour the Prime Minister's commitment before the general election to free people from the crippling financial burdens and the prospect of selling their home to pay for care? It would give everyone a stake in how care is provided.
Above all, such a move would mark a step change in the way that care was provided. It would end at a stroke perverse cost incentives and create a level playing field between home-based and residential care. For example, it would remove the need to decide whether a bath was being provided to meet social needs, in which case it would be means-tested, or medical needs, in which case it would be free. By drawing a clear distinction between personal care and daily living costs, the royal commission offers clarity where confusion has reigned.
The second, and equally important, recommendation supported by all members of the royal commission is the establishment of the care commission.
Mr. Hutton:
The hon. Gentleman started his speech by stating that he could not say whether he agreed with the royal commission's main recommendation on personal care, but--I am sure he will correct me if I am wrong--he has just accepted, on behalf of the Liberal Democrats, the main recommendation about personal care being free. Can he confirm that?
Mr. Burstow:
I have been saying that there are very powerful arguments in the majority's report, and I have outlined them this afternoon because not enough has been done to outline them until now; and apparently the Government have not been listening to them, but have been listening far too much to the dissenters.
The debate is about what the Government are doing, not about what the Conservative party or the Liberal Democrats are doing. It is about what the Government, who are charged with this responsibility, are doing, not least because they set up a royal commission to do a job for them and have since spent nine months wondering what to do with its findings.
The second of the Government's main proposals is undoubtedly a welcome piece of news from the Secretary of State. There can be no question but that we need a body to provide a strategic overview of the care system. We shall obviously consider in detail the Secretary of State's proposals when the Bill comes before the House. However, I wonder why we must wait for two more years before the new body comes into being. Why cannot we take a leaf out of another Secretary of State's book and establish a shadow body to start pulling together the necessary elements of the new agency so that it can start to do some of its work in advance? It is possible for a shadow body to be established, and I wonder why the Minister has not considered that possibility.
Mr. Hutton:
We have. We have already announced that we shall be doing that. That is what we have in mind.
Mr. Burstow:
I am pleased that the Minister has been able to make that announcement. I do not think that the Secretary of State said that a shadow body would be established. The right hon. Gentleman talked about 2002, but we have now had an additional announcement, which is very much welcomed.
I believe that the royal commission offers a rational and humane basis for reforming our care system, but how is the care to be afforded? We know that the costs of the royal commission's proposals come out at about £1.1 billion. All too often we hear the figures of £6 billion to £7 billion, which might be the costs in 2050. I cannot think of any other policy that any Government have produced that has had costings through to 2050. The comprehensive spending review, for example, had a three-year forward view.
If we average out the good and bad years over the past 100 years, our gross domestic product has grown by 2.25 per cent. a year, and over that period there has been an explosion in the number of people living longer. However, we have been able to afford the increased costs. Perhaps these facts have been overlooked.
It is said that the royal commission's proposals will benefit only the well off. I believe that those who produced the minority report have that wrong. If the argument is valid, surely it applies to the winter allowance and free television licences for the over-75s. Both those welcome new universal entitlements are going to rich and poor alike, and they add up to £1.1 billion per annum in public expenditure.
Why is personal care any different? The fact that personal care costs fall heavily and unexpectedly on a few makes the case for ending charges even stronger. That is why I asked the Secretary of State--I did not get a satisfactory answer--why the wealth of a dementia sufferer should determine the care that he or she receives.
The Government set up the royal commission to recommend reform of the long-term care system, and it has reported. However, the report is not a manifesto pledge redeemed on its own. The Prime Minister told us
at the beginning of 1999 that this was the year of delivery. Nine months of dither and delay have fuelled uncertainty about future arrangements for long-term care. Can we have some straight answers? Will the Government rule out free personal care? We have heard that they are not ruling it in, but nor are they ruling it out.
If the royal commission's personal care proposals have no place in the Government's plans, they should make that clear and not wait for a White Paper in six or seven months' time. Are the Government saying that the nation cannot afford to vote an extra one fifth of 1 per cent. of GDP--0.2 per cent.--to the care of senior citizens? The next comprehensive review must deliver a durable and compassionate policy that puts an end to uncertainty about long-term care costs.
Mr. Phil Hope (Corby):
I welcome the debate. I particularly welcome the announcements made by my right hon. Friend the Secretary of State on national care standards; the finance of long-term care; consultation papers on the detail, which we look forward to; access to social services; and minimum standards.
The royal commission has produced a far-reaching report. It is interesting that it is entitled "With Respect to Old Age". Perhaps it should have been subtitled "In Condemnation of the Tory Government". The report includes some damning indictments. It describes the system of care that we inherited when we took power. It refers to it being designed around a series of different bureaucracies rather than around the needs of individual older people. It prevented the national health service and local authorities developing joint working and created a strong lack of trust in the system. The commission says that the result was a sense of betrayal, a lack of trust and a genuine sense of helplessness. That is what we inherited from the Conservative Government. It is so important that we have a response from a Labour Government, who will tackle the inequities and unfairnesses and allow older people to have trust in a system that meets their needs.
Miss Kirkbride:
Is the hon. Gentleman proud of those on the Government Front Bench and of the Government, who clearly will not introduce legislation on these matters within this Parliament? Only a White Paper is on offer next summer, not legislation and not real proposals.
Mr. Hope:
According to my maths, the Conservatives were in power for 18 years, during which time they could have brought forward proposals to deal with the needs of older people. We inherited a situation where 1 million pensioners were living below the poverty level. We have tackled that directly through a basic income guarantee for pensioners and free television licences for over-75s. We need take no lessons on support for pensioners and other people from the Conservative party.
I shall draw attention to experiences in Northamptonshire and to the work that the county council has been doing in its best value review--one of the most comprehensive and detailed analyses of social care ever
undertaken in the county--of residential care for older people. The provision of social care services to older people represents possibly the largest area of activity for social service departments, in terms both of spend and of the number of people receiving those services. The spend in Northamptonshire is about £45 million, and 7,000 people are affected.
The review highlighted the key issue that services for older people cannot be considered in isolation. For example, the provision of residential care is directly affected by home care services, care management and assessment services by other organisations such as health authorities and health trusts, and housing departments. There is a complex interrelationship between different services. If change is introduced in one area, we must consider the impact of that on others.
A critical feature of the review was that the county council widely consulted and involved users, carers and staff at all the homes in the area to ensure that they understood the problems and the issues that the council was trying to tackle and had some ownership of the outcome of the review.
I hope that my hon. Friend the Minister will take note of what I am about to present as Northamptonshire's solutions. A consensus has been built up in the county about the right way forward--a way that builds on best practice. I hope that the work that has been done will provide a model that will inform the response and the White Paper when it is published.
Emphasis was placed on offering choice in meeting the needs of older people, on supporting people in their own homes when that is their wish, supporting carers, ensuring high quality in all service provision, joint working between the different agencies that affect the lives of older people and a whole-systems approach. That is designed to ensure that everything is taken into account, including the policies of the health authority and the Department of Health, as well as of the local authority and the social services department. Unless we take the picture as a whole, we create perverse incentives, bed blocking and the practice of passing on elderly people like parcels around the system, without the resources to meet their needs. Unless we adopt a systemic approach, we shall not achieve the outcomes that older people deserve.
All the available evidence from service mapping, activity data and expenditure patterns reveals in Northamptonshire an over-reliance on residential care, with the result that funding is being diverted to relatively high-cost residential care. Fewer resources are available to invest in a broader range of preventive and other services that would help people to be supported at home. That over-reliance on residential care appears to be associated with relatively high rates of admission to hospital of older people, especially those aged 75-plus.
What can we do about that? What is being proposed in Northamptonshire? The research that was carried out in association with the review showed that any decision to enter into residential care does not have to be inevitable. It showed also that early action can be taken to provide support in the community, and that that can alleviate a perceived risk and a major factor. People are predisposed to think that they have to go into care because they cannot be cared for at home. However, if there is a full assessment of need and a consideration of rehabilitation and the wider range of services that can provide support in
the community, many service users, who would otherwise enter residential care, can be cared for in their own homes. That is an important philosophy for the individuals involved and it has huge implications for the development of services in the community.
The widespread consultation that I mentioned clearly highlighted a strong preference for people to remain at home wherever possible, and the provision of a broad range of community-based services was also seen as particularly important. The need for residential care will remain--there is no question about that--but there should be a strong emphasis on high standards of provision and of care, with more people being cared for in their own homes.
Northamptonshire began to develop specialist services in several key areas. We discovered that rehabilitation can provide the time and the opportunity for service users to regain lost skills and abilities, for example, after a period of hospitalisation or an accident at home. Experience elsewhere suggests that, with the appropriate services, people can be helped to return home with support rather than being warehoused inappropriately in residential care that does not meet their individual needs.
Another area of specialism is respite care. It can provide essential support to carers and it is most effectively provided in familiar high-quality surroundings. Flexible respite care can benefit both service users and carers.
Services for older people with mental health needs must be arranged in a way that is appropriate to the particular needs of that user group. Familiarity and continuity will be important features in that specialist service to offer a continuum of care that offers day, respite and long-term residential provision.
Another area that we considered was access to services and fairness. There is evidence that the take-up of services by members of black and minority ethnic communities is low, although, if special services are provided, the take-up is significantly higher. Therefore, all services--whether in the local authority, the independent or the health sectors--need to ensure that they provide equality of access at all times. An emphasis must be placed on that. As well as recognising the merits of that approach, we need to recognise the merits of supporting initiatives that provide specific services to meet specialist needs. The Government could take many new initiatives to promote equality of access for the black and minority ethnic communities in Northamptonshire and the rest of the country.
Supported housing is another critical way of promoting independence. The importance of developing a range of housing options for older people was widely identified during the consultation process, as a critical element of any strategy to maintain more people in the community. Full consideration of housing needs, through joint assessment arrangements, must be an integral part of any care management activity. The potential of aid, adaptations, new technologies and imaginative approaches to the flexible delivery of care in people's homes must be exploited to the full. I am sure that the Government can do a lot more to promote such innovative approaches. Similarly, a greater availability of very sheltered housing
provision, which offers intensive care and support, can be part of the strategy to promote the independence of older people.
The conclusions as to the way forward were interesting. The best value option that is provided in Northamptonshire has three or four main elements. The first involves the transfer of 15 to 17 of the county council's residential care homes to the independent sector. In Northamptonshire, what works is what counts. Seeking to find the right blend of provision includes that transfer. The county council is also developing the specialist services that I mentioned and works with district councils to promote a programme of reprovision in the form of very sheltered housing.
That package enables the commissioning of such specialist services and of very sheltered housing through the release of capital that was locked up in existing long-term care provision. That service model may also be able to attract private finance into the sector in Northamptonshire to support older people. Better value for money is therefore being achieved in the long-term care places purchased by the council, and that releases money for community-based alternatives. Early action to prevent admission to hospital and residential care will limit the growth in the number of people supported in long-term care in the future. The strategy is to keep more people in their own homes and to provide specialist services, very sheltered housing and private sector residential care of a high quality. That strategy will provide a continuum of care for older people in Northamptonshire.
Of course, some issues--especially that of raising standards--need to be addressed. I much welcome the review of standards in residential and nursing homes that is being undertaken. We have seen the draft standards and there are resource implications. If those standards are to be met, we must provide the means to do the job. My hon. Friend the Member for Blackpool, North and Fleetwood (Mrs. Humble) referred to home care, and we need to increase standards there.
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