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Mr. Letwin: I have been reflecting on the hon. Lady's latest series of remarks and I am unclear whether she supports the position that I think we clarified was that of the Liberal Democrat's spokesman, that the state, and hence the present generation of taxpayers, should meet the full cost of long-term care for those in long-term care today regardless of their income or capital. Is that what she is saying?
Ms Squire: I am urging the Government to give serious consideration to the royal commission's recommendations on personal care and on that being free of charge. Today's pensioners deserve top priority in whatever money is available. I need to hear more of the arguments about whether that should apply to those of us who have a few years yet to retirement age. But we have a particular responsibility to today's pensioners because of what they went through and the expectations that they built up during their working lives.
I welcome Ministers' comments about the importance of recognising the contribution of carers to our society. Voluntary carers provide the largest amount of long-term care, free of cost or at low charge, estimated to be worth up to £40 billion a year. I hope that Government announcements next summer will recognise the role that carers play and ensure a system of full support for them.
Mrs. Marion Roe (Broxbourne):
I welcome the opportunity to contribute to a debate on the important subject of long-term care, and to consider the recommendations in the royal commission's report and the points made in the note of dissent. However, I must point out, as other hon. Members have done, that people inside and outside Parliament have expressed grave disappointment because the Government have not made decisions on all the report's recommendations, although
The royal commission's report is not the first report on long-term care to be presented to the House of Commons. When I was chairman of the Select Committee on Health, it held two inquiries into long-term care. One related to national health service responsibilities for meeting continuing health care need, and was published in November 1995. The other covered the future provision and funding of long-term care, and was published in July 1996. Both reports were unanimous and provided the initial investigation into and detailed analysis of a highly complex and controversial issue. Therefore, I speak as somebody who has taken an interest in the subject for a long time.
What is the question to which answers are required now? Population forecasts up to the middle of the next century are relatively reliable. Unfortunately, future demand for long-term care is dependent not only on the size of the elderly population but, crucially, on much more unpredictable factors such as the number of people who live alone and the health status of the elderly. Of course, the latter depends on developments that cannot be foreseen, such as the extent of medical progress and the degree to which healthier life styles are adopted. Therefore, all attempts to calculate future demand towards the end of the lifetimes of those who are not young will contain an element of crystal ball gazing; I think that statisticians call it "an expanding funnel of doubt".
I endorse the royal commission's view that there are no immediate demographic time bombs for long-term care; the demographic and dependency ratio trends suggest that no major problems loom in the short to medium term--that is, up to around 2020. After that, the trends will present more of a challenge and we should consider their implications now.
It is right that any changes to present models of care and methods of financing long-term care should conform to seven key principles. First, any changes should maximise the individual's independence, self-respectand choice. At the heart of any system should be encouragement of independence and autonomy for the individual, and provision of reasonable opportunity for people to choose the type and setting of the long-term care that they require. It is also important that the system is sensitive to the particular needs of ethnic and religious minorities.
Secondly, any changes should be understandable and perceived as equitable. There is a widely held perception that the current arrangements for funding long-term care lack fairness.
Thirdly, any changes should improve the way in which long-term care is planned, organised and purchasedby multidisciplinary, knowledge-based agencies. The community care reforms are based on the aspiration for services to be purchased and provided to suit the needs of the individual rather than the interests of service providers. Therefore, good information is required on the needs of individuals and local populations, and on the effectiveness of the varying forms of long-term care services, including, for example, preventive and rehabilitative services.
Fourthly, any changes should provide better support and encouragement to informal carers, in terms of practical help--for example, training and respite care--or financial help. Informal care is, and will remain for the foreseeable future, the bedrock of long-term care provision. Given the potential for changing demographic and other social trends to reduce the supply of informal carers, there is a strong argument for ensuring that priority is given to changes that will improve the ability and willingness of informal carers to provide care.
Fifthly, any changes should include mechanisms to ensure that an efficient and high-quality service is provided in all care settings. Long-term care services are often provided to clients, who, by the nature of their conditions, are vulnerable. Therefore, it is clearly important that mechanisms are in place to ensure high-quality services in all care settings.
Sixthly, changes should be affordable. Public support for changes is likely to be forthcoming only if they are seen to be affordable by individuals as well as the state. Any movement towards a system of long-term care that is "funded" as opposed to "pay-as-you-go" should recognise that one generation would be expected to contribute twice--for its own future care and for the care needs of today's elderly people. I believe that any such change would need to be phased in over a long period in order to be affordable and acceptable to the transitional generation.
Seventhly, any new programme of public expenditure on long-term care should, in the case of services provided or funded by the national health service, be--as it is now--available equally to all citizens according to their assessed need for care and, in the case of means-tested social care services, be designed to meet necessary care need for citizens who have insufficient income or capital to pay for such care from their own resources. We all listened carefully to the remarks of my right hon. Friend the Member for Tonbridge and Malling (Sir J. Stanley) about his constituent, with whom we have great sympathy.
What are the options for funding long-term care? It is apparent that long-term care is an expensive service for the taxpayer and for any individual who contributes towards the cost of his or her care. As I said earlier, there is a perceived unfairness in the current system for financing long-term care by means testing state-supported residents in residential or nursing homes. That approach penalises people who have saved during their working life, while rewarding with free care those who have been unable, or unwilling, to save. It is grossly unfair to the thrifty, because it represents a disincentive to save and a challenge to those able to divest themselves of capital. If we are to build a more secure society, we should encourage people to help themselves and to be independent, if possible, through saving carefully for their old age. Thrift should be encouraged and assisted, not undermined.
Surely it must be right to find a way for the state to work with those who are prudent and not against them. For example, partnership schemes give additional protection of assets against a means test when it is applied. We must not forget that society as a whole has become wealthier and the substantial increase in the number of elderly people who own their own homes means that many people have assets significantly above those specified in the means-tested threshold. If that is
coupled with the fact that people are, on average, living longer, the disquiet on that issue can be understood. I therefore fully support the Conservative party's policy whereby, if individuals make provision for themselves, the Government will protect more of their assets should that provision run out and they need to use state-funded care.
It is important that as many options for future funding of long-term care as possible should be considered and assessed. The partnership schemes are only part of an overall package that may include other mechanisms such as immediate need annuities, long-term care insurance, equity release schemes, geared pensions and tax relief as well as schemes founded on general taxation or social insurance such as those in Germany. As we know, state expenditure on long-term care in the United Kingdom is currently funded on a pay-as-you-go basis, which would mean--bearing in mind the changing demographic profile and, in particular, the changes in the dependency ratios--that such schemes could ultimately become too expensive for the country as a whole to afford. I wait, with great interest, to learn exactly where the Government are going on that crucial question of financing.
I shall now discuss the caring services that should be provided. There is no doubt that examples of good practice in the provision of long-term care should be publicised more widely and that there is a need to expand the scope and quality of domiciliary, rehabilitative and respite care. In my view, that would benefit the individuals concerned and be likely to be more cost- effective for the funding authorities. Greater attention should also be paid to the need to improve housing facilities for the elderly and the disabled and to achieving more effective liaison between housing, social services and health authorities.
Housing improvements can offer a happy conjunction of cost-effectiveness for the providing authorities and improved quality of life for those who inhabit the housing. It is important that housing services fully exploit their potential for contributing to the Government's community care objectives, particularly with regard to the development of very sheltered housing schemes and ensuring that ordinary sheltered housing schemes are attractive to current and future generations of users. For example, account should be taken of the wider development of collaborative schemes such as those in respect of community care alarms.
We are all aware of the anomaly whereby it is possible to receive free nursing care in some situations but not others. Nursing care is free in hospital and at home, but citizens pay for it if they have to go into a nursing home. That creates all sorts of barriers to achieving seamless care. However, the cost implications of any changes to that situation must be taken into account for any comprehensive provision of nursing care. A number of colleagues have commented on those implications, and again I await with interest the Government's decision on an important issue.
I should also like to raise the question of under- resourcing by social services departments for independent sector placements and the resulting pressure that that is putting on the sector. My hon. Friend the Member for Runnymede and Weybridge (Mr. Hammond) has already commented on that issue. There is no doubt that many people who have been assessed as needing residential care are being forced to wait on a waiting list while some local
authorities persist in wasting money on direct provision of care that is often more than 60 per cent. more expensive to provide than comparable or even better care provided by the independent sector. Surely that cannot be an acceptable way to proceed and I should like the Minister to tell the House what action he is taking to stop that practice.
As chairman of the all-party hospice group, I should like to make a plea on behalf of the hospice movement and its involvement in long-term care. The Department of Health, in circular EL(96)85, stated that the palliative care approach should be integrated into the routine clinical practice of all health care professionals in the NHS. The hospice movement believes that that principle and policy objective should be extended to all long-term care in the private and voluntary sectors.
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