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5 Jun 2008 : Column 971

Mr. Lewis: I give way to the hon. Gentleman.

Mr. Lansley: I am grateful to the Minister, as clearly he is not going to move on to talk about the relationship between health care and social care in personal budgets. Does he agree with me that, given that we are trying to have more co-ordinated commissioning and to break down the barriers between health and social care, it is important—contrary to what the Government said in their White Paper of January 2006, with which we disagreed—that we look to develop opportunities for health care, where it is predictable and stable over time, to be added to social care budgets and managed as a personal budget?

Mr. Lewis: I am absolutely delighted that the hon. Gentleman has supported the recent statements from the Prime Minister, the Secretary of State and Lord Darzi that we ought to use personal budgets as a potentially powerful vehicle to break down the Berlin wall between social care and health care. Lord Darzi said in his interim report that we now need to consider that, and in his final report he said that we need to spell out clearly how we believe it should happen. There is absolutely no doubt, particularly for people with long-term conditions, for example, that over time, the obvious solution for many of them will be to bring together streams of health funding and social care funding in an individual budget that is focused on their personal needs. We need to go about that carefully and to get it right, but I agree entirely with the hon. Gentleman that that is inevitable and, as I said, I am delighted that he endorses the views of the Prime Minister and the Secretary of State.

It is also important to say that we have a new system of local area agreements that is bringing together local government, the health service and the voluntary sector at local level. It is interesting that local authorities have voluntarily identified social care—particularly self-directed support, personal budgets and the needs of carers—among their top priorities for local area agreements. That will also ensure that we have much better joint working at local level.

I have asked the regulator, the Commission for Social Care Inspection, to conduct a review of the eligibility criteria that govern social care. We all know that there is inconsistency of access to social care services both within and between local authority areas, so later this year CSCI will report to me on how we can adopt a more acceptable approach to eligibility criteria. We recently announced the extension of our dignity in care campaign—I am delighted that Sir Michael Parkinson has agreed to be our dignity ambassador—and we will go around the country focusing on this issue. It seems to me incredibly important that in every care home, on every hospital ward and in every domiciliary service, people debate every day what dignity and respect means for older people in their care. There is a limit to what Government can do from the centre, but if nothing else, we can provide leadership and ensure through commissioning and policy, as well as through the things that we say and do, that respect and dignity are seen to be important.

Susan Kramer (Richmond Park) (LD): I really appreciate the Minister’s giving way and I apologise for not being here earlier. I was listening to the debate
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upstairs, and I came to the Chamber because I did not hear a subject that I am concerned about being covered. The Minister talks about dignity; let us consider elderly patients with dementia and their treatment in care homes. As he will know, my hon. Friend the Member for Twickenham (Dr. Cable) and I have lost the battle to keep open the flagship facility at St. John’s hospital, which deals with such people. We are finding that all the alternatives use a chemical cosh to control people with extreme behavioural problems, which surely is not acceptable to anybody in this House. Will the Minister address that issue in the remainder of his speech?

Mr. Lewis: It is very kind of the hon. Lady to join us and I agree entirely with the point that she makes about people with dementia. I pay tribute to the hon. Member for Sutton and Cheam (Mr. Burstow) for the significant work that he has done to get this issue up the political agenda. That is why, this autumn, the Government are launching the first ever national dementia strategy. We will focus on a number of issues: not only early identification of the symptoms and appropriate diagnosis and referral, but the quality and nature of care that people with dementia receive. We will also focus specifically on the question of inappropriate medication, which is obviously a concern not only to us, but to many families. We have to be careful not to exaggerate the scale of the problem, but it is clear that medication is being used inappropriately—to suppress people, rather than to treat them appropriately. That cannot be acceptable in the context of dignity, or of a civilised society and best professional practice.

Mr. Kevan Jones: Does my hon. Friend agree that although many families want to keep dementia patients and people with Alzheimer’s at home for as long as possible, there comes a point when they cannot cope, and the health service needs wards and other facilities for people with challenging or difficult behaviour resulting from their condition? Does he also agree that in places such as Durham, where the local trust is closing down such wards, people will be left in a very vulnerable position?

Mr. Lewis: I agree with my hon. Friend. What is important is that in Durham—I would be happy to talk to him in more detail about this—the local authority and the primary care trust come together to ensure that the right continuum of care, from home-based support to day care, respite care and full-time care, is provided in that community. Some of that care—the full-time care—can be provided in residential and nursing settings. Some of the people concerned will have acute health conditions and might require acute NHS accommodation. From my experience of having, unfortunately, spent some time sat on an acute ward because of a family member’s illness, I know that an acute NHS ward is not the best place for most older people with dementia.

The right relationship between the NHS and local government needs to be in place to ensure that enough places are available in nursing care, so that those people receive the quality, dignified and specialist care that they require. That is one of the issues that the national dementia strategy will specifically address, but, as I say, I would be happy to talk to my hon. Friend about the situation in Durham.

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Jeremy Wright: The Minister will anticipate part of what I am about to say. He rightly says that the right place for these very vulnerable individuals to be is not an acute medical ward. Let us suppose that the right place is the proper type of care home with the necessary staff and resources to deal with their condition. Would it not be true to say that those people also need to be provided with some medical support from a specialist mental health team, and that such teams should come to care homes more often than they do now to offer support to the staff in those homes?

Mr. Lewis: Again, I pay tribute to the work that the hon. Gentleman has done on the all-party dementia group. He is right to say that we need a combination of getting universal services to be far more sensitive to the needs of people with dementia and their families and, equally, ensuring that providers of those universal services have access to people with specialist knowledge and expertise. That will be one of the key objectives of the national dementia strategy. In some circumstances, care workers will not have the professional expertise or qualifications to deal with people in the necessary way, so the national strategy will examine that.

Mr. Paul Burstow (Sutton and Cheam) (LD): I am grateful to the Minister for giving way, because I appreciate that he wants to conclude his remarks. I just want to ask him whether the national dementia strategy will come with some indication of how resources will be redirected and what additional resources will be applied to deliver it. For example, if inappropriate medication were used less, resources could be unlocked to invest in the training of staff, so that they could provide the extra support necessary to deal with the challenging behaviour encountered in many care homes.

Mr. Lewis: Of course resources are an issue; we must always consider whether we are using existing resources to best effect and whether we would ultimately save money if we shifted money to prevention and early intervention. All of those matters have to be addressed. I say gently to the hon. Gentleman that not a moment goes by without a Liberal Democrat making a spending commitment on the Floor of this House and in a “Focus” leaflet, but such commitments are never costed. The problem with being in government is that all spending commitments have to be costed. Of course, the question of resources has to be addressed.

I come to other issues that we are addressing this year. We are reviewing the “No secrets” guidance, which deals with the protection of vulnerable adults. We want to ensure that we have the right protection framework in place for vulnerable people. It is important to get the right balance between allowing people to exercise maximum control over their own lives and protecting people who may be very vulnerable. It is also important that the adult protection framework reflects the move towards direct payments and individual budgets, so that we do not end up in a contradictory position.

I have mentioned that we will announce soon a 10-year strategy to support the 6 million people who are carers. We are also consulting on the independent living strategy for disabled people. This debate is inevitably skewed towards the needs of older people,
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but we should not forget that the challenges we face concern all adults, and disabled people now have the right to expect equality of citizenship, independent living and full lives. I am proud of the progress that the Government have made on ensuring that disabled people have the opportunities that the rest of us take for granted.

I recently announced a specific study on adults with autism and Asperger’s syndrome—another area that needs to be brought out of the shadows. We have long debated the fact that a growing number of children have autism, and we need to do more to support those children and their families. The Government can be proud of our “Aiming high for disabled children” commitments and reform, and of the record levels of investment, which will expand short breaks over the next three years. All those children with autism will grow into adults, and we know that the choice for many such adults is between learning disability assistance or mental health services. However, many adults with autism or Asperger’s have neither learning disabilities nor mental health problems, so we need to ensure that we have the right policies in place to support those adults.

In the next few weeks, we will announce a significant renewal of our policies for supporting adults with learning disabilities to achieve the maximum possible quality of life. We have made much progress since the “Valuing People” White Paper, but we have not made much progress on access to jobs and employment. Many people with learning disabilities, if given the right support and chances, could hold down a job, and it is scandalous that neither the private sector nor the public sector is doing enough to ensure that more jobs are available for people with learning disabilities. I hope that we can see a commitment from both sectors to work together on a specific push to open up job opportunities for people with learning disabilities.

I am pleased to say that we are joining forces with four national charities in a £80 million campaign over the next four years to focus on the issue of stigma and mental health, which remains one of the biggest barriers in our society to people having a decent quality of life. The statistics are clear: mental health issues touch the vast majority of families, but the stigma remains, which is why I welcome the fact that an increasing number of well known figures have been courageous enough to talk about the fact that they have struggled with mental health problems at some time in their life. That is important for people who are struggling with a mental illness, but who do not feel able to seek professional help. That can lead to dreadful consequences, as we are all well aware. My hon. Friend the Member for Bridgend (Mrs. Moon) is doing remarkable work in relation to the tragedies in her constituency—the issues are difficult to cope with, and we are not quite sure what is happening in that community—and trying to ensure that young people feel able to open up and seek support if they are struggling with mental health problems.

This year, for the first time, local authorities will be required by law to carry out joint population needs assessments. There is a growing emphasis on the importance of joint commissioning. Lord Darzi will produce his report on the future of the NHS. For many patients, it is the connectivity between the NHS, local
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government and the voluntary sector that determines their health and well-being, so as Lord Darzi maps out the next stage of the NHS’s reform programme, it is important that we make those connections and encourage and support integration. The other place is now debating the creation of the new regulator to bring together the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Commission.

I shall end on the subject of the Green Paper on the long-term future of care and support. Both sides of the House are united in believing that we have to address this as a country and as responsible parliamentarians. First, the Green Paper is not just about older people, but about all adults who need additional support to have the best possible quality of life and to live independently in our society. Secondly, it is not about tinkering with the adult social care system, but about an entirely new vision for a care and support system that can respond to a changing society.

We are all aware of the nature of the challenges: demographic change, demand and affordability. We need to answer the financial question about how we will cope with demographic change and rising demand for these services. How will we respond to changing aspirations? An increasing number of people want care in their own home rather than in institutions, but our generation expects high-quality care and will accept nothing less.

We need to tackle the “no help here” culture, where people are told that if they have £21,000 a year or more, there is nothing that we can do to help them to choose care and make difficult choices. If someone goes to the local authority and says, “My mother is lonely and isolated. She is not getting out very much and does not have many visitors to her home,” they are told that that is a loneliness problem and a low-level need. We need to do something about the notion that people’s loneliness and isolation are nobody’s responsibility. We have to tackle the Berlin walls between health and social care and between health, local government and the voluntary sector.

Roger Berry (Kingswood) (Lab): Is my hon. Friend also prepared to consider the Berlin wall between local authorities? Are the Government considering making care and support packages portable from one local authority to another?

Mr. Lewis: My hon. Friend raises an important point. A person for whom I have a tremendous amount of respect, Baroness Campbell—a tremendous champion for the rights of disabled people—is proposing some amendments on that subject to the Health and Social Care Bill in the other place. There is certainly an issue about the possibility of retaining the level of support in the short term when someone moves from one local authority to another, while the local authority carries out the necessary assessment processes. The more fundamental issue is that, as part of the debate, we have to resolve what should be universal and what should be subject to the discretion of local authorities and local PCTs. That will be central to creating a satisfactory new care and support system. Unlike in the NHS, there has
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been a massive amount of devolution and localism in social care. One of the challenges for the long-term review is what should be universal and what should be subject to local discretion. Of course, we also need to address the questions of the means test, the threshold and, as I said earlier, the group of people who work hard, play by the rules, do the right thing, are not rich, are not poor and feel that the system is unfair to them.

In the end, the responsibility must be shared between families, public agencies, the voluntary sector, the private sector, where appropriate, and local communities. People are absolutely clear about what they want and expect: independence, control, flexibility and, increasingly, personalisation. As the debate rages, it is important to focus first on the quality and the system that people want. We then have to address the difficult question of the respective financial responsibilities. What is it right to expect the state to fund through general taxation? What is it right to expect of families and of individuals?

Every party in this House accepts that the responsibility has to be shared. There are no easy solutions. The debate needs to be about fairness, transparency and affordability. How do we get a system that is seen to be fair, that is clear and that the country can afford in the long term? This is about not only the cost, but the benefit. In the end, we spend a significant amount of money on caring for people when they have deteriorated because the money is in the wrong place in the system. There is a debate about how we can shift money from the acute end of the system to the early intervention and prevention end of the system, so that we prevent people from deteriorating in the first place.

No party in the House now advocates—one party did so for some time—that, for example, free personal care should be a reality. The debate is about the respective responsibilities of the state, the family and the individual. The Government would genuinely like to achieve consensus in the same way as we achieved it on pensions policy. It is a shame that the Conservative party has begun to move away from that consensus to some extent. It would be in the country’s interests if we could achieve long-term sustainable consensus on the system, but of course that is not totally in my control.

Finally, I am delighted that we have had the opportunity of the debate. I look forward to hearing the contributions of right hon. and hon. Members. The provision of care and support is one of the great issues that face our society. Perhaps more importantly, an increasing number of families are struggling daily to cope with the realities of ensuring that their older relatives who suddenly become ill have the dignity and respect that they deserve and the maximum possible quality of life. It is our responsibility to come up with the solutions, but we need to do so in partnership with families and local communities.

2.50 pm

Mr. Stephen O'Brien (Eddisbury) (Con): I am very glad that we have the opportunity to debate this crucial area of public policy on the Floor of the House today. The assumption is that between one in three and one in five of us will need some form of long-term care, with about one in 10 of us needing to live in a care home.
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About a fifth of those who need long-term care will have some form of dementia. Two thirds of the care home population have some form of dementia, and that is likely to continue.

I immediately take the opportunity to pay tribute to my hon. Friend the Member for Rugby and Kenilworth (Jeremy Wright), who has done such an enormous amount in establishing and taking a big lead in the all-party group on dementia and in giving great advice in authoritative reports to hon. Members in all parts of the House.

What was estimated to be a £14 billion gross spend in 2006-07 is forecast to double to between £24 billion and £31 billion, depending on the decisions that we make now. In addition, the baby-boomer generation, having put its parents through the system, is about to go through the system itself. The national feeling is that those who have done the right thing in paying their stamp, scrimping together hard-earned savings in cash or assets, paying off their mortgages if they had them or sacrificing some lifestyle choices in their earning years to build and earn pensions and are now on ever-threatened fixed incomes—particularly in view of the current rising cost of living—are very anxious as the consumers of long-term care, as are their families. As the Minister said, they are the ones who are unlikely to settle for a system that is perceived as either unfair or inadequate.

This key issue is growing in the minds of English people—technically, given devolution, they are the people we are talking about today, but it is fair to say that the issue has a strong read-across to the other parts of the United Kingdom—partly because of their own experience and partly because of increasing media interest. I single out and congratulate in particular the Daily Mail on its dignity for the elderly campaign, the Daily Express on its respect for the elderly campaign and, indeed, the BBC’s “Panorama”, “File on 4” and “Today” programmes on raising the profile of the issue. I join the Minister in accepting that, when the media have been responsible, they have indeed helped to highlight the issue.

Mr. Ivan Lewis: It is reassuring to hear the hon. Gentleman describe this as one of the most important issues that we face. The leader of the Conservative party established a working party on social care. Will the hon. Gentleman tell me how often that working party has met and whether it has reached any conclusion?

Mr. O'Brien: The great advantage of working parties is that they advise our party, and I hope that they greatly benefit what we are doing. That working party met very frequently, covering not just social care but health, housing and education. Of course it would be completely wrong to single out any of those parts. The Minister must know, from the research that I dare say he jumped up to try to read into the record, that the working party has met numerous times. It is important to recognise that we are all spending a lot of time and effort trying to understand and grapple with the issue that faces all of us and that is very much on the minds of the people we represent.

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