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None the less, we are debating the structure of care reform. There are two serious problems with some of the options presented in the Green Paper. First-I will
not go on at great length about this because we debated it in Opposition time last Tuesday-there is serious difficulty with the Government's intention to integrate disability benefits into the National Care Service funding. Of course, the Government did a U-turn last Tuesday and completely changed the proposal to integrate for current benefit recipients. It is fascinating that the Government are now proposing that over-65s who receive attendance allowance-let us say £60 a week on average-and disability living allowance should have that money taken away, so that it can be given to the local authority and then given back to them to spend in exactly the same way.
Mr. Lansley: Apparently that will happen with no loss in transaction costs in the process. That is absurd. We know why the Government have ended up in that position. Under pressure, they did a U-turn but, to put it gently, it has left them looking very exposed.
For the longer term of the introduction of the reforms, the Government intend to integrate those disability benefits to pay for the up-front, universal entitlement to care. The effect would be to take away a cash benefit that recipients can use to meet a range of needs and costs and to substitute a care package. From our point of view, that remains unacceptable. We need to buttress and strengthen the right to control, and to personalise, care services, and continuing access to a cash benefit remains important for that to happen.
In response to the Secretary of State's statement on the Green Paper in July, I said that it is important to reach a common assessment of need-one that informs the non-means-tested cash benefit and the means-tested or insurance-funded social care entitlement. As with the extension of personal health care budgets, care users need the assessment process overall to become simpler and more integrated, for the resulting budgets and assessment processes that arise to be applied flexibly to meet their needs, for there to be a choice of providers, and for the assessment of need to be portable, as people will inevitably move around the country.
Mr. Lansley: Yes. In simple terms-I shall repeat the language I used-I am talking about an assessment of need; it is not an assessment of entitlements. Of course, entitlements will depend, nationally, on a cash entitlement on the one hand, but on the other on a local authority's decision and discretion about what it provides for what level of need. However, a single assessment of need seems to me to be perfectly understandable. Perhaps the Secretary of State should explain that to his former colleague, and I will come to what the noble Lord Warner said in another place in due course.
"We need a more bipartisan and coherent approach than is provided for in this Bill...I am resigning myself to the fact that many of us will have to try to make the Bill more sensible and realistic about costs and funding arrangements",
"Good places to start would be some national rules on service eligibility criteria to avoid a postcode lottery and making local assessments of individuals portable to other areas."-[ Official Report, House of Lords, 26 November 2009; Vol. 715, c. 541-42.]
The second difficulty with the Bill is that the Government just do not seem to have an idea of how many informal self-funders there are. The Local Government Association, in its response to the Bill, said:
"We are concerned that the actual number of beneficiaries (and therefore costs) could turn out to be very different from the Government's estimates. The Impact Assessment which accompanies the Bill provides little reassurance. We are particularly concerned that the estimated number of people with high care needs who self-fund their care may be too low."
"We need to see exactly who will be helped as a result of free personal care at home. To this end, the following areas require further definition...what are 'critical' as opposed to 'substantial' care needs, what 'personal care at home' will cover in full, when the NHS should step in and fund the care."
"We would like clarification about the definition of personal care at home, especially when services described may be better delivered outside the home or where personal budgets are currently used to deliver similar outcomes. There is significant uncertainty about the true costs of the proposals as we do not know how many people who do not currently receive services might come forward."
That is why we cannot have any confidence about what the cost of this Bill will be. By their own admission, the Government have nothing other than a gross estimate-a generalised estimate-of how many people are receiving informal or family care, or who are self-funding but not using council-arranged care. The evidence from Scotland demonstrates that large numbers of those people start to become claimants of free personal care if it is offered to them.
"The Government's view is that the Bill has little overall effect on public sector manpower and public expenditure."
So £670 million-on the Government's estimate-is of little effect. Convert that figure into dollars and we really have arrived at a billion here or a billion there. Soon that adds up to real money, but that does not seem to matter to the Government.
Where will that money come from? In response to an intervention, the Secretary of State seemed to be completely unable to explain why, in last week's pre-Budget report, what should have been represented as a £200 million transfer from the NHS in England into the Department
of Health's expenditure simply does not appear in the Red Book. I am astonished that the Secretary of State could not explain that. He was at pains to mention the "myths" about where the money would come from, so perhaps he can explain where it will come from. He has been quoted as saying that some £60 million of it will come from "lower priority research projects". Which are these lower priority projects? Which such projects did the Government see fit to fund in the first place?
I have seen a long list of research projects, and the Government used to make considerable play of the fact that they had increased the NHS research and development budgets. Which advertising campaigns will the Secretary of State stop to pay for this Bill? Will it be tobacco control, the current swine flu campaign, next year's seasonal flu campaign, the sexual health campaigns or the Department's contribution to "Frank", the drug campaign? And which local authority activities will contribute the £250 million? On the face of it, the Government are arguing that it will come from a reduction in residential care home payments, but the impact assessment does not suggest that anything like that number of people will switch from residential care. The Department think that only 2,700 people would transfer from residential to domiciliary care.
Nor does the Green Paper offer a credible way forward in relation to insurance funding. The compulsory process is not really a basis for consensus because, in effect, it would just transfer into compulsory insurance something that would, to all intents and purposes, be just a taxation per head. Compulsion and tax amount to much the same thing.
Mrs. Lait: Would my hon. Friend be prepared to speculate on the cost of staffing for the intensive rehabilitation that will be required, including new occupational therapists, physiotherapists and psychologists?
Mr. Lansley: There is no evidence in the impact assessment that any of this has been thought through. All that is included by way of costs is the Government estimate that it will cost £1,000 per person, made up of 30 hours at £30 an hour. But Governments wishing to provide additional services have to think about the inclusive costs. They cannot say that the marginal cost of trained staff is £30 an hour, because they have to think about the average costs over the long run. They have put marginal costing in the assessment on the basis that, magically, all those staff would be available from October 2010. We know that that will not necessarily be the case.
It is important to be clear about what we want to see forming part of this consensus. I do not wish to give the impression that we oppose everything about this Bill-or its purposes. We have made it clear that we need a much more preventive focus on the shape of social care for the longer term. The NHS and local authorities can and should come together to deliver better preventive services. Those should not be confined to reablement, and the measures that often work best-as we have seen from examples-are telecare, telemedicine and home adaptations, for example, which are being done early rather than just waiting until people have had falls or operations and have to be discharged home.
Much of the care given to the elderly in their own homes is by relatives, who are often excluded from being paid for undertaking that service. Is there
not a danger that some of those relatives will use the Bill as an opportunity to withdraw and allow their contribution to be picked up by paid people? Is there not an argument that spending money on respite care for relatives might be a cheaper and better option than paying for the salaries of staff caring in people's homes?
Mr. Lansley: My hon. Friend makes a very good point. We need to guard against the risk of diminishing the contribution that informal and family care can make, as that can often give the care recipient the greatest sense of security and well-being. That is why my right hon. Friend the Leader of the Opposition and I have been so keen on the extension of emergency and planned respite care. The money that the Princess Royal Trust said had been allocated by the Government has not all got through, but it is important that it is used for that purpose. The big picture, as I was saying, is that, wherever possible, we have to give care recipients and their families the opportunity to use personal budgets to help to make that happen. The Secretary of State talked about direct payments, but they are used in a very small minority of cases-some 4 per cent. of total adult care recipients. That is a very small start. It is important that we develop the concept of personalisation and bringing those budgets together to make it happen.
Norman Lamb: Returning to the costing of reablement, the hon. Gentleman described costing as taking place on the basis of a certain number of hours multiplied by the number of people who will benefit. Is it his understanding, as it is mine, that there is no assessment of the cost of adaptations or of equipment, telecare and so forth, which may well be a fundamental part of the package of reablement to enable the person to remain at home? That appears to be out of the equation.
Mr. Lansley: Yes, the hon. Gentleman is absolutely right-there is no reference to that. Indeed, this is one purpose of the proposals that we have been discussing for some years: creating a public health service that operates with dedicated funding for public health from within the NHS, and, indeed, local authorities working together.
More recently, the hon. Gentleman's party has joined in with the concept. Of course, this is precisely where we can begin to consider some of these programmes: the benefits accrue not only in the community at large and to those families, but to local authorities and the NHS, which makes a good case for investment on the part of the public health service as it is not simply confined to the question whether it offsets hospital admissions. That is often the narrow basis on which the NHS judges these things.
We have seen programmes such as a telecare programme in Scotland that achieved savings of £11 million from 7,900 older people and an improvement in their reported quality of life; a community alarm service in Birmingham that showed a substantial return on investment and reduced residential care need; and telecare schemes for frail older people in north-west Surrey, which showed that telecare focused on safety and security reduced the number of people entering residential care by 11 per cent. in the fifth year after implementation.
Those are not necessarily reablement examples. It is important for us to consider these preventive opportunities on their merits, through evaluation, and to implement them as part of a proactive public health service. I am surprised at the narrowness of the Government's approach to reablement alone. I am also uncertain as to why they see it as necessary to link access to free personal care to an obligation previously to have agreed to a reablement process.
As I mentioned, partnership is clearly a necessary part of the consensus that we now need to pursue. From my point of view, that includes local government. Frankly, central Government should treat local government as a partner, which means consulting on such approaches and saying to local government, "On average, across the country, you are paying 40 per cent. of the cost of adult social care. We will treat you as a partner and discuss how we will reform this for the longer term, recognising that council tax payers and their elected representatives provide a substantial proportion of the funding, and in many local authorities more than 50 per cent. of the funding, for social care."
In those circumstances, it is outrageous that the Government published a Green Paper in July and then said something completely different in September, the implication of which was that local government would simply have to pay up or be taken to court.
Mr. Hayes: Surely my hon. Friend is not suggesting that the Secretary of State has neither sought nor received representations from local authorities? It is inconceivable that he would move ahead with such speed without showing that diligence, for, as my hon. Friend suggests, this will have considerable repercussions for local authorities of all political flavours.
Mr. Lansley: Just to help my hon. Friend, I should say for the record that he speaks in an ironic fashion-and so the record will show. I do not know whether the Secretary of State had any choice in the matter, and I am not sure that the Prime Minister intended that local authorities would have much choice.
The consultation has gone out. It is not about whether the Bill should be introduced or its principles; nor is it based on its economic modelling. It is not based on the underlying argumentation. The consultation is based on a practical question: if the Government are to distribute money for this purpose, is it best to do it on this measure of need, or that measure of the number of older people with particular characteristics? That question is perfectly reasonable; it just assumes that local authorities have no say whatever in whether the service should be provided or how they should exercise discretion about it.
It seems to me that a consensus is available, if the Government wish to proceed on the basis of consensus. There is a consensus on the necessity for prevention and preventive processes. Therefore, we agree that reablement should indeed form part of these proposals, but it should not be the only preventive measure. There is a consensus on personalisation, but much more needs to be done. We see access to cash benefits as an essential part of that. There is a need for partnership-in our view, a partnership with local government, with discretion for local government in deciding how council tax payers' money is used. That is essential. The Green Paper itself says that if elected representatives are to decide how
council tax payers' money should be used, they must have some discretion in that. From our point of view, that partnership should also include the opportunity for people to protect their home and their assets through a voluntary process of insuring against those risks.
Does the Bill provide any of those things? Not too many. I say that the Bill might be flawed because its stated purpose is to provide free personal care beyond the six-week point. I did not notice the Secretary of State explaining the Bill in these terms, but let us get to this point. The Government are proposing virtually to abolish consideration in Committee, so we might as well have some of that debate now.
The Government propose the abolition of the six-week limit on the time during which free personal care can be provided at home. Simply removing the limit would allow free personal care to be provided to people whether they were at home or in long-term residential care, but the Government have introduced a further restriction in clause 1(2), whose effect is that this will not apply
"to a person living in accommodation that an establishment provides to the person together with the care".
The Government argue in the explanatory notes that the restriction means that people living in care homes will not get access to personal care. I put a perfectly reasonable question to the Secretary of State, which he did not satisfactorily answer: why are people who go into long-term residential care with high care needs to be discriminated against in this way, compared with people who stay at home? None the less, we shall leave that question on one side.
For the sake of argument, let us say that there is a legitimate distinction to be drawn. However, the Government then say, "But people who live in sheltered accommodation or extra care housing are not to be excluded." We have arrived at the position where they say, "Why is this so?" On extra care housing, the explanatory notes state:
"The accommodation and care provided in such accommodation are not provided together but under separate arrangements made by the individual."
Fine. We know what is going to happen, do we not? As soon as legislation of this kind is introduced, large numbers of care services providers that currently make provision by way of a single contract with people-one that provides accommodation and care together-will suddenly find it necessary, no doubt for business reasons, to provide different, separate contracts for accommodation and for care services.
Providers will say to the Government, "If people are in extra care housing and they have two contracts, one for care and one for accommodation, they are eligible for free personal care that pays for their personal care needs. I am a care provider. I have a contract for accommodation and a contract for care services. I want exactly the same services provided to me." For the life of me, I cannot see how that evident flaw in the legislation can be reconciled. At best, we will end up with an enormous distortion to the care market, with large numbers of care providers recreating their services so as to distinguish between accommodation and care.
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