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3.27 p.m.

Baroness Seccombe: My Lords, first, I ask the indulgence of the House. I am afraid that I am unable to observe the convention of the House in remaining in the Chamber for the entire debate. I have a long-standing commitment so I shall have to leave early. I have apologised to the closing speakers, and especially to my noble friend the Minister.

The debate on continuing care is part of a wider debate on community care in general, which affects many stages of our lives. This afternoon, however, I shall concentrate on care for the elderly. I start by addressing two common misconceptions.

First, community care is not a new concept. For many years and in many circumstances care has been provided for people in their own homes, or in homely surroundings in the community. But it has increasingly been recognised that long-term institutional provision, particularly in geriatric wards in hospital, may often be

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degrading and dehumanising. Providing appropriate care for elderly people in the community, properly financed and properly organised, is, I am sure, an ideal towards which all of us would wish to aim. We live in a compassionate country where we value choice for our elderly relatives. Living in their own home or in homely surroundings is, for many, vitally important.

Secondly, when care is provided in the community that does not exclude the possibility of it being provided by the health service free of charge where there is a need for health care. The 42,000 NHS community nurses working across the country would, I am sure, confirm this; as would the 1½ million elderly people who are treated by those community nurses every year and the many who receive health care in a residential setting.

As noble Lords will be aware, earlier this year the Government published draft guidance on continuing care. This made it clear that the NHS has, within available resources, an ongoing responsibility to meet long-term health care needs—including the needs of people who require continuing care from the NHS in a residential setting or in the community rather than in a hospital.

Clearly, people's individual needs for care differ, but their general requirements remain the same. In each case, they require a full assessment of their needs. They need a clear decision on whether they require continuing NHS care —a decision based on a clinical judgment—or whether they require social care. Also, they require information and advice on discharge procedures and on options for long term care. These requirements were set out in the recent guidance. It stressed the need for health authorities and local authorities to work closely together. Contrary to general belief, it did not change the responsibilities of the NHS to provide continuing care, but sought to reinforce and clarify existing responsibilities. Indeed, I understand that working relationships between health authorities and local authorities have already improved recently, as a result of the agreements which have been negotiated between them as part of the community care reforms.

Nevertheless, the distinction between health care, which is provided free of charge by the NHS, and social care, provided according to means, has been in existence since the foundation of the welfare state. The House may be aware—certainly noble Lords opposite must be aware—that it was a distinction recently endorsed in principle by Labour's Social Justice Commission.

But there is also a third sector which provides care for elderly people: the voluntary sector. Many of us throughout our lives are conscious of the great kindness and support given to those who live near and are in need of a helping hand one way or another. I should like to pay tribute to those who give so generously of their time and love.

I have been deeply impressed by the very valuable work done by young people, who are often still at school; and more and more retired people care for a parent in their 80s or 90s. But many elderly people reach a stage where more formalised care is necessary and

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this is where residential care plays its part. Clearly, it is essential that their needs are assessed without the ethos of care becoming lost in bureaucracy.

Local authority social service departments have willingly grasped the nettle of organising such assessments and arranging for services to be provided. In most cases good progress has been made. But, as in the case of any new initiative, some local authorities may have faced a few teething problems.

I have recent experience of looking after an elderly relative. I found the rigidity of the system a little difficult; for example, those requiring help with getting ready for bed may be forced to accept it at any time between 6.30 p.m. and 10.30 p.m. In such circumstances nothing can be arranged for the evening, which consequently can be lonely and miserable. Clearly, greater flexibility may be required.

There has been much publicity over funding for community care. Some local authorities claim that they have exhausted their funds at this stage of the financial year. I read that with some amazement. The amount available for social services spending in this financial year, including community care, is £6.4 billion, which is nearly double the amount available four years ago and an increase of 48 per cent. in real terms. No other area of local government spending has increased nearly so rapidly. It is up to local authorities themselves to discharge effectively their new responsibilities—responsibilities for which they have long campaigned.

However, I am confident that in working with the health service and the independent sector they will be able to move us towards the "seamless service" of health and social care, provided according to individual need, which we all seek.

3.35 p.m.

Baroness Hamwee: My Lords, I thank the noble Lord, Lord Ashley of Stoke, for introducing this very timely debate. I am glad to have the opportunity to look at what care in the community should mean and how it can be paid for. I believe that it should mean encouraging independent living, where that is practical, and particularly facilitating an informed choice for users. I include carers among the users. It should mean enhancing the development of communities, so that the designation "care in the community" can be given real substance. It is a concept that we on these Benches support.

It is ironic that so much effort was put into debating whether or not community care budgets should be ring-fenced. Would that the cash were there and that it were now a material issue. The noble Baroness, Lady Seccombe, spoke of social services departments "claiming" to have exhausted budgets. The claim is a very real one.

I too see the matter somewhat from the viewpoint of social services. Like the noble Baroness, I believe that the provision should be a seamless provision—both health and social services—and that the right perspective is the perspective of the user. We know of ministerial statements that there are no changes in policy but we must all also have encountered the wide perception that in fact health care boundaries are

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shifting, leading to greatly increased demands on local authorities. The reduction in waiting lists, day surgery, the management of performance related to throughput and contracts concerning the volume of patients must all have their effect.

If there is to be less structural cohesion between health and social services—by that I mean the use of the local authority structure to bring health services into local democratic control and locally accountable—then various issues must be addressed: issues about defining the boundaries of responsibility; issues of quality, such as where very ill people want to be; and there must be the maximum of openness and clarity with patients and carers on the services that they can expect and the financial contributions that will be required of them. It seems to me that one of the tragedies of the current situation is that the relationship between the NHS and social services departments must tend to be less collaborative without enormous efforts to be more so.

The debate is about financing. That includes financing by individuals. There is an increasing tendency of the NHS to define its boundaries as relating to those who are acutely ill. As the noble Lord explained, costs going to local authorities means the covert—I do not use that word with any sense of malice but it defines one of the hidden effects —withdrawal of free health services and in their place a charged means-tested service. I accept that care at home or care in a nursing home—many nursing homes are homes—is often more acceptable than care in hospital; but that care should be accessible.

It seems to me from a local authority perspective that increasingly services provided by local authorities are not necessarily provided most cost-effectively or appropriately. Let me mention domiciliary care. Too often those who provide domiciliary care—those at the sharp end—were originally home helps. They have had a little training but the strain on them in undertaking what is increasingly a nursing function must be enormous. Of itself, that will lead to a vicious spiral in recruitment. On the other hand, nurses are trained not just to give direct health care but to diffuse emotion and counsel when there is a bereavement. We need to review the use of our resources overall.

Over the past few days I have asked colleagues what might come positively from the current crisis. Sadly, I have not found any real, positive, constructive ideas—and this is a crisis. Indeed, the only sentiment that I can identify is that, among the public, who think that local authorities should put all their efforts into picking up litter and dealing with other important but perhaps more minor matters, there may be a greater understanding of the emphasis that local authorities will have to put on social services care.

I conclude with a thought that was put to me at a meeting last week by a representative of a carers' organisation. Among those for whom we need to care—not all, but a part of the client group—are elderly people. They come from a generation who thought that their national insurance contributions would fund their care; who fought the last world war or are the widows of people who fought the last world war. This year we

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commemorated the Normandy landings; next year we shall commemorate VE Day. The Royal British Legion act of remembrance ends,

    "We will not break faith with you".
Let us not do so.

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