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5.34 p.m.

Baroness Cumberlege: My Lords I am very grateful, too, to the noble Lord, Lord Ashley, for raising this very important subject for debate this afternoon. Like the noble Baroness, Lady Jay, and other noble Lords here this afternoon I hope that his courage will be rewarded and that he makes a speedy recovery. I am also very grateful for the very thoughtful contributions that were made by many of your Lordships who I know have personal expertise and experience in this particular field. I will try to respond to the various points which have been raised.

The noble Lord, Lord Ashley, is right in highlighting that, ever since the creation of the welfare state, there has been a division in responsibility between the National Health Service and local authority social services—a division between people who need medical and nursing expertise and those who need support and help with everyday activities. Ever since the creation of the welfare state, people who have been cared for by the NHS have received clinical care free at the point of delivery, while social services have been able to seek contributions towards the cost of care, and have done so, from the people who can afford it.

As my noble friend Lady Seccombe reminded us with her usual clarity, this boundary between health and social care is not new. It has been well recognised and has been part of our system since 1948. Although sometimes difficult to define, it is recognised by those responsible for planning, purchasing and delivering

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care. It has been recognised, too, by governments and by other commentators. Indeed the recently published report of the Social Justice Commission established by the Labour Party with some Liberal Democrat membership states that:

    "Although the dividing lines between treatment and care can be difficult to agree, the distinction offers the basis for a clearer approach to funding."

nd it goes on to say:

    "Given the many demands on resources, however, it is not feasible to extend the founding principle of the NHS—that treatment should be free at the point of use—to the comprehensive provision of care and help with everyday activities."

While a boundary in the division of responsibilities between the NHS and social services is necessary, it need not jeopardise a sensible and comprehensive service to individuals. Many people will need both health and social care and will want to move from hospital into a nursing or residential home or indeed, with enough support, return to their own familiar home with friends and relatives around them. It has always been a challenge, both for governments and for agencies, to improve collaboration between health and social services and to ensure that people benefit from a seamless service. Local health authorities working closely with social services and the private and independent sectors have achieved some notable successes—as was outlined by some noble Lords here this afternoon—but only in some parts of the country. In others, we know, there has been room for improvement.

The need to strengthen local collaboration has been a central feature of the community care arrangements. Local authorities have been given the lead responsibility and it is essential that they work closely with the NHS and other agencies such as housing, in planning and commissioning services, in assessing individuals needs and in arranging the support necessary to meet those needs.

We have strengthened the incentives for close working by requiring local authorities, as a precondition to receiving the Community Care Special Transitional Grant, to reach agreement with their local health authorities, not only in the arrangements for hospital discharge but also in clarifying their responsibilities for long-term care.

It was only 18 months ago that the new community care arrangements were introduced, and we have been encouraged by the progress already made. This is a view endorsed by the Association of Directors of Social Services, which has repeatedly declared the first year of community care to have been a success. My noble friend Lady Macleod of Borve was absolutely right. It is clear that people are being offered more choice and appropriate support. She is also right in saying that more people are choosing to stay in their own homes.

Not only are more people being cared for in their own homes, but 10 per cent. of people who would have gone into a care home under the old arrangements are now being supported in their own home. Health and local authorities are working together to offer more imaginative support which is tailored to meet the needs of individuals and their families and carers. We are witnessing schemes which involve arranging for

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someone chosen by the dependent person to visit in the morning to get them up, to cook meals during the day or to help with gardening or shopping—whatever is needed to help preserve a person's independence and allow them to stay at home. These schemes are flexible. As my noble friend Lady Gardner of Parkes advocated, some involve volunteers; others are funded by local authorities.

My noble friend Lord Jenkin of Roding is also right when he says that we should not underestimate the work and effort which has been invested by local social services departments and health authorities to achieve these changes. His view is endorsed by the independent Audit Commission and the Association of Directors of Social Services, as well as the department's Social Services Inspectorate and the National Health Service Executive. They have all confirmed that the careful preparatory work undertaken prior to the Act coming into force has meant a sound start in most places.

The noble Countess, Lady Mar, suggested that the community care Act was not welcomed. That was not so.

The Countess of Mar: My Lords, I am sorry to interrupt the noble Baroness. I did not mean to imply that the Act was not welcomed. It is very welcome and working well in a great many parts of the country. Just a few are not getting the funds to meet their liabilities.

Baroness Cumberlege: I am grateful to the noble Countess. I misunderstood her. I thought she said that it was a question of, "We told you so". Clearly I misrepresented it. I shall look it up in Hansard. It is a policy that has been widely welcomed from many quarters.

The noble Countess suggested that the community care grant was not ring-fenced. It is ring-fenced. She also highlighted the difficulties in some shire counties which are experiencing some of these problems. I should like to issue a word of warning here to local government. I feel that local government needs to be careful. There is a body of opinion in this country which does not want local government to be responsible for community care. It is not a view that I share. I spent 28 years in local government and I know its value, especially when an authority is well run. But, if people lose confidence in local government's ability to deliver services, especially within increased resources, the temptation to review its new responsibilities will be very great. I for one would be sorry if community care were thought to be an inappropriate responsibility for local government.

Turning to resources, local authorities have been well funded to meet their new responsibilities. Over £1.2 billion has been made available this year, which includes £20 million extra for respite and home care. Next year the budget will be over £1.8 billion for community care alone, which will include an extra £30 million allocated for home and respite care. Those are substantial increases by anybody's standards. They mean that since 1990-91 the total resources for social services, including community care, will have gone up

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from £3.6 to £6.4 billion, an increase of 48 per cent. after allowing for inflation. There is no local authority which has not had increased resources.

No one hearing those figures could doubt the Government's commitment to resource community care fairly. The noble Baroness, Lady Farrington, will know from her close connections that local authorities fought hard for those new responsibilities. They now have the task of carrying them out successfully. The vast majority are doing so and as a result are making a tangible difference to the quality of some very dependent people's lives. But one or two are finding it difficult to cope with the range of their new responsibilities and the need to plan their spending over a full year taking into account the build-up in the numbers of people whom they are supporting.

The noble Lord, Lord Ashley, was right to highlight the damaging effect of squabbles between agencies. My noble friend Lord Jenkin also reminded us of what can be achieved when people are imaginative and determined and work effectively together. When that does not happen, it can be disastrous, as the Health Service Commissioner's report concerning the Leeds case illustrated. The Government took that report very seriously. The commissioner was critical of the fact that the health authority failed to secure long-term health care and inappropriately discharged a very severely incapacitated man who had had a stroke. Although the health authority's action took place before the introduction of the community care reforms, we considered that the report raised wider issues. In the summer we issued draft guidance for consultation which reminded health authorities of their responsibilities for securing long-term care, an issue which has been widely discussed this afternoon.

The draft guidance, as we hoped, stimulated debate—a national debate. We received many thoughtful replies to our consultation paper, which will influence the final version of the guidance. But there have been some misunderstandings and misinterpretations of the guidance and I should like to take this opportunity to correct them.

First, I can assure the noble Baroness, Lady Jay, that it was not our intention to change the responsibilities of the NHS for long-term health care but to reinforce them. We are clear that health authorities do have a responsibility, which includes long-term in-patient care, whether in an NHS hospital or funded by the NHS in the independent or private sector. Following this guidance, all health authorities will be required to review their arrangements and to ensure they are securing adequate provision. If they are not, then we shall insist that they make the necessary reinvestment. I understand the dilemma which the noble Baroness, Lady Robson of Kiddington, and the noble Lord, Lord Hollick, outlined in terms of standards.

Secondly, we are setting a clear framework at the centre, but it must be right that health and local authorities, working closely together, should determine precisely where local responsibilities lie and who will fulfil them.

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Local services will always vary depending on the facilities available. For instance, in some areas services have been centred around an old long-stay hospital; in other areas such a facility has never existed. In some areas the independent sector is well developed; in others it is almost non-existent. It is right, therefore, that local people, who know the strengths and weaknesses of their communities, should decide in close partnership with the populations that they serve what is provided and where. That is the whole principle of population needs assessment.

Thirdly, we are interested in transparency, an issue that was raised by the noble Baroness, Lady Hamwee, and the noble Lord, Lord Thurlow. After local policies have been developed in consultation with local interests—local authorities, providers of services, GPs, voluntary organisations and other representatives of users and carers —the draft guidance states that a clear statement must be published by them which offers local people an explanation. We agree with the noble Lord that people need to know on what basis doctors and other professionals involved in individual cases will take decisions. They need to know the eligibility criteria for long-term care.

Finally, the draft guidance emphasises the need for clear policies in hospital discharge. For many patients, leaving hospital is a straightforward event involving, probably, an out-patient appointment and a follow-up visit with their GP. That is not the case if people are not able to support themselves at home. They may need to be cared for in a residential or nursing home, or require a range of services in their own home for a long period of time. Those decisions are important and far-reaching. They need to be made not only by the vulnerable person concerned but by their family and their carers.

We have required health and local authorities to reach agreement on integrating hospital discharge with local authority procedures. Recently, we have produced and issued widely the practical Hospital Discharge Workbook, which sets out ways in which arrangements for hospital discharge can be reviewed and improved, recognising the key roles of different agencies and the need to take full account of the needs of patients and their families. In addition, the draft guidance reinforces a number of issues for health authorities and hospitals which must be taken into account. Finally, we shall continue to look at this area closely in our monitoring of the new community care arrangements. In the light of the national debate we want to finalise this guidance soon. I can assure your Lordships that the views expressed this afternoon will be taken into account. In an attempt to answer specific questions, I feel that it would be wrong for me to pre-empt the final document, but I do not believe that it will be possible to give my noble friend Lady Eccles the assurances that she seeks in the light of it requiring new legislation.

The noble Lord, Lord Brimelow, raised the issue of Camden and Islington district nursing services. I am always very reluctant to comment on individual reorganisations unless I have had the opportunity to talk to those involved, both staff and their managers. Whether the current workforce is of the right capacity in terms of numbers or of the right level of skill is

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impossible for me to judge. I shall certainly write to the noble Lord. I am sure that he will also be interested in the views of my noble friends Lady Gardner and Lord Jenkin of Roding, who have experience of these issues.

The noble Baroness, Lady Masham, after giving a very moving account of a particular case—I am pleased to say that such a case is very unusual—raised the issue of time limits for assessing individuals. We recognise that in some areas there are lengthy waiting times for assessments, especially by occupational therapists. We take that matter seriously and the Minister for Health, my honourable friend Mr. Malone, has already started a round of talks with interested groups, including local authorities and the College of Occupational Therapists, as to how we can make some improvements speedily.

The noble Baroness, Lady Nicol, and my noble friends Lady Macleod and Lady Seccombe were right to focus our minds on the carers and their crucial contribution to community care. I can reassure them that they are at the very heart of our policy. The noble Baroness, Lady Nicol, asked also about the sale of property to fund nursing home and residential care, as did the noble Baroness, Lady Robson. Though local authorities must look at the value of a resident's property —in most cases it is their former home—they must ignore it if it is still occupied by the resident's partner, a relative who is 60 or over or who is incapacitated, or a child under the age of 16. Local authorities have discretion to ignore the value of the property in any other circumstances where someone is still living there and it would be reasonable for them to do so, for example, when a former carer continues to live there. A resident cannot be forced to sell their property without a court order. However, in most cases local authorities put a charge on the property so that when it is eventually sold they may recoup what they have paid in fees on behalf of the resident.

The noble Baroness, Lady Robson, asked about the opportunity that people have to refuse to be placed in a private nursing home. Patients can refuse to be placed in a nursing home or residential care home where there is a charge. In such cases social services and the health authority should try to find a satisfactory alternative, such as a range of services to support them at home. Patients never had a right to stay indefinitely in a hospital bed when doctors and others decide that they do not need continuing in-patient care.

My noble friend Lord Mottistone raised the issue of funding in the Isle of Wight. Since 1st April 1993 the total resources for social services on the Isle of Wight have increased by 12.5 per cent; from £14.3 million to £16.1 million. Since 1991 the increase in total social services resources on the island has been 90 per cent. Those are substantial sums which demonstrate the Government's commitment to community care and social services generally. Though I accept that the increase in the grant this year is not as large as the council had hoped, it is its responsibility to manage those increased resources carefully and effectively.

My noble friend Lord Ashbourne spoke of the difficulties faced by some of the Sue Ryder homes. Last summer I had discussions with the noble Baroness, Lady

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Ryder of Warsaw, and I am disappointed that the issues have not been resolved. I shall certainly write to my noble friend and to the noble Baroness.

This has been an important debate. The provision made for the care of the elderly, frail and disabled people in our society is of crucial significance to us all. The community care reforms, widely seen as the most ambitious legislation in social care since 1948, are beginning to take shape. After only 18 months there is clear evidence that things are beginning to change for the better. But there is still a long way to go. These changes were not meant to happen overnight: it is a programme for the next 10 years. But your Lordships can rest assured that this Government are committed to ensuring that the full benefits will be delivered and a seamless service given.

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