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Viscount Ullswater: My Lords, I did indeed mention service agreements. I should have to inquire whether that is the same as service level agreements. I indicated that that approach may be better rather than having a legalistic contract. But what is extremely important is that local authorities should know exactly what they are to receive and costs of that. I believe that that is what the Bill does, and I commend it to the House.
The noble Lord said: My Lords, the financial problems being experienced by older people in care are increasingly in the public eye. None of us can have failed to notice the press articles about people losing the properties for which they have paid over a lifetime of work in order to meet the costs of their care. In a number of cases, the families of older people are being called upon to meet the difference between the costs of care and the support which is available. That causes a great deal of heartbreak and hardship for families who wish but are unable to bridge the gap, which may mean the difference between quality care in a comfortable environment and care in far less suitable accommodation. I certainly would never wish to experience some of the problems about which I have heard from those families who have found themselves in that situation. However, I know exactly how they feel. Therefore, older people and their families are facing real problems in meeting the shortfall between the costs of care and the ability to pay for it.
In a very short debate it is difficult to cover all the problems, but I should like to bring to your Lordships' attention one particular issue which is beginning to affect the care available to many older, vulnerable people in residential care and nursing homes. A number of cases have been drawn to my attention of people who have been evicted or threatened with eviction. In
People living permanently and voluntarily in a private residential or nursing home before April 1993 have preserved rights to higher rates of income support to help meet the costs of their care. Those rates are set by central government and take no account of local or regional cost differences. Age Concern has received a large number of inquiries from older people and those concerned with their welfare which indicate that there is a growing concern about the ability of older people who have preserved rights to meet the costs of the residential and nursing homes in which they live. Older people face severe difficulties in areas where preserved rights to income support are not sufficient to meet the costs of local care. Local authorities are required to contract with homes at the local rate and are expected to negotiate the best terms available. However, income support levels are still failing to meet the costs of care in many parts of the country.
Where there are shortfalls between the income support rates and the costs of care, only limited help is available. Local authorities can help residents with preserved rights over pension age who face eviction or the closure of a residential home only by making arrangements for them to move to another home. If the person needs to move into a nursing home or already lives in a nursing home, local authorities have no power to offer anything other than advice. They are not able to provide top-up money to enable a person to live in the same home. For people over pension age in nursing homes, there is no clear-cut statutory responsibility should they face eviction from or closure of the home. I could cite many examples of that.
Therefore, the situation is even worse for people in nursing homes who face eviction. Local authorities have no power to offer anything other than advice or guidance, although they have the power to make alternative arrangements for people under pension age who have preserved rights and are in nursing homes. Health authorities have responsibilities if they originally purchased the nursing home place. Otherwise, a health authority may have a responsibility only if the resident's care needs fall within their locally determined priorities as to those who should receive long-term National Health Service care and those who should not. Therefore, the onus for finding alternative accommodation for those people over pension age in nursing homes lies with the resident or his relatives, with perhaps some help from a home owner. That is because the pensioner will have arrived at the home as a result of private arrangements. That is laid down in government regulations.
The rules are complex and are far too complex to cover in detail, but they were issued as part of the Government's community care policy. I accept that the proposals were intended to prevent exploitation by less scrupulous providers of care homes by transferring
Let us consider somebody who is in that unfortunate circumstance. He may be old, sick, or both. He is visited regularly by children, relations and friends and then suddenly finds that he is moved 50, 60 or 70 miles away, where he has nobody. He has been well-established in one place and has had set patterns of life, which are extremely important to older, sick people. In some cases a sudden move may have tragic consequences.
A number of charities have been extremely helpful in that regard. They are working together. I know that one charity is donating £2,000 per year. But for obvious reasons we cannot rely on the charities to continue to bridge the gap. Charities have financial difficulties. They are unable to meet the increased costs of those people and we should not demand that they do so. We are in no position to demand that charities should take on that task.
Members of the all-party group on ageing issues met with representatives of Age Concern, the Association of Charity Officers and a provider of homes earlier this year. Members of that group were deeply concerned about the prospect of eviction hanging over that most vulnerable group of people. The numbers are not small. In a Written Answer in another place, the Under-Secretary of State for Social Security, Mr. Roger Evans, said that there were 116,200 people in residential care homes and 84,460 people in nursing homes who were in receipt of the higher income support limits. Those people will be at risk if they are unable to meet the difference between the cost of their care and the income support which they receive.
However, the Minister failed to quote from the other part of that most important document which says that local authorities are in difficulty in negotiating fees at income support levels or below, or, indeed, anywhere near it. In fact, the report says:
But, as the report asks, how can that upward flexibility in local authority baseline fees be reconciled with evidence that nursing and residential home fees for elderly people have not kept pace with either income support upratings or the average earnings index between 1993-94 and 1994-95? The Minister could have quoted
Age Concern has also produced an analysis of the financial shortfall between income support and the weekly charge of homes for elderly people. Its report shows that the number of people in care whose charges are above the weekly income support limits fell from 46 per cent. in February 1994 to 45.4 per cent. in 1994. None of us will be surprised at that, knowing the kind of people with whom we are dealing.
People with preserved rights to income support will have been resident in residential care or a nursing home before 1st April 1993. Their numbers will inevitably fall. Therefore, the cost of funding the difference is not a major long-term commitment. It cannot be. Indeed, the very nature of the thing indicates that such people will not exist for as long as that. In May 1994, 57,160 people in residential homes in Great Britain were in homes with charges above the weekly income support limits. That is not a large proportion of the ageing population. However, it is an unacceptably large number to be facing eviction.
Income support moneys may not meet the cost of care for a number of reasons. One area may be more expensive than another. We know of examples in London and the home counties where the charges are far in excess of those in areas such as Humberside in Yorkshire and such other places. There is a huge difference.
In those cases the resident has some limited options as regards what to do in attempting to meet the shortfall. First, such people can negotiate with the homeowner. But that could lead to a great deal of acrimony, delay and discussion, and in the end very few such cases are settled. Secondly, they could try to raise the shortfall themselves. However, in many cases that is impossible. Thirdly, they could see whether there was another home in the area with a vacancy at income support rates and then move. But, if there were such a place, those people would experience the same difficulties as they had experienced in the home that they were in. Therefore, it is unlikely that they would find a solution down that road.
Once those possibilities have been exhausted, the resident is left in the situation where he or she still does not have enough money to pay for the accommodation and care. Although many homeowners endeavour to maintain a resident for as long as possibleindeed, some are very good at itthere may come a point when that is no longer viable. At that point the resident may well face eviction. I recognise that that is an emotive term. It comes in many guises. It rarely appears as an eviction notice. The agreement with the home usually states that either party must give a period of notice which is often as little as four weeks. However, its effects are equally as devastating. If one receives such a letter after four weeks, it is obviously just as devastating as receiving an eviction notice. There are a number of examples of actual evictions which I do not have time to give your Lordships.
As I stated earlier, the "preserved rights" were issued as part of a move to community care. There was no malicious intent in their introduction. But, unfortunately, they have led to some of the most vulnerable members of our society being faced with the prospect of eviction from care homes. Again, Age Concern has raised a number of issues which it feels Ministers in the Department of Social Security should consider to alleviate the distress and financial burden which the preserved rights rules have placed on older people in residential care and in nursing homes and also on their relatives. I understand that those points have been delivered to Downing Street and the appropriate Ministers. I hope that the Minister who is to reply tonight will have something to say about the suggestions made.
However, if the noble Lord cannot think about all of those suggestions, I believe that he ought to be able to say tonight that the Government accept the proposal that the Secretary of State for Social Security should take into account and actually reflect the local variations in the amounts being contracted by local authorities in the uprating of preserved rates of income support, using the powers under Section 135 of the Social Security Contributions and Benefits Act 1992. We raised that question many months ago. That section of the Act gives the Secretary of State for Social Security powers to take into account the differences in local authority areas as regards such costs. I believe that that is the least assurance that I could hope to receive from the Minister as a result of tonight's debate.
Lord Donaldson of Kingsbridge: My Lords, I am most grateful to the noble Lord for introducing the debate in such a very complete way. The truth is that it is a very complicated question. Therefore, one is very glad, if one can, to avoid talking about the complications. As the noble Lord has dealt with them fairly satisfactorily and made it perfectly clear that things will not do as they are, I will move away from detail and make one or two generalisations largely based on personal experience.
I should like to thank various organisations who have given me information on the subject; for example, Help the Aged, the Citizens Advice Bureaux, the National Council for Hospice and Specialist Palliative Care Services and Age Concern. They are all charitable concerns which are mixed up deeply in the problem. They are all equally dissatisfied with what is going on.
Quite a number of people in this House are old enoughalthough, I hasten to add, not all of those who are present in the Chamber tonight are anything like old enoughto have a proper understanding of the misery and worry facing people of our age who, often as a result of painful bereavement, find themselves pushed from pillar to post in an endeavour to find somewhere to die in peace. Many of us are of an age when serious illness and eventually death of ourselves or of a loved one is to be expected. I want to report the fact that, if
I believe that the noble Lord who introduced the debate is trying to ensure that this very hard to bear period in all our lives is made equally bearable for those less lucky than ourselves who cannot afford to pay their way as we can. When I say "we", I am speaking for myself and a number of colleagues. I believe that any government worthy of our support should struggle to find a way to help people less lucky than ourselves to meet such crises despite lack of funds to pay their way. My slogan is: we stand on the right of every citizen rich or poor, male or female, to die in his or her own home.
I wish to say a few words about the help available. First, of course, there is the GP, who will arrange visits as required in case of illness, even sometimes twice daily, from the local health authority district nurses. I have had to deal with two or three and each was first class. Then there is the hospital. Hospital treatment is expensive if you can pay, but rightly so. However, the hospital is anxious not to keep one longer than one's treatment demands. When the time comes for one to go, the question is whether one can go home if provided with some extra help, or whether one must go to a nursing home or hospice. Here carers come into the matter. Again, they are not cheap, but I have found them most excellent.
This brings me to the hospice movement, of which I cannot speak too highly. Associated with it are such charities as the Cancer Relief Macmillan Fund and Marie Curie Cancer Care. Once again, I have had experience of all these and I was astonished at their effective kindness and tact and their excellent educational influence on confused and unhappy people.
Some of these charities confine themselves to cancer cases, but not all. Therefore help can be obtained in all cases. There are over 200 day hospices which enable people who are terminally ill to spend time away from home and offer physical care and social support as well as respite to carers, many of whom are of course elderly themselves.
Let me recommend one simple and direct government action which would do a great deal of good and would not be too expensive, and that is to increase the existing National Health support to hospices, which now averages 38 per cent., to 50 per cent. of total hospice expenditure. I would like to add that to the various changes already recommended by the noble Lord, Lord Stallard.
I have been speaking of people who are not only old but also ill. Of course there are manyI am one myselfwho are old but who are not particularly ill and who need carers in the home rather than trained nurses. I manage with a son and two daughters, whose help is never ending, and with two charming girls who are young mothers who come to my small house for half an hour twice a week and do all the washing, ironing, sweeping and cleaning for £5 an hour each and who are out of the house before I have realised they are in it. The family help, of course, is fundamental and people without that help are in a much worse position.
The noble Lord has discussed in valuable detail the question of helping people who have too little money to avoid eviction. That is the hub of the question. It is a matter of cash being provided to avoid a desperate and disagreeable situation for someone who is old and probably already rather confused. I agree with the noble Lord that the situation has been allowed to get into a muddle and that elaborate objections are made to almost every course which may be suggested in difficult cases. As we have an energetic and clear-minded Minister who does not suffer from old age to reply to this debate, I hope that he will lay down clear directions to avoid the hard cases which have been mentioned, where unhappy people are sometimes evicted and do not know where to go. I stand by the slogan, "Every citizen must be allowed to die in his own home". I hope that the Minister will accept the slogan.
Lord Desai: My Lords, we are grateful to my noble friend Lord Stallard for the debate he has introduced. I am neither old nor a resident in care and therefore I have no personal interest in this matter. I have not been a recipient of the various briefings that other noble Lords have received. Therefore I shall stick to generalities.
I was pleased to note that the noble Lord, Lord Donaldson, pays a wage that is above the minimum wage as advocated by my party. Five pounds an hour is a good deal above the minimum wageand long may the noble Lord continue in his good Labour practice.
I want to examine why this situation has arisen, not only in terms of residential care for the elderly but also in terms of housing benefit. The Government want to introduce flexibility and choice in the provision of various services. As regards the housing market, they wanted to introduce much more private renting and greater flexibility. As regards care for the community they want to introduce flexibility. If one allows prices to be determined by the marketit is not a fully free market but rather a quasi-free marketand one has administratively determined uniform payments, one is bound to find that some people will find their money falls short, as happens with some elderly people. As regards housing benefit, if one is committed to pay whatever the market charges, soon one will find that one is paying too much. The panic that has arisen as regards housing benefit shows that there is an inconsistency in allowing the free market to determine private rents and having a commitment to pay housing benefit and then worrying about the budget.
A similar situation has occurred as regards the matter we are discussing now. If one wants flexibility in provisionas I presume we dosome care has to be taken and some arrangements have to be made to make the payments to people who are entitled to them not uniform but slightly variable. That is a tricky thing to do but it has to be done. Let us say that 16 out of 42 local authorities have agreed to pay care costs that are above income support level and they are in London. But, typically, those elderly who find themselves living in an inner city area will suffer a shortfall whereas people who are not living in inner cities will find that, by and large, they can manage. Because market costs are
I note that the noble Lord, Lord Skidelsky, is in his place. He does a lot of thinking for the Conservative Party and perhaps I should therefore pass this problem to him. It may be possible to pay an inner city allowance or make it more age-related. The problem arises when old people cannot pay. In that situation it would be almost cruel to evict them. Many of the really elderly are women. Women represent a much larger proportion of those over 80 than do men. Typically in our society women have fewer assets to fall back on, whereas men may have some assets or may have earned something through their lifetime. Some subtle thinking is required to address this problem. I do not believe that a great deal of money is at stake here although when any sum of money is mentioned unfortunately people tend to throw up their hands in horror and say, "Oh my God, we cannot afford £10 million. It is too much". If the shortfall is £100 a weekI am taking a figure out of nowhereand there are roughly 60,000 people at risk, to pay them £100 extra would result in an expenditure of about £30 million. The Minister may throw up his hands in horror and ask where my party is going to find £30 million. I remind him that given the social security budget of £90 billion, £30 million represents a small fraction of that. If the party opposite can find £5 billion out of nowhere for a tax cut, I am sure they can find £30 million from somewhere; but I do not want to make a party political point.
There is a conflict between the free market provision of social serviceswhich may be perfectly welcomeand an administratively fixed uniform payment. That issue will come up again and again, and some thought will have to be given to it in terms of a special concession, either age or location-related, or through other tax concessions that make it possible to meet this particular challenge.
A related matter has the opposite effect of what is intended. The Government have been very keen to take people away from SERPS and occupational pensions and into personal pensions. SERPS and occupational pensions are to some extent gender blind. They give men and women more or less the same pension. However, as far as personal pensions are concerned, a man who pays £100,000 to buy an annuity and subscribe to a pension plan will receive £10,000 per year for the rest of his life but, for the same amount of money, a woman will receive £8,000 to £9,000. Because it is a private pension plan it makes perfect sense as women live longer than men. Nevertheless, women have to save more money to get the same provision as men. Although it makes perfect sense for a profit-maximising private company to operate in that way, I believe that elderly women should have a tax concession or something like that to redress the imbalance. We shall find increasingly
Baroness Sharples: My Lords, I am very grateful to the noble Lord, Lord Stallard, for allowing me to say a few words in this debate. I should declare an interest on behalf of my husband who died at home last month. When he became unable to do everything for himself early in 1994 I applied for attendance allowance and was duly granted the lowest scale after the statutory wait of six months. When it became obvious that he needed full-time care, in April 1995 I applied for a review of his case. Six weeks later I had not even received an acknowledgement of my request. After two further weeks I received a form which I returned immediately. When I pointed out the delay, the office in Blackpool apologised and was extremely charming. I had no argument with it. There had been a considerable upheaval in the whole system. The office explained that no increase in the allowance would be payable for another six months, even if there was a review.
Can my noble friend explain why, having been granted the original attendance allowance, a further six months' wait was needed following a review? My husband was not a wealthy man. What is left of his estate, having paid for private carersI wished him to stay at home, as he did until he was no longer aware of what was going on around himgoes to my step-children, quite rightly. There must be thousands of people who find that further six-month wait very unfair. It is for that reason that I raise this matter today. When my noble friend comes to reply I hope that he will have plans to vary the extra six-month wait for the higher rates of attendance level.
Lord Haskel: My Lords, I apologise for the absence of my noble friend Lady Hollis who has unfortunately been called away on urgent matters. The need for this debate illustrates that the Government have not thought through the problems of long-term care for the elderly, particularly those in residential homes. I am grateful to my noble friend Lord Stallard for introducing the debate. I do not wish to repeat the arguments that he put so eloquently, nor do I wish to repeat the moving points made by the noble Lord, Lord Donaldson. My noble friend Lord Desai spoke about the problems of the free market when the bill was being paid by the Government or the local authority. I shall be interested to hear the Minister's response to that. In addition, the points put by the noble Baroness, Lady Sharples, demand a reply from the Minister.
As all speakers have pointed out, those with adequate money or a supportive family usually have little problem. The difficulty arises when there is a shortfall between income support and the charges made by the home. As my noble friend Lord Desai pointed out, when income support is enough to pay for the cost of care in some areas there are no problems. He told us that in
Local authorities have power to help only when people are in residential homes, are evicted or are on the point of eviction. The last thing the relatives want is for the resident to have to move to another home. Local authorities have no power to help beyond giving advice to those who are in nursing homes. The problem is made worse because of the fragmented responsibility between the Department of Health and the local authority and the Department of Social Security and the local authority. All of us agree that it is inhuman to ask elderly people of 80 or more to move from one residential home to another.
A number of suggestions have been made. One is the Hartley Booth solution which would allow local authorities to intervene and help residents to remain in homes if there was medical advice that it would not be in their interests to be moved. Perhaps another interim solution is to give local authorities power, but not the duty, to top up to avoid unnecessary disturbance. That would enable local authorities to negotiate acceptable rates with home owners. The local authority would probably pay in the end anyway, but it would avoid a lot of unnecessary difficulty.
The principle which guides the Government is that we are determined to do our best to ensure that older people receive a decent level of care. We are justly proud of our record in this area. In 1979 there were just 12,000 people in residential care and nursing homes claiming benefit to meet their fees at a cost of £10 million. Since the introduction of the community care scheme, the numbers claiming income support with preserved rights to the higher limits has obviously fallen. However, there are still just over 200,000 receiving help through this old scheme at a cost of around £2 billion. That is quite apart from the income support paid to nearly 80,000 people in homes under the new scheme and the large amounts of money paid by local authorities to support new residents.
There is, of course, other income from the state, such as retirement pension and attendance allowance, that is taken into account when calculating entitlement to benefit. The whole adds up to a vast amount of money which, I firmly believe, shows the Government's commitment to these very dependent people.
We believe that income support limits have generally kept pace with costs. Indeed, practically all limits have increased in real terms since 1985. The elderly limit for people in residential care homes increased by 16 per cent. in real terms between April 1985 and April 1994, and that in nursing homes by 38 per cent. Those real-term increases are significant, especially as we have to bear in mind the Government's overall public expenditure objectives and take decisions in the light of cash available for benefit uprating as a whole. Organisations like Age Concern will, quite rightly, pressure us to do more, and we will, of course, never be able to do everything that they ask.
The noble Lord, Lord Stallard, asks if we have any plans to increase income support payments to meet the full costs of care of older people. We already meet reasonable costs and charges for care. Our aim could not be to meet all fees however high they may be set. That would be an open-ended commitment, and we should bear in mind that fees can reach £1,000 a week or more.
In 1993 we changed the system of funding for care of elderly people from a national, income support-based system to a local, community care-based one. It is clear, in retrospect, that we were right to do so. The new scheme allows a much more flexible, innovative, appropriate response to the needs of individual people and, I hope, goes a long way to solving the problems outlined by the noble Lord, Lord Desai. It also achieves excellent value for money.
There is a general misconception that all local authorities are contracting for fees way above the level of the income support limits. In fact the level of contracts still tends to follow the limits, although I accept that there are local authorities which contract above the limits. Indeed, a small but increasing number of local authorities are contracting below the limits. Additionally, some authorities are continuing to contract at their 1994 levels and not increasing the level of fees they will meet in line with our increases. I hope that that
At this point I should like to associate myself with the remarks made by the noble Lord, Lord Donaldson, about people's desire to die in their own homes and about the sterling work of the hospice movement. Under the community care arrangements, the Department of Social Security made a transfer of resources to health authorities for hospice care. We fully support the work of the hospice movement.
When we changed the system we gave preserved rights to all those in registered residential care. That is to say, we guaranteed that they would remain within the old system, and continue to receive the income support limits. We did this to aid the smooth changeover to the new scheme; to reassure current residents and provide security for vulnerable groups; to remove the need for care assessments for current residents; and to reduce administration for local authorities. Noble Lords will recall that the idea of preserved rights proved immensely popular, and indeed there was a rush to enter residential care before the closing date.
Several noble Lords have asked us to make changes to the preserved rights arrangements. We shall listen to what has been said carefully and consider what might be done in response to the points raised, taking account of our responsibility to the taxpayer. However, I should warn your Lordships that most of the points raised are well known to us.
Age Concern and others have brought to our notice a very few cases where people have been forced to move home because their existing home would not continue to look after them at preserved rights levels. Even a few such cases are a few too many. The vast majority of homeowners are responsible, caring and committed. I am sure that local authorities would prefer to deal with those which live up to these ideals.
Perhaps I may give the noble Lord, Lord Stallard, some comfort. Local authorities now have new powers to provide a safety net in cases where someone is evicted. However, it was never anticipated that local authorities would have powers to top up income support limits.
We have thought long and hard about how we might deal with the problem and have considered, I believe, all the remedies proposed by noble Lords, along with many others. However, we have yet to find a remedy which will work and which will not lead to the kind of general escalation of fees that has been seen before. For example, in 1991 most income support nursing home limits were increased by £45 a week. Instead of reducing the number of residents whose fees were met by income support, nursing homes simply increased fees by the amount of the benefit increase.
Our best estimate is that to solve the problem faced in its ultimate form by perhaps a dozen residents out of 200,000 would cost the taxpayer at least £200 million a year. The noble Lord, Lord Desai, had a good grasp of the magnitude of the problem. Even my noble friend Lord Skidelskyin his temporary residence on the Bishops' Bencheswould be hard put to find an answer to it. We shall continue to look for one.
Many people in residential care receive private and charitable help. We applaud that. However much the Government do, people will always want to do more for their own relatives and for those people with no one to help them. It would be quite wrong for the Government to act in such a way as to prevent relatives, friends and charities stepping in and assisting. Indeed, the benefit system deals generously with such contributions by disregarding payments intended to top up benefit levels to enable people to live in the home of their choice. Many people in receipt of such help would appear to be in a home above income support limits because they receive that help.
I trust that I have made the Government's position clear. We are determined to do our best to ensure that older people receive a decent level of care. However much we may disagree with some noble Lords about
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