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The Earl of Longford: My Lords, I am grateful to the Minister. But I must not take credit for something that is not a virtue. I am now partially sighted and I am a patron of the Partially Sighted Society, so I cannot use notes.

Lord Mackay of Ardbrecknish: My Lords, the noble Earl reminds me of something that perhaps I should not tell your Lordships. One of my colleagues, the Secretary of State for Foreign and Commonwealth Affairs, has never used notes in his speeches and became extremely upset when those interesting devices--teleprompters--came on the scene. His colleagues started to make speeches which appeared to be without notes when in fact they were using the teleprompter. He tried to find a way round that to ensure that his point was made, and the teleprompters are always removed when he speaks. I therefore appreciate the noble Earl's intervention.

One of the important points made by the noble Earl, which I wrote down and underlined, was "respectful help". He made it in his usual pleasant and jocular way, but it was a telling point. Bluntly put--he did not say this--it is the difference between not helping at all and over-helping; that is, assuming that everybody over 65 is decrepit and needs all the help everybody else can give them. Although I have not reached the age of 65, I have friends who have and they do not seem to require or even wish my

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help, except in the case of two of them when it comes to netting the salmon that they have managed to catch (I want their help the other way round on the rare occasion that that happens).

The noble Earl made that point and it is well worth emphasising in my summing-up. The right reverend Prelate the Bishop of Worcester and my noble friend Lady Elles spoke of the need to make people feel that they belong and are part of the community; the need to talk with them and involve them in activities. That is vitally important, but it is not something which the Government can do. It is something we should all be doing and encouraging others to do.

My noble friend Lady Seccombe and others spoke of old age as being a state of mind and mentioned how her mother discussed her "elderly" friends. It is not long since my wife's aunt, who I believe is 92, baked scones and organised tea parties for the "old folk", as she called them. The fact was that all the "old folk" were younger than she. I suspect that that attitude is part of the reason she is still with us at 92.

Either the noble Lord, Lord Butterfield, or the right reverend Prelate the Bishop of Worcester said that we should practise for old age when we are younger by sensible dieting, taking exercise and taking part in activities. No one mentioned this, but it is sad when someone retires and finds that he has no other interests outside the job which he has left. That is perhaps where practice for retirement can help.

My noble friend Lord Jenkin of Roding and my noble friend Lord Chelmsford underlined the need for good pension provision. Not much was said in our debate about pensions and that is perhaps because--I see the noble Baroness, Lady Hollis, in her place--we exhausted that subject last Session when we dealt with the Pensions Bill. However, I very much hope that the Pensions Act will help to underline the need for good pension provision. I say to my noble friends that we are undertaking a large campaign of information to the world at large and targeting it at younger people on the back of the Pensions Act to bring to their attention the possibilities that are there and the importance of starting to make pension provision at a young age.

The main part of this debate is perhaps about the boundary between healthcare and social and residential care. It may help if I say a few words about the history of these events. Ever since the creation of the welfare state in 1948 there has been a division in responsibility between the National Health Service on the one hand and local authority central services on the other for meeting the needs of people who require long-term support. Some people need the medical and nursing expertise and the specialist care that only the National Health Service can provide; others need support and help with everyday activities, which, depending on the extent of the person's incapacity, can be provided either in a residential setting or in the person's own home.

This distinction, ever since 1948, has marked the division between care which is free at the point of delivery under the NHS, and social services care, for which local authorities may, and regularly do, seek

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contributions towards the cost from people who can afford it. It is hardly surprising that people are sensitive about this boundary between "health" and "social" care; but it should, I think, be appreciated that it is not anything new and is a recognised feature of our system. While it is sometimes difficult to define, it has been recognised by those who are responsible for planning, purchasing and delivering care. It has been recognised by governments of both parties since 1948 and by other commentators, including, notably--if I may say this to the noble Baroness, Lady Jay of Paddington--last year, the Borrie Commission on Social Justice. It said:

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

We have had a reasonably non-party political debate so I do not want to ask the noble Baroness whether that remains the position of the party opposite and it has accepted what the Borrie Commission has said or whether it is part of thinking the unthinkable on which Mr. Smith and his colleagues have set out. But that is what the Borrie Commission said. I believe that most, if not all, noble Lords will agree that there is a distinction and that it is a distinction which, whether we like it or not, we have to maintain.

The boundary is not a static feature but shifts over time, especially with the continual advances in medical science and social changes. In 1948, people were consigned to indefinite periods in hospital who would now receive rehabilitation and be discharged home to carry on with their lives, with perhaps some support from social services. My noble friend Lady Platt of Writtle underlined that point when she mentioned the film she had watched which illustrated the point that in years past people were taken into residential hospital care and were left there for many years. They then became so institutionalised that they could not possibly have lived on their own even when the geriatricians and others got round to thinking in a different frame of mind and tried to see whether they could rehabilitate them into the community. I am happy to say that those days are past and I am sure that we are all determined, whatever our party, that they should not return. It is a matter for celebration that the NHS can do a great deal more now than it used to be able to do to help people to remain in their own homes. I shall return to that issue in a moment because a number of speakers made some very interesting points about it.

There have been great improvements in treatments to remedy conditions which a few years ago would have been crippling and which meant that it would have been impossible for people to stay at home. Better anaesthetic techniques mean that operations can be carried out on people at quite advanced ages, as we all saw just a couple of weeks ago when the Queen Mother underwent her operation. We were all delighted to see her coming out of hospital and showing everyone else--all the other old folk, just like my old aunt--that, if one has some spirit about, age can be put aside. That is a good example to everyone of what can be done. Indeed, I suspect that a few of your Lordships are going around

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with artificial hips and various other things. The noble Lord, Lord Butterfield, described to us how he has been helped by some of his medical colleagues with the little pump inside his chest.

So it is hardly surprising if, as a result of all these medical advances, people who would once have needed hospital-based care can now manage at home, perhaps with some support; or, if they are too frail for that to be a realistic option, can enter residential or nursing home care in a comfortable, homely environment. The 1980s have seen a great expansion in the independent residential and nursing home sector as the availability of social security money made it easier for frail elderly people to enter a residential or nursing home. Beds for people 65 and over in private nursing homes increased by more than 500 per cent. between 1983 and 1993.

As I said a moment ago, hospitals should not be, and should never have been, people's homes. Residential or nursing home care can provide a homely and comfortable environment superior to the standards obtaining in some of the old and totally unsuitable "geriatric wards" which the NHS had, especially during the 1980s.

The noble Lord, Lord Butterfield, and my noble friend Lord Jenkin underlined the need for research into matters which the noble Lord, Lord Butterfield, described so well for the non-scientists among us as brain failure. One speaker mentioned that the number of consultant geriatricians has increased by about 81 per cent. since 1979. On the subject of research, perhaps I may say to the noble Lord, Lord Butterfield, that the Department of Health is developing a mental health research strategy which will include research into dementia. Almost all the speakers in the debate talked about the need for good assessment and rehabilitation, the noble Baroness, Lady Robson of Kiddington, being one of the last ones to do so. I agree with her on that, as do the Government.

I turn to the community care reforms of April 1993. They continued and strengthened the drive away from institutional care and the development of community and domiciliary based services. We have provided generous funding for this work. Local authorities are responsible for assessing needs for residential and nursing home care and for providing the necessary financial assistance, with the resources we have allocated to match these new responsibilities. Over all, in 1995-96 local authorities received an extra £1.8 billion for community care. By the end of 1996-97 local authorities will have been given an additional £2.2 billion--a considerable injection of resources at a time of considerable budgetary restraint. We plan to inject a further £350 million in 1998-99, demonstrating our long-term commitment to the success of community care. By the end of that financial year more than £2.9 billion extra will have been put into community care.

Elderly and vulnerable people are now being offered more appropriate support to enable them to stay in their homes wherever possible, and are getting more choice, better support and services tailored to their individual needs. Domiciliary services are on the increase. During

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1994 local authorities provided 24 per cent. more home help or home care contact hours than in 1993, and day centre places rose by 19 per cent.

Perhaps I may turn to the guidance on NHS responsibility for meeting continuing care needs, mentioned by a number of speakers. The noble Baroness, Lady Jay, certainly mentioned it, as did the noble Baroness, Lady Robson. The community care reforms have proved very successful in promoting and emphasising non-institutional forms of care. However, it is true that the role of the NHS in providing continuing care for those with greater dependency does require clarification. In February of this year the Department of Health issued some very important guidance to the NHS and to local authorities on the responsibilities of the NHS for meeting continuing healthcare needs. I hope that what I am going to say on this subject will go some way towards answering the questions posed by my noble friend Lord Dean of Harptree and the BMA Alzheimer's Disease Society in its submissions to him.

First, this guidance confirms and clarifies the responsibilities of the NHS for meeting a range of continuing healthcare needs, including the capacity to secure continuing in-patient care, whether in an NHS hospital or funded by the NHS in an independent sector facility. Secondly, it requires authorities to take action to fill any significant gaps in their current services, in their area of course. It aims to achieve greater consistency across the country in the provision of continuing health care by a national framework, which sets out what the NHS should be doing to meet continuing healthcare needs. This is probably as much as has ever been said in one place about the scope of the NHS responsibilities in this area.

The framework gives a strong steer on when people should receive NHS continuing in-patient care; for example, if the level or nature of their condition requires on-going and regular supervision from specialist doctors or nurses, or if their condition is very unpredictable. While individual health authorities, doctors and nurses need some freedom to interpret this framework in the light of local circumstances, we are expecting all health authorities to reflect these core conditions in their eligibility criteria.

The guidance also focuses on the need to improve arrangements for hospital discharge of people who have continuing health or social care needs. I believe that that was a point made by my noble friend Lord Glenarthur. It ensures also that there will be a greater openness about continuing healthcare services. Health authorities' policies and criteria must be open for consultation locally with all groups with an interest, including in particular local authorities with whom the policies and criteria should be agreed, and with patients' representatives. The final policies and criteria are to be published in community care plans.

My noble friend Lord Jenkin of Roding and the noble Lord, Lord Butterfield, talked about the range of services provided by the NHS. I believe that my noble friend described it as from the medicine of old age to the medicine of health care; the one being more appropriate to care outside hospital and the other in

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hospital. A very important feature of the work we are doing on continuing healthcare is looking at the range of services which we wish to see developed. While in-patient beds are a key part of an authority's pattern of service, we are stressing that they must make plans for rehabilitation, recovery after illness, respite care, palliative care for people who are terminally ill and specialist services to people in residential or nursing homes, community health services and specialist transport. Hospital discharge arrangements are to be given high priority to ensure that all the necessary services are in place. Overall, the focus is on getting people back into the community wherever possible and on making placements based on proper assessment, and consultation with the patient and his or her family. We do not want to see a return to the old and outdated models of care such as the old-style geriatric wards.

One of the real problems faced by many parts of the health service has been called, when I was the Health Minister in Scotland, "blocked beds". My noble friend who succeeded me as Health Minister mentioned this problem, which is nationwide. We very much hope that these kinds of ideas and guidance will help reduce, if not eliminate, that problem.

The noble Baroness, Lady Robson, and, I believe, the noble Baroness, Lady Jay, suggested to me that we should have used the opportunity presented by the issue of this guidance to impose national criteria for continuing healthcare services. I hope I have outlined that we are aiming for broad consistency. I believe that it would not be either feasible or desirable to require authorities to provide precisely the same patterns of continuing care services. Existing services vary considerably depending on the facilities which are available locally. In some areas services have been centred around old long-stay hospitals, while in others such a facility has never existed. In some areas the independent sector is well developed and in others it is less strong.

Finally, health authorities and local authorities need to have the flexibility to agree locally the precise boundary between their respective responsibilities, so that they can work together to meet the needs in as seamless a manner as possible. Detailed national prescriptions of exactly what should be provided by whom may sound attractive, but we believe that it would be unlikely to be helpful in reality. We are committed to making sure--

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