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At the bottom of this argument is a fundamental and difficult dilemma. Long-term care is essential. It can be paid for from public money or privately; there is no third option. There is a theoretical case, and the majority of the Royal Commission set it out as well as it could, for increasing the share of public money. That is a matter to be considered in the present Comprehensive Spending Review. However, I am not convinced—the Minister may put me right, but I doubt he will—that there is any prospect whatever that the CSR will come up with the Niagara of cash that would be required fully to fund improved care from the taxpayer. The Government’s priorities are education and health. You can argue with that if you like, but it does not leave enormous scope for increased spending in other areas.
Rather than rerun old arguments—I am afraid I have done so a bit today, but I hope I might be forgiven—we need to think more creatively about how we get more private provision and private money in. Developments here have been pretty disappointing. Private insurance for long-term care has not developed very well. There are not enough advisers, a point I owe to the remarkable Denise Platt, who has so informed the debate today. It is surprising that there are no private organisations offering old people holistic advice on where to acquire the balance of things they require to sustain their lives at home, and the Government have some role in encouraging that.
To end on a more healing note than has animated the rest of my remarks, I think that we can all unite on this one thing: we need better care for elderly people. It is not adequate. There is not enough of it, and it is not properly provided. We need it irrespective of whether it is organised, funded and provided publicly or privately. If the Government are not going to do the job—and in my view they cannot—they should say so frankly and do what they can to encourage the private sector to fill the gaps that are inevitably left.
3.44 pm
Lord Best: My Lords, in thanking the noble Baroness, Lady Pitkeathley, for bringing forward this debate on social care, I declare my interests as chair of Hanover Housing Association, which provides housing and care for some 25,000 people in England; as president of the Continuing Care Conference, which brings together care providers from the public, private and voluntary sectors; and as president of the Local Government Association.
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Today, I will share some thoughts on the “what now” and “where next” for the voluntary sector in care provision, picking up on two contrasting developments in social care that have featured in this debate. On the one hand, there is the Government’s important and positive emphasis—as noted by the noble Lord, Lord Harris, among others—on choice for care service users and empowerment of people needing some care to take decisions for themselves. On the other hand, there are cost pressures at a time when increased longevity and greater numbers of people needing care come up against fierce public expenditure constraints on social services budgets.
In relation to consumer choice, the Government underlined their commitment to greater self-determination in last year’s White Paper, Our Health, Our Care, Our Say, and are encouraging take-up of direct payments that enable people to do their own thing and arrange their own care—for example, the disabled young man who prioritises visiting the gym rather than having his flat cleaned. The Government are piloting individualised budgets that tailor care packages to suit the individual. All this is great stuff—user empowerment, as pioneered by articulate people with disabilities and championed by the Joseph Rowntree Foundation and others for more than 20 years. However, only 1 per cent of the budget of social services departments goes on direct payments. Individualised budgets are still at a tentative, pilot phase. For those without the money to pay their own way, dependency on a cash-strapped local authority means accepting the standardised care packages that the local authority can negotiate with care providers. Yet we each have preferences and, often, the form of support that an individual wants is not found in a standard care package.
Worming the Cat is the title of one of the Joseph Rowntree Foundation reports, because that is what one elderly person wanted her carer to do; she did not want help with cooking, which, however painstakingly, she wanted to do for herself. One resident in a Hanover extra care scheme told me the other day that her care worker is not allowed to take her to the hairdresser, as this is not part of the specification in the care contract organised by the adult services department. However, having her hair done was very important to her self-esteem and was a chance to meet old friends.
The problem with choice is cost. In this debate, we have heard about the severe pressures faced by social services departments to ration what is available and to go for the economies of scale that are hard to reconcile with user control. Let me bring together questions of choice for users on the one hand and the impact of cost pressures on the other, in the context of voluntary bodies such as the Hanover Housing Association, which is one of the largest providers of retirement housing and extra care. Before becoming chair of this organisation some months ago, I had not appreciated the switch taking place in the care of older people, not just from the public sector but also from the voluntary sector to the rapidly growing and now dominant private sector.
To obtain public funds for care provision today, an organisation must win the competition for a contract. Since most of the cost of supplying care is in care
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Many voluntary bodies, including Hanover, find it hard, culturally, to pay the minimum possible wage and we cannot compete successfully with those private operators. Let me be clear: I do not think that Polish, Slovakian or Czech workers are any less clever, hardworking or caring than British care workers. I have met some delightful eastern European carers in recent weeks and I can see that the language difficulties can usually be overcome fairly quickly.
However, Hanover—like, I guess, other care organisations—is not prepared to enter this low-wage contest. We have decided not to tender for care contracts at all. This has led us to reconsider our role. What exactly are we there for? Is it always to be the provider of services to older people? For other organisations, that would mean services to disabled people or those with learning difficulties and so on. Or is the role of a charity such as ours to address that desire of each of us for choice, for the independence that comes from choosing and being empowered to take decisions, not as a provider but as advocate, adviser and ally?
After talking to a large number of our residents, I see a real need for agencies that stand alongside the service user and support that empowerment process. We are working with another charity, Counsel and Care, to take this forward. Older people need advocacy in dealing with care commissioners; they need advice on their entitlement to attendance allowances, on pension credits that can lift them out of poverty, on their entitlements to care, on equity loans—as suggested by the noble Lord, Lord Lipsey—on befriending services that may be available from volunteers within their local communities, and on fitness and well-being. Within this holistic, supportive role—that is, not providing all the services, but seeing that they are provided—the voluntary body as the independent broker can help to increase the miserably low level of take-up of direct payments. The voluntary body is acting as advocate, adviser, ally, enabler and broker.
With fears that the Treasury’s Comprehensive Spending Review will not come up with nearly enough extra cash, and given the rapid expansion of care contracts with private sector providers, the future role of the voluntary sector may involve a shift from being provider of services to enabler and empowerer of the individual older person or other service user. If so, perhaps this will not always be a change for the worse.
3.52 pm
Baroness Massey of Darwen: My Lords, I am grateful to my noble friend Lady Pitkeathley for introducing this debate. Her knowledge and experience in this field are highly valued, and she covered in her introduction a wide spectrum of issues. As she said, the Government have done a great deal to focus on issues of concern. As this year’s CSCI report notes, improvements have been made and, as others have said today, there is a basis for action.
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I shall focus on two of my particular concerns. One is care within substance misuse services and the other is grandparents as carers. The CSCI report states in its executive summary:
“People say they want services that help them to realise their potential and make the most of their life chances”.
In that context, I shall speak about substance misuse and where clients need to be helped through care to greater health and happiness. I declare an interest as chair of the National Treatment Agency for Substance Misuse. We were established in 2001 as a special health authority charged with doubling the numbers in treatment by 2008 and reducing waiting times. These targets have been met two years early. In addition, staffing levels have improved and user/care involvement in treatment has been well established.
This success reflects what good social care should be about. I shall give examples of some factors for success and perhaps the Minister will comment on them. The first is funding and high-level interest, which provides a focus. Interest in drug treatment from the Prime Minister, the Home Office and the Department of Health has increased funding. Secondly, ring-fenced funding at a local level has protected services. Local involvement through drug action teams, with budgets pooled from national and local funding, has ensured community interest. Other factors include the development and dissemination of models of care guidelines. These clarify the need for commissioners and providers to increase their focus on improving the client journey through a structured care programme, including assessment and co-ordination of care.
Models of Care promotes a well co-ordinated service across all organisations that need to be involved. My organisation, the National Treatment Agency, supports planning with drug action teams at a local level through its regional managers and staff. Absolutely key is the collaboration between all agencies that touch the drug user: health and education agencies, social services, housing and employment agencies and the voluntary sector. Good commissioning is also key, as has been said. We have developed a sound model for social care planning in relation to substance misuse and I believe that it could usefully be taken into account in relation to other aspects of care. We have changed attitudes and structures, a point referred to by my noble friend Lady Pitkeathley.
I want now to look at carers and, in particular, grandparents as carers. Part 2 of the CSCI report states that,
is essential. However, only 7 per cent of councils mentioned having a dedicated carers partnership board and there is very little cross-department collaboration. Perhaps the Minister can tell me whether that has improved.
With my substance misuse treatment hat on, I come into contact with grandparents who are looking after their grandchildren because their children have died from substance misuse, are in prison, or are incapable of looking after their own children. Between 250,000 and 350,000 children live with parents who are problem
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I have now been involved in two meetings with grandparents, hosted by my noble friend Lord McKenzie of Luton, in the Department for Work and Pensions. My noble friend had been wonderfully supportive. He has met grandparents and action points have been identified. Some are very simple. They include producing a simple leaflet on the rights and entitlement of grandparents. For example, there seems to be enormous confusion about what they can claim financially. We have recommended producing guidance to local authorities, which seem to operate in different ways and with differing calculations of how to reward grandparent care. We recommend contacting the Local Government Association. We recommend collecting good practice. We need to ensure that support for grandparent carers from social workers is equivalent to that given to foster carers. We need to look at possible grants for emergencies. We need to ensure that departments at all levels, national and local, are aware of the problems. We need in future to look at how the Bill on children in care can help children who are looked after by grandparents. That means helping grandparents with a better financial package and a better care package.
It would be unfair to ask the Minister to comment today on all these factors. I just want to make him aware of the issue and to ask whether his department will talk to the department of the noble Lord, Lord McKenzie, and other government departments to try to help this group of carers who give up so much to help children.
I have given an example of how caring works when well organised, well monitored and well structured. I have also given an example of where we need to do better. Social care is an important element of a civilised society. It is a symbol of how a society functions. Getting it as near right as possible has advantages for everyone.
3.59 pm
Lord Harrison: My Lords, noble Lords will recall that subterranean army of terracotta soldiers found some years ago in Xian in China. Carers remind me of them because they, too, are subterranean and silent; they, too, have many common features; and they, too, like the statues with their individualised faces, have their own personal stories about caring. That is why I am so pleased that my colleague, my noble friend Lady Pitkeathley, has brought the debate to the Chamber today. I would say to her that it is the second debate today on slavery, because caring can too often be that.
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We do not have to look too far to unearth that hidden army. Often, they are in our own immediate families. A personal story comes from one who is very dear to me who for most of her life has spent that lifetime in vigil with a loved diabetic son and a loved husband, who has only recently succumbed to Parkinson’s. She speaks for all that silent army of carers when she talks about the dramatic introduction that she had to Parkinson’s when her husband first fell ill. She says:
“Of course, being married, one automatically takes on, willingly, caring for one’s own spouse, but being in the midst of caring, I couldn’t see the wood for the trees. What do official carers offer? What do they do? Where do you get your information from? The GPs and various clinics should be positive and not expect the patients’ spouses to do all the asking. Sometimes carers are just plain exhausted and don’t have the energy to pick up the phone or write a letter”.
In concentrating today on Parkinson’s, I hope that I can illustrate some problems experienced by all carers doing the job that we so value. I declare an interest as patron of the Chester and District Parkinson's Disease Society. There are some 120,000 sufferers of Parkinson’s throughout the country but some 500,000 are affected as carers. Three-quarters of Parkinson’s carers say that they themselves have a health problem—and no wonder when for most of them their charge may have an existence of 14.6 years, which is the average duration of a PD sufferer. That is really quite a considerable chunk out of your life to be looking after someone else.
Parkinson’s has the distinction as a disease of fluctuating in nature; it is a complex condition, with clinical circumstances requiring a quick response, and there is a need for specialist advice not only for the sufferer but for the carer. They desperately need the multi-disciplinary teams, such as the Parkinson’s disease nurse specialists; the local support workers to give information and advice; district nurses, who were so wonderful when I had a period of illness; social services; and occupational therapists. But consulting such teams cannot always be done quickly by the carer and the sufferer, and we need to do more.
Some of the problems concern information about carers’ entitlements to assessments. A study by Carers UK in June 2003 showed that only one in three carers has had such an assessment. Indeed, in June 2006, the Parkinson's Disease Society held a focus group in which none of the carers had had such an assessment. Then there are financial difficulties. Many carers face financial hardship; their net income on average is lower than that of non-carers, but they then bear additional costs, such as higher transport costs or expensive food if a special diet is prescribed, extra heating and specialist equipment. Then there is the lack of access to high-quality respite care, currently funded through the carers grant and paid by central government to local government. I am pleased that the Government increased it by £60 million last year, but there is still an unmet need.
The PDS focus group also referred to the respite care and the fact that sometimes the service providers do not thoroughly understand the disease and therefore do not provide the best care. There is vagueness about the eligibility criteria. Sometimes respite care should
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We need to do more to help the two out of five PD carers who receive no additional help in caring for this challenging condition. Of course, the role of the Parkinson’s disease nurse specialist is crucial not only for the sufferer but for the carer, because good advice means so much. In 2005, a Parkinson’s Disease Society survey, appropriately entitled Just Invisible, highlighted the problem of the level of care appearing to diminish as the condition advanced. That begins to install in the sufferer and the carer a feeling of abandonment and hopelessness.
So carers should have a holistic assessment not just about the immediate carer’s needs but beyond that and then the right to receive the benefits that derive from such an assessment. Often the assessment is made and then the help is not provided. Financial difficulties need to be addressed and the pittance carers are allowed, £45.70, needs to be raised to the other earnings replacement benefits equivalent with a corresponding increase in the carer premium of means-tested benefits. All that could help the Government because, for instance, if the extra £100 million was spent on keeping people within their own homes it could mean a saving of £200 million per year that would otherwise be spent on hospitalising.
I have so many other things to say, but I see that my time is drawing to a close. However, I would mention what the noble Baroness, Lady Pitkeathley, said about carers’ breaks. I recommend a very good programme that Diabetes UK has installed and I know that members of my own family have benefited from children’s support holidays and from adult support weekends where spreading the information to the carers of those who are immediately around a member of the family is so vital and important. I would have liked to have asked about children in schools who often have to look after a parent at home. I am in ignorance about that but I would like to invite the Minister to reply to some of the points that I have made this afternoon.
Allusion has been made to the conclusion of 10 wonderful years by our Prime Minister. I have therefore written this little ditty:
4.07 pm
Baroness Barker: My Lords, like the noble Baroness, Lady Pitkeathley, I declare an interest as someone who works professionally in social care. I congratulate her on her excellent timing, because it seems to me that it is a good day to talk about retirement and issues associated with it. I am not going to go into verse, but I am going to start with Tony Blair. In 1997 he said:
“I don’t want to live in a country where the only way pensioners can get long term care is by selling their home and where they struggle for survival, scrimping and saving, cold, alone and waiting for death”.
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Ten years on, as we approach CSR7, that is a good benchmark from which to view the progress that has taken place in the past 10 years and to think forward about what needs to be done in future.
This is a timely debate, coming as it does in the week when the BMA has proposed a constitution for the NHS that would include a statement of what it terms core services that would be provided. Over the past 10 years, one question that has never properly been answered is where the role of the NHS and its responsibility for older people ends and where the role of social care begins. The Government have ducked and dived around the central question of continuing care. It will surprise none of your Lordships to learn that I take a distinctly different view from the noble Lord, Lord Lipsey, and I take a different view of the situation in Scotland. I commend to noble Lords, as I have done previously, a report on care from Stirling University. It explains why costs have increased in Scotland but also points to the immense benefits, particularly to carers, of being able to continue work and to be economically active, because they know that there is going to be a basic entitlement to social and personal care.
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