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As we move towards CSR7, the question of where family responsibility for social care ends and the role of the state begins becomes ever more urgent. People aged 65 and over constitute some 16 per cent of the population, but account for 43 per cent of NHS expenditure and they occupy 65 per cent of acute beds. In 2004-05, older people accounted for 58 per cent£6.38 billionof social services expenditure, not including the £1.7 billion of which the noble Viscount, Lord Tenby, spoke. In addition, older people received 71 per cent of all social care packages.
In April, Sir Derek Wanless, author of the Kings Fund report on the future of social care for older people, noted that one year on from his report little has changed other than there being wider agreement that the current system is in crisis. Budget increases are welcome but have not kept pace with growing need. The people who have missed out are those with moderate needs and modest means, as other noble Lords have said. The Joseph Rowntree Foundation produced a report in April on older peoples views on their experience of available resources in later life. It is important research, because many respondents to that survey had a high level of responsibility in saving towards the costs that they thought would occur in retirement, but many found it difficult to plan for the biggest determinate of costs in later life: ill-health. They knew neither what their needs would be nor what social care they could or should expect. That survey highlights a factor that is often overlooked. While there is agreement that people should be encouraged to save for their retirement, both for income and for their care, there is no way of knowing what level of state health and social care they can expect, making it extremely difficult to plan prudently.
Julia Unwin, director of the Joseph Rowntree Foundation, in an article in April, argued for a clear system of social care entitlements, citing countries such as Japan, Germany andI should say to the
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Helping someone to carry out the basic functions of everyday living is not cheap, and it is not a cost that a private individual can really budget for. Private insurance on reasonable terms is not available because insurers know too little about the longevity and health of older people several decades ahead to be able to offer products on reasonable terms.
The noble Lord, Lord Lipsey, conceded that point.
The noble Lord also talked about equity release. He is not the only person who has seized on the idea of equity release as an answer to how we get more money into the social care system. Equity release is attractive but it is not without its difficulties. It is an option that might work for some people at a time of rising house prices, but what happens if property values fall? Is it not wrong to conflate two issues, healthcare and housing, each of which has a degree of risk attached, into a giant lottery, thereby compounding the difficulties for individuals? The consequences of that on the housing market are, as yet, unknown. Even Kate Barker, in her report on housing, recognised that there were issues regarding older people and their occupation of housing, but she did not analyse them fully. Yes, it is right to enable older people to use equity release for such things as repairs and adaptations to enable them to live independently, but the funding of care for an extended and indeterminate period cannot be sustained solely or even largely by capital release.
A further issue to which the Government need to give urgent attention was raised by Sir Derek Wanless in his report and by Dame Denise Platt in her report on the status of social care. I refer to the development of a robust evidence base for social care. Sir Derek questioned whether the current configuration of social care services delivers the desired outcomes. Dame Denise pointed out that while the Department of Health contributes £10 million to research into social care, that compares with the £650 million spent on health research. Even though there is the research programme Modernising Adult Social Care, research is dispersed around a number of different organisations and academic institutions.
What is clearand I say this very strongly as somebody who works in the fieldis that there is a thirst among social care professionals for an evidence base to what they do. They see that as the biggest single contribution that could be made towards designing a system which meets the needs of older people and their carers. At a time when the NHS, via departments such as the Care Services Improvement Partnership and Care Services Efficient Delivery, is bringing back a huge evidence-based change and reorganisation of health services for older people, there is no equivalent programme for social care. When it comes to the point when the commissioners have met the procurement officers and push has come to shove, low-level preventive social care services continually lose out against medical services, which may be redesigned in such a way as to give immediate wins to the NHS.
I agree on one point with the noble Lord, Lord Lipsey. That is something I do not say every day but today I really mean it. We know in the voluntary
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Earl Howe: My Lords, of all of us in this Chamber, there are few, if any, who can provide a more authoritative view of the state of social care than the noble Baroness, Lady Pitkeathley, and I add my own thanks to her for introducing this debate so clearly and so well. As with almost any topic under the remit of the Department of Health there is cause for praise and cause for disappointment. However on this occasion, rather than launch into a criticism of the Government, I would rather pick up a few of the themes of this debate and explore some of the extremely problematic issues of policy with which Ministers of whatever Government will have to grapple for some years to come.
It is the modern way to talk about challenges rather than problems. If we regard the future provision of social care as a challenge, then at the root of that challenge, as has been said, are the demographics. Over the next 20 years we will be looking at no less than a 40 per cent increase in the number of people aged 65 and older. I have heard some people say that this trend does not really affect things one way or the other. People may be living longer but they are living healthier and more active lives. Unfortunately that is not right. We are going to see not only more elderly people but more people living with disability and chronic illness. Wanless reported that the number of older people suffering from some sort of disability is growing nearly 10 per cent faster than the number of those without a disability. If those statistics are converted into a graph reflecting the demand for social care, we see that demand rising by about 50 per cent between now and 2026. At the same time, we know that the unit costs of social care services typically rise at a rate higher than the ordinary RPI. If those things are put togetherI obtained these figures from Professor Julien
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The reality of this situation has to be faced. Someone may ask whether, as a society, we can afford it. The answer is that we have to, but we will have to make some adjustments along the way. The noble Lord, Lord Lipsey, pointed to some long-term options, but some of the short-term adjustments are confronting us at the moment. The strain on budgets at local authority level is, as we have heard, already causing a number of social services departments to ration adult social care to individuals with the highest levels of need. That is not good. Low-level need counts as well, and it counts a great deal. The quality of paid-for care may be going up, but the number of people receiving that care in their own homes is falling. That falling trend is exactly contrary to the one that all of us here want to see, including, I am sure, the Government. The whole thrust of Our Health, Our Care, Our Say, which I for one strongly support, was to promote a shift from treating patients in acute settings to looking after them in the community, forestalling health problems, and making it possible for health and social services to work more closely together. Those were all good concepts, but none of us meant by them that we should put more and more of the strain for delivering care on to families and unpaid carers. We are more than 12 months down the track and the visible progress in implementing the White Paper is a little disappointing.
How far are we getting with joint working between health and social services? One positive step taken recently was the relaxation of the rules for the commissioning of low-level social care services by GPs. Another helpful change is that the areas covered by PCTs now more closely reflect local authority boundaries. But the NHS reorganisation and upheaval that brought that into effect last year did nothing to move the process of integration along. In many areas, there is still a them and us feeling between the NHS and local government. The shortage of money in PCTs, as well as in local government, has made these joint arrangements difficult to embed properly. By next year, we are supposed to be seeing joint health and social care networks springing up: teams of people drawn from both sectors who can support those individuals with more complex needs. We are led to understand that pilot projects are not far away, but we need to see them in action quite soon if progress is not to fall behind the plan.
When CSCI reported at the beginning of this year, it pointed to a growing gap between government policy and the reality of what service users on the ground experience. One problem area is that of commissioning, where many local authorities are not thinking out of the traditional box of commissioning residential care and are not putting enough emphasis on allowing those whose needs are being served to exercise choice, control and independence over their lives. Many authorities do not carry out a proper assessment of needs, and that applies particularly in the case of people with more complex health and care problems. One cannot make blanket criticisms in a field such as this but, in many local authorities, there is no doubt that the mindset has to change away from,
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Nowhere perhaps is this mindset more evident than in the provision of informationanother subject that noble Lords have touched on. A lot of very revealing work has been done in this area recently by the Picker Institute. When people need help, they want to find out what is available, but it is very difficult for the average person to do that. GP practices are not generally good at pointing people in the right direction, and there is very little co-ordination between the NHS and local government in providing information that is relevant. The result is what the Patients Association has described as a maze, which people are left to navigate themselves through as best they can.
Once again, all this points to an attitude of mind that needs changing. I do not know whether the Minister saw the lead article in this week's Local Government Chronicle, reporting the comments of Paul Snell, the chief inspector of social care, who has made the point that it is not good enough for councils to focus solely on those people whose care they fund or procure. In some parts of the country as many as 80 per cent of people in receipt of care use their own money to buy it, and because of tightening budgets in local government those numbers are rising. So for those individuals and those who are fortunate enough to be in receipt of direct payments, it is incumbent on councils to act as honest brokers to help people to make informed and impartial choices and to enable money to be spent to best effect. Other than in a few places like West Sussex, that simply is not happening.
Here we are not talking about an absence of policy, but poor or unimaginative delivery. This is also about transparency and honesty. The other day, I was very struck by the Secretary of State's remarks on Sky News, when she said that PCTs were absolutely entitled to restrict access to treatment for smokers and people who are overweight. This is not the moment to have a debate about that issuewe may agree or disagreebut it highlights that patients need to understand their rights. There is a widespread expectation among the public that the state can and will provide. People need to be aware of precisely what the state can and cannot provide and under what circumstances. It is not right that as publicly funded care is progressively rationed, people should be unaware that the bar is slowly being raised; nor is it fair that in different parts of the country the basis on which needs are assessed should differ. There are very good systems for assessing needs on a basis that would result in comparability and fairness around the country, but they are not used.
It was interesting to hear the Chancellor of the Exchequer say at the last Labour Party conference that personal care for the frail and old was,
As this is a long-term issue for government, it implies the need for a broad consensus on state funding and what citizens should be entitled to expect from which arm of the state. It implies a joint recognition that we
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The noble Baroness, Lady Pitkeathley, has articulated not a set of problems, but a set of challenges which I hope the Government and all concerned with the delivery of social care will rapidly take up.
The Minister of State, Department of Health (Lord Hunt of Kings Heath): My Lords, we have to finish the debate at 4.46 pm, and I shall attempt to respond to the main points raised in this splendid debate. I congratulate my noble friend not only on her initiative in securing the debate but on her tour de force of some of the key issues that we as a society face generally and the contribution that social care has to make.
It is interesting that, in facing up to some very big challenges for the future, there has been a greater sense of confidence about social care and its achievements in this debate than I have observed in many previous ones. It is important that we celebrate the achievements of the past few years. That will be a great confidence booster when dealing with some of these very difficult matters in the future. I agree with the noble Earl, Lord Howe, on demography, and the fact that we as a society have to face up to some very difficult decisions and issues. I also detect a consensus emerging on the need for a well informed debate which does not believe that there is one simple answer to the issues that have been discussed today.
A number of noble Lords mentioned the important CSCI report on social care which showed that services are improving. It is important to remember that, although it then referred to what it described as shortsighted commissioning decisions by local authorities and issues surrounding eligibility, to which a number of noble Lords have referred.
Let me say to the noble Viscount, Lord Tenby, that I do not underestimate those resources issues. However, although the NHS has had a considerable increase in resources, which I believe was justified and which has benefited many older people, the contribution to local authorities has increased by 39 per cent in real terms since 1997. The Commission for Social Care Inspection has reported on improved social care services for adults for the fourth successive year.
I hear what my noble friend Lord Harris says about the priorities that local authorities have set. However, in 2007-08, authorities will benefit from government grants of about £1.6 billion for specific initiatives in adult social services. There are many examples of significant investments in that area as well.
I understand that there is considerable interest in the current discussions on the Comprehensive Spending Review. I will reflect over the next few weeks whether it would be advisable for me to send the ditty of my noble friend Lord Harrison to the Chancellor of the Exchequer.
I cannot say anything more about the CSR than has already been stated. However, the 2006 Pre-Budget Report faces up to a lot of the long-term issues that have been raised, particularly the number of older people and the implications for public services. It mentions the Wanless review for the Kings Fund and the report of the Joseph Rowntree Foundation, which the noble Baroness, Lady Barker, mentioned. It says that in assessing proposals as part of our long-term vision for older people in the current CSR, the Government will consider whether they are affordable, whether they are consistent with what is described as progressive universalism and whether they promote the independence, dignity and well-being which so many noble Lords have mentioned. My department is in continuing discussions with the Treasury about the CSR settlement.
I do not underestimate the concerns that noble Lords have about eligibility criteria and the suggestion that local authorities are raising them, as the social care inspectorate has said, although it is a fact that the number of people receiving social care is rising rather than falling. I echo the comments of the noble Earl, Lord Howe, about the risk of neglecting what he called low-level need. Not dealing with those needs means storing up trouble in the future. The message to local authorities has to be that dealing only with those with the highest need is not a good use of their resources. They need to place emphasis on preventive services, helping people with lower needs to avoid admission to hospital or residential care.
My noble friend Lord Lipsey returned us to a debate on free personal care that goes back many years. I disagree with the noble Baroness, Lady BarkerI think that experience has been borne out and that my noble friend was right when he took his courageous view on the royal commission at the time. I was interested in the comments of the noble Baronesss colleague, Sandra Gidley, that were reported as arising from the Liberal Democrat conference when she called her partys policy of free personal care dishonest because people thought that their accommodation costs would also be paid forwhich is certainly not the case.
Looking at the experience in Scotland, I am not sure that I altogether recognise the rosy picture that the noble Baroness, Lady Barker, painted from the research she quoted. In fact, a number of local authorities in Scotland have to pay money back to clients who have been wrongly charged in relation to preparing meals for the elderly, and there are waiting lists in some councils for assessing peoples personal care needs. We were told that free personal care would suddenly eradicate all of these problems, but that idea has not been shown to be true in practice. We know that there are simply no easy answers when it comes to funding.
We all want personal services to be offered to people in this category. The noble Lord, Lord Best, and my noble friend Lord Harris talked graphically about that and about the importance of direct payments and individualised budgets. Although that has huge potential, I also understand the concerns expressed about what was described as a slow uptake
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The noble Lord, Lord Best, made some interesting comments about the voluntary sectors role as enabler and empowerer rather than as one of necessarily providing services. As the noble Baroness suggested, individual budgets and direct payments could have a very important role. My noble friend has championed the role of carers for many years. She also mentioned the current strategy review. I will ensure that the important remarks of my noble friend Lord Harrison are fed into the review. I particularly take his point on the need for public authorities and GPs to be proactive in providing information to carers, rather than expecting carers to struggle through a system to find out what help is available to them. That applies as much to child carers as to adult carers.
I also noted the comments of my noble friends Lord Harrison and Lady Pitkeathley on emergency respite care, which I know is an issue of concern. My department plans to issue guidance to local authorities in summer 2007 to help them recognise the need for more effort. Likewise, I can tell my noble friend Lady Massey that I have taken note of her comments on grandparents and about my department meeting the Department for Work and Pensions. I shall certainly ensure that that happens. As she will know, we have made provision in the Pensions Bill to help grandparents if they are primary carers. However, I accept that more needs to be done.
The noble Viscount, Lord Tenby, made some interesting comments about learning disability services, which I fully understood. I also understand that there are real issues about information for users and their families. It is important that the partnership boards which he mentioned are involved in helping on decisions rather than feeling that they are being ignored. I very much agree with him on that. He also made some very interesting remarks about commissioning. Indeed, a number of noble Lords spoke about the need to enhance the commissioning process, not just in social services but in the health service. It is the same issue. I was very interested in the comments of my noble friend Lord Harris on the development of an institute of commissioning professionals. It sounds like an excellent idea. Dame Denise Platts report is very important in that regard, and I pay tribute to her work. Her report stresses the issue of leadership and how it can be enhanced. Commissioning skills have to be seen in that context. We want to take that forward.
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