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Recently, I went to a dance performance at the Queen Elizabeth Hall—other noble Lords may also have attended—to watch the Candoco Dance Company, which mixes disabled and able-bodied dancers in one troupe. It was an amazing performance and it was very difficult to tell the difference between those with disabilities and those without until it was made clear to us. Who would have dreamed of that happening years ago? That is an indication of what could be done. Years ago, I remember my mother, who was a very keen bowler of county standard, being delighted to help with bowls matches for those who were blind or very partially sighted. I never quite knew how that was managed, but I know from what she told me that it gave great pleasure all round. We need to be far more imaginative than we have been hitherto. I pay tribute to those organisations which provide activities for people. I think in particular of the place where I was an MP, in Plymouth, where Plymouth Age Concern had done a magnificent job in making all manner of provisions for their people and had immensely improved their lifestyles and happiness—and probably their health as well.

There is a great deal to be done. I can only touch the surface of it in this opening speech, but I look forward to the contributions which will be made hereafter in the debate. If we wanted a single example of the contribution that older and disabled people can make, we need look no further than this House itself, where the average age is 69. I rest my case.

11.53 am

Lord Lipsey: My Lords, first, I should declare a couple of interests as president of SOLLA, the Society of Later Life Advisors, and as a member of the editorial panel of the study into decumulation—sorry about that word—being carried out by AIFA, the Association of Independent Financial Advisers.

This debate, so admirably introduced by the noble Baroness, Lady Fookes, is timed just as we celebrate—I suppose that that is the right word—the 10th anniversary of the royal commission on long-term care of the elderly chaired by the noble Lord, Lord Sutherland of Houndwood, to which the noble Lord, Lord Joffe, and

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I signed what was in effect a minority report. Pretty well everyone who commentates on this field believes that we need to move on from that royal commission, which palpably did not lead to the introduction of a permanent solution to the problem. By all means let us move on, but there is one thing which it is not possible to move on from. That is the dilemma that in the end prompted the noble Lord, Lord Joffe, and me to write our minority report: there is a limit to the amount of money that government—society—are willing to devote to the care of elderly people. Within that limit, we face and always will face a choice. We can spend money on paying for services which, at the moment, better off people have to pay for themselves, or we can spend that money on better services, more care, more help for carers, smarter housing for people living in their own homes and better care homes—all are services that people need. I am afraid that in the real world we cannot do both. In Scotland—the noble Lord, Lord Sutherland, may talk about this—they have tried to defy this logic by introducing free care. The consequence, besides runaway costs, has been the severe rationing of services.

South of the border, we await the Green Paper—my God, we may have climate change but spring gets later and later in Whitehall. I meant to say that as we await the spring White Paper, the situation is not much better. Ministers, led by the Prime Minister, have canvassed radical reform of the care system for all the good reasons set out by the noble Baroness, Lady Fookes. Charities for the elderly are demanding that more be done to help with the costs of long-term care. I give an example. The Joseph Rowntree Foundation, which has done some very useful work in this field, puts forward four possibilities for a partial reform: equity release, higher capital limits for care home fees, higher personal allowances for care home residents—which of course I particularly support—and free personal care for people needing nursing care. The foundation says that even in the present climate, these provisions can be afforded. Well, they cost £800 million, so it obviously has a different view of what the present climate is like than I do.

The landscape of “realityland” is very different. The last public expenditure plans provided for an increase in spending in this field for elderly people of just 1 per cent a year on social care. That 1 per cent is dwarfed by the costs implicit in the ageing of the population. Local authorities, as CSCI among others has pointed out, are having to cut home care for all but the most severely disabled older people. This actually means that the less severely disabled will deteriorate and have to go into homes rather than be cared for at home, all in the interests of short-term economy—that is a disaster—and that 1 per cent was before the credit crunch. Now, thanks to the crunch, the Government are borrowing billions to bail out banks, and the interest on those billions will have to be paid when the recession is over.

It we turn from the social pages of the newspapers to the economic pages, we see a complete consensus that public spending is going to be subject to an eye-watering squeeze. No one wants to cut health or education, but in these circumstances and in my judgment, the chance of the Government funding a major new

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programme of spending on social care is not high. We must use the public money we have to better effect—that is pretty obvious—but in this bleak landscape, many of the hopes voiced by the noble Baroness and which will be voiced by others in the debate are only hopes.

I have one other positive proposal. There will not be a lot more public money. It follows, therefore, that if we are to make headway, we must look at the potential contribution from the private sector, something that has been almost entirely neglected. One example is the role of equity release. Despite the recent weakness in house prices, most people retain substantial equity in their homes. This is particularly true of elderly people who often bought their homes years ago when prices were low. Equity release enables them to access this asset to pay for care. Some very good work is being done in this field by the Safe Home Income Plans organisation, which will be published shortly. It is a way in which people can pay for care of all kinds, whether it is care at home or care in care homes.

Another is the development of private insurance for care costs. This has been terribly in the doldrums for reasons that I do not have time to go into, but backed by Ministers and if certain tax problems were sorted out, it could play a real role in taking from people the worry of how they are going to pay for their care if they need it. This is for better off people, it is true, but it is they who have to pay under the present system.

Wearing my SOLLA hat, we are all used to councils advising people what to do, but neither they, nor social workers, have a monopoly of wisdom. SOLLA is designed to increase the skills of independent financial advisers who choose to work with the elderly, get to know what they really need and give them advice. Often, that is what they need most because it is such a bewildering landscape and good advice is priceless.

Private provision of this kind is not a substitute for public provision, even though I fear that public provision will become more of a safety net. The SOLLA report said as much. It said that we have to plan for public expenditure on the basis that it will be a safety net and not a duty of local authorities. It will not be a substitute, but it can be a useful supplement, particularly for the better off who should pay for their care from their own resources and not from the limited resources of the state and the taxpayer.


Baroness Thomas of Winchester: My Lords, I, too, congratulate the noble Baroness, Lady Fookes, on the eloquent way in which she introduced this important debate. This issue will get more acute as the population ages. As the noble Baroness said, not only will the population age, but more and more long-term disabled people will want to live as independently as possible, which was the subject of the debate on Friday. I will not repeat what I said then, nor will I ask the Minister when the Green Paper will be published, although I was going to. This is a difficult climate in which to try radically to overhaul the social care system, but that should not prevent the Government from doing more than tinkering around the edges. However, there will be many consequences of the downturn, not least for

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local government. I believe that my noble friend Lady Barker will explore some of those matters further in her debate next week.

Today, I shall draw on the Hampshire commission’s report into personalisation and the future of social care, Getting Personal: A Fair Deal for Better Care and Support, which brought together not just local politicians across all parties but experts from all over the country with a social services background to look at the future of adult social care. The commission reported last November. Its recommendations are well worth studying and range from action that can be taken locally to that which needs legislation. An example of the latter is that the commission, in common with many Members of your Lordships’ House, believes that the carer’s allowance should continue to be paid to those aged over 65 in receipt of the state pension. That is not allowed at the moment because of the overlapping benefits rule.

The Hampshire commission’s first recommendation is the universal offer, which would have to be made by the Government nationally. It would include access to information, advice and supported self-assessment for all, regardless of their level of need or their financial situation. Those with more intense and urgent care needs would have a right to brokerage to support planning and arranging care, regardless of means. Furthermore, the Government would have a duty to promote and publicise the scheme so that everyone would be aware of their entitlements. That is a sensible proposal and means that no one would be given short shrift just because they had not been assessed as eligible for social care.

People who need care—usually older adults—told the commission that they felt “lost and bewildered” when trying to get health and social care. They felt unsupported in trying to access information, even when they were eligible for services, while those who were ineligible often got no information of any kind. A carer’s story reported in the Hampshire commission’s report is typical. She said:

“My mother was in hospital after a stroke. The consultant advised that she would not be able to walk unaided, feed, dress or wash herself again and that we should find a nursing home for her. It was suggested that we should talk to the hospital-based social services team. We did, and on hearing that she would be self-funding, the shutters came down, and the help and information offered was zero”.

That attitude simply will not do.

Some respondents to the survey were distressed that social services were not interested in giving any advice when they asked for just a little help, such as that which used to be given by a home help, even to elderly people who lived alone and had recently been discharged from hospital. Unless these people cannot wash and feed themselves, no one seems interested in how they are going to manage, yet having someone looking in to see if a person is all right can make all the difference to their lives. It is not always possible for elderly people to ask family members or neighbours to keep an eye on them. Many have no family left and, if they are housebound, they are increasingly out of touch with their neighbours, particularly if they live in urban areas.

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The second recommendation of the Hampshire commission’s report is another sensible proposal: that urgent social care should be free for up to eight weeks for all those at risk of admission to hospital or who are being discharged from hospital, where there is likely to be joint care with health. The report states:

“The fact that health is free at the point of delivery and social care is means tested is a persistent barrier to joined-up services and can be particularly hard for people to understand at points of crisis”.

This finding chimes with that of Age Concern and Help the Aged when they state:

“Most people also hold incorrect assumptions about entitlements to social care, thinking that care and support is free at the point of need, like the NHS”.

The Wanless report of 2006 makes this point strongly:

“It often comes as an unwelcome surprise to older people to discover that social care is means-tested and they are expected to rely on their own savings and income until their assets have fallen to the threshold set for state-funded care. It is a common complaint that the existing system penalises those who have saved for their old age”.

The commission strongly supported the principle of personalisation of social care, saying that there was now evidence that the poor take-up among older people in Hampshire was beginning to change and that outcomes were improving. It said that the current system through which people obtain social care was,

The report demonstrates that self-directed support in Hampshire can be highly successful in making life better for older, frail people and those with complex and high-level needs when they are given the right amount of time to make decisions, the right support and real freedom of choice.

There are many more proposals in the Hampshire commission’s report but I will mention just one more, which I think is vital: the importance of training more people in the caring profession. The report makes the point that the current social care workforce is ageing and that there is a need to attract more young people into care work, including those for whom it will be a stage in their career rather than a career-long choice. With the growth of personal budgets in health and social care, a workforce with wider skills than ever will be required to fulfil all the different roles that will be required, including personal assistants and those able to offer advocacy, brokerage and support planning.

12.08 pm

Baroness Emerton: My Lords, I thank the noble Baroness, Lady Fookes, for initiating this debate and for so ably setting the scene on a pertinent subject at the moment given the increase in the numbers of older people. Most elderly and disabled people wish to maintain their independence and dignity and it is important that everything possible is done to ensure that this is made possible by engaging, as we have already heard, whatever agencies are necessary, whether that is for care at home, residential care or hospital care.

It saddens me as a retired practising nurse that the care of older people is having to call for remedial action in order to ensure that basic needs are met. Only this week, the regulating body for nurses and

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midwives, the NMC, has issued guidelines for the care of older people. The document highlights six key points of guidance that reiterate the requirements of basic care. The document was written by a nurse, who was so horrified at the treatment her father received before dying that she has, as a result, taken up the challenge and developed highly innovative ways of treating older people. She was commended at the recent nurses’ national award ceremony. This guidance is designed to demonstrate best practice for all nurses working in hospitals and the community.

Much work has been done to improve the care of older people but more remains to be done. Five years ago, after a flourish of bad publicity on the care of older people, my noble friend Lady Cox and I, both retired from practice, thought we should find out whether there was any truth in these dreadful reports. This we did by bringing together a small group of senior nurses representing management, teaching, research and practice. After two meetings we agreed as a group that there was evidence supporting these reports and that we should try to do something about the situation.

Two members of that small group were members of the Burdett Trust for Nursing who persuaded the trust to commission a piece of work, resulting in the publication in 2006 of a report entitled Who Cares, Wins: Leadership and the Business of Caring. The conclusions for healthcare providers were that they need to,


The report was supplemented by an explanatory study of the clinical content of 60 NHS trust board meetings. Only 14 per cent of the 60 sets of minutes contained any clinical mention.

Members of this House will be familiar with the great deal of progress that has been made since the publication of that report, thanks to the NHS review conducted by the noble Lord, Lord Darzi, with its strong emphasis on high quality care. In addition, the Burdett Trust for Nursing commissioned a further piece of work through the King’s Fund, which has just published a report entitled Ward to Board. This was a study of seven pilot units that worked through the recommendations of the Who Cares, Wins report. Within the past few weeks the Royal College of Nursing has published a further report, Breaking Down Barriers, Driving Up Standards, a study into the ward sister’s and charge nurse’s leadership and managerial roles. I hesitate to mention more reports, but these all point to the need for effective leadership, from the patient to the board, with the appropriate accountability and authority at all levels. There has to be a balance between finance and quality but, regrettably, the most recent Healthcare Commission report into the Mid Staffordshire Foundation Trust demonstrated clearly that the emphasis was on financial targets to the exclusion of high quality clinical outcomes.

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Against that background of needing to balance the delivery of high-quality care through effective leadership roles with defined accountability and authority within the allocated financial resources, I shall move on to the principles that apply specifically to the care of older people and those disabled people requiring long-term care. That reminds me of the work that I did over a period of 10 years in the late 1970s and into the 1980s, with those suffering from learning disabilities and psychiatric conditions, with which my noble friend Lord Rix, will be familiar. These services had suffered as what were described as “Cinderella services” through a lack of resources in both finance and a specially trained workforce. Restoring the balance to high-quality care required leadership, tenacity of purpose and the ability to champion change. During that time there were several inquiry reports all sharing 30 of the same areas of mistakes that led to poor-quality care.

Thankfully, we have moved on, but we cannot afford to ignore the signs that indicate that in some areas there is poor quality of care where clinical pathways have not been established and sufficient resources made available, either in hospital or the community. It is at our peril that we ignore the opportunities presented by the next-stage review, the other supporting reports and guidance from the regulator. Each indicate the direction needed to be taken to ensure that these groups of people receive the high- quality care and support that they deserve, to allow so far as possible a fulfilling life of independence and dignity that does not impose impossible strain on their families and friends who undertake the caring function.

The enabling legislation in the current Health Bill clearly sets out ways forward for raising standards. It is important that work is already in hand, led by the Chief Nursing Officer, Dame Christine Beasley, towards implementing the recommendations of the Minister’s review, encouraging the development of education for nurses and midwives both pre-registration and post-registration, bringing in teaching to establish best-evidence practice of high correlation of theory to practice and the work introducing measurement of quality care, all working towards enabling staff and empowering the people towards high-quality care.

However, could not further consideration be given to how implementation can be achieved by building on leadership skills, championing change processes within the appropriate attitudinal approach and sensitivity required for the compassionate care needed by this group of older people and those suffering from longer term disabilities?

12.15 pm

Baroness Greengross: My Lords, the noble Baroness, Lady Fookes, spoke so eloquently about these important issues and I congratulate her on securing this debate.

We know about the ageing of our population and we know that the huge numbers of older people will include many with acquired disabilities even if they did not have them earlier, so we are talking about very large numbers of people. Yet unfortunately age discrimination is still rife and those older people who need care and support often get much smaller packages than young people who have similar needs. I remember

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saying very often that if you are going to get a disability, make sure you get it before the age of 64 because your benefits and the help you get will not be the same if you are older. That is really unacceptable and it just goes on.

We need a clear timetable for reform where it is so urgently needed. All the different payments and care sources need to be brought together so that people who are frail and vulnerable and often in a crisis situation—where they and their families may be in urgent need of advice—do not have to go from one place to another. If you are frail, old and tired, you cannot always do that. People just need a one-stop shop where they can get the advice and help that they need without charge and they know exactly what is going to be available to them.

We also really need to have human rights embedded in the services that are provided. Human rights can do a great deal to ensure dignity and respect for people, and should be at the heart of commissioning as well as regulation. At the moment an awful lot of the help that is provided has become more and more task-oriented and time-limited. If a care assistant or a worker goes into somebody’s home they just have time to get them up or put them to bed. They do not have time to deliver the humane care and the kindness really needed by the sort of people we are talking about, who are very vulnerable, often very lonely and desperately in need of help.

The personalisation agenda is very good. It can help enormously and, as the noble Baroness, Lady Fookes, has said it must be introduced with a high degree of sensitivity, recognising that a lot of people will need continuing help in managing the care package they will receive. That package and the resources allocated to it should be fair and transparent; it needs to be outcome-focused, as Age Concern and Help the Aged have stressed continually. Free advice is essential and funding remains an enormous issue.

On dementia, which the noble Baroness, Lady Fookes, underlined, 75 per cent of people in care homes today suffer from some form of dementia, but two-thirds of all sufferers are actually still living in the community. This is a desperate situation, not just for them, but for their families and those who care for them. Unfortunately, we know that the early stages of dementia are often misdiagnosed and that dementia research is abysmally underfunded. It receives just 2.5 per cent of the Government’s medical research budget, but more people suffer from this than suffer from cancer or heart conditions. It is an urgent need. We must get more research done because we must find the answers to this huge problem.

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