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The fact is that there is currently a substantial gap between demand and what is available; again, this will become even more pronounced in the months and years ahead. Day services are being cut, as I know through personal experience. Even more alarmingly, 73 per cent of councils now offer support only to those deemed to have substantial needs. This, of course, stems from councils currently being under extreme financial pressure. It has been estimated that, even with less expenditure and reduced support, three-quarters had overspent their learning disability budget by 2.7 per cent in 2006-07—that was the situation then, let alone now. The previous national director for learning disability has stated that an additional £1 million for each English local authority would be needed every year for the next 10 years to provide good-quality social care, adding up to a whopping £1.5 billion over current expenditure levels. The mind boggles.

I applaud the work of CSCI and many local authorities, particularly my own. I also give three cheers for the departure from the uniformity of old. Let us rejoice at self-advocacy and people-centred planning and at stretching the horizons and quality of life for all those in social care. Amidst all the justifiable enthusiasm for independence and self-enhancement, however, one must never forget that there are many who, sadly, may be unable to look after themselves completely—a fact of life of which the parents and carers are only too well aware. This experience and knowledge must never be ignored or dismissed lightly by the authorities. In giving thanks, I reserve my special tribute to the many hundreds of dedicated social workers who labour with love and energy to make life better for those in need. They really deserve such a tribute. Whatever financial stringencies confront us in the years ahead, let it never be said that we neglected by one iota the well-being and human rights of our vulnerable communities.

12.51 pm

Lord Sutherland of Houndwood: My Lords, I add my thanks to those given to the noble Baroness, Lady Fookes, for securing time to debate these very important questions. I shall confine my remarks to the long-term care of older people. The disability case was so well put by my noble friends Lord Rix and Lord Tenby that I shall focus on the older section of the community. I declare two interests: I am president of Alzheimer Scotland, where I see marvellous things being done on a voluntary basis by those who care, by those who need care who provide support for others and by those members of the wider community who have become involved in their excellent work. I am also an adviser

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to Scottish Care and to English Community Care Association, organisations devoted to improving the professionalism and quality of care homes in our community.

Where are we now? Several years have passed since 1996-97, when the Labour Party assessed the big issues in the light of the forthcoming election and included as a very high priority in its manifesto the need to address long-term care of the elderly. Reference has been made to the previous Prime Minister’s attitude to this issue. A Royal Commission was established, but here we are, in 2009, essentially facing the same questions. That is a scandal and a disgrace. The Government have had plenty of advice. They did not like the Royal Commission’s advice. The Joseph Rowntree Foundation has produced two reports and the IPPR has produced a report, as have the King’s Fund, Derek Wanless and others. They have had plenty of advice. What is lacking is the will to create a policy that will drive direction. My basic question to the Minister has to be, when will we have a policy? Let it not be after the next election, as a further two years would be wasted, with their attendant misery.

A key principle enunciated by the Royal Commission is the need to have equity, which I do not think anyone doubts. One could argue about what this means. I pin my colours to the mast when I say that it means spreading the risk across the whole community. As has been said, you may have liver failure, lung cancer or a broken arm, but care will be provided by the state, whereas if you have dementia, a form of brain disease, you are in a very different position indeed. That is appalling. If we cannot afford to cover all these conditions, we should at least ensure that the risk is spread so that there is equity between various forms of illness. As some noble Lords have said in their excellent speeches, a single pattern of assessment with a single common set of criteria of need that operates without postcode intervention and local authority change is required. The lack of such an assessment causes much agony and annoyance across England. It does not happen in Wales, and we should ask why. It is not that there is more money or a different policy, rather that they seem to be able to make it work. It does not happen in Northern Ireland, and I shall come back to Scotland in a moment. A single pattern of assessment and definition of needs, accompanied by a single point of commissioning, is required—what my noble friend Lady Greengross referred to as the one-stop shop. Those in need, carers or those who need care desperately call for a single point of contact, a single reference, where they can be dealt with as whole human beings, not as a series of bureaucratic items spread round various Civil Service departments. Behind that lies the need for a single budget, which was recommended by the Royal Commission more than 10 years ago.

The local authorities that are most successful in this regard in these difficult times are those that have managed to bring together health provision and social care provision, sometimes through a single chief executive appointment. This has happened at key points throughout the country. It works well, everyone benefits and money is spent more efficiently. Will the Government ensure that this best practice is spread more widely?

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The range of funds available can cause uncertainty for those in need of care. No one attempts to co-ordinate health service funds, social care funds, attendance allowance, disability allowance and housing adaptation budgets. I challenge the Audit Commission to determine whether we are getting value for money in that regard. Huge sums are involved but often different criteria are applied to them, which means that they do not constitute best value for the community or the individual.

The noble Lord, Lord Lipsey, used two mischievous —or worse—expressions in regard to funding in Scotland. He said that Scotland had runaway costs and severe rationing. On the best interpretation, that is the product of irresponsible headlines. I will not tell noble Lords the worst interpretation as it would be unparliamentary to do so. However, the provision of care in all its forms for older people in Scotland costs £2.5 billion, of which personal and social care accounts for £225 million—that is less than a tenth. Of that, £30 million in attendance allowance is saved, so you can knock that off. The difference between Welsh policy and Scottish policy amounts to 14 per cent of total costs paid from the private sector. That means that the gap as regards what is not provided in Wales but is provided in Scotland is about £40 million. However, there is a £30 million saving in attendance allowance alone. What happens to the attendance allowance money? It stays with the Department for Work and Pensions and does not go back into care. I am being signalled that I have spoken for nearly seven minutes. I end with the single message that we should look at the numbers and find out what the net cost is, not the headline cost. I hope that the Government will soon define their policy.

12.59 pm

Lord Kirkwood of Kirkhope: My Lords, this has been a fascinating debate. We have heard 10 excellent speeches. I, too, congratulate the noble Baroness, Lady Fookes, on initiating the debate. Its timing is absolutely perfect. In those 10 speeches, we have heard about families who have been very significantly affected by physical or mental impairment. The noble Baroness, Lady Gardner of Parkes, made an emotional and powerful speech which demonstrated that no matter how strong a family is, the fickle finger of fate can strike unexpectedly. This is not an argument just about people who are in financial adversity; it can hit anyone.

If you are looking for another example, look at what the author Terry Pratchett has been able to do in demonstrating his courage. He is so successful and established, and his bravery in confronting his condition is an example and a signal for many that there are planning and practical things that can and should be done. I hope that this debate will encourage people to think about these kinds of things.

More than anything else, I add my voice to those who say that the delay that the Government are now engaged in is completely unconscionable. The noble Lord, Lord Sutherland, used the word “scandalous”. Many of us studied the valuable piece of work that the noble Lords, Lord Lipsey and Lord Sutherland, did 10 years ago. For me, it was the appendices and the volume of evidence that the Royal Commission put into the public domain that convinced me beyond

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peradventure 10 years ago that this was an unanswerable case and something had to be done. There were high expectations that something would be done, and those expectations have been dashed.

That is not a cost-free problem. In those 10 years, if people had had a signal about the direction of travel that the Government were going in, they could have made practical dispositions and taken steps to try to configure their lives during their working life by saving contributions, taking out insurance policies during their working life and building up circumstances to protect themselves for longevity and long-term care. No one has been able to make any sensible dispositions, because we do not know what the circumstances are going to be. It is absolutely imperative. It is not the Minister’s fault, because she is perfect in every way as a Minister. The Government have got a case to answer given the lack of any real direction of travel.

Reports have been published not just by the Royal Commission but by the King’s Fund, the Wanless commission and the Joseph Rowntree Foundation. There is no shortage of things that can and should be done. The noble Lord, Lord Lipsey, is right to say that the resources that we are looking for will be harder and harder to find. That is not a reason for doing nothing. I do not think that he was saying that; I think that he was saying that we have to be practical and realistic. Everyone is prepared to be practical and realistic, but as a nation we have to understand that the total wealth devoted to this subject will have to increase, because we are all living longer. One in four people born in the United Kingdom today will live to be 100. Even if we do nothing, it is going to cost us more.

Of course, the funds have to be found from somewhere, and we cannot look to the Government to do everything, because taxation has a part to play. No one is saying that this all must be paid for out of general taxation. People are looking for individuals to be encouraged to make working-age contributions, and they even are looking for families who can to make positive contributions, either out of personal pensions, state pensions, liquid assets or heritable assets. No one thinks that this is going to be easy, and everyone wants to contribute to sharing some of the costs.

The point made by the noble Lord, Lord Sutherland, about sharing risks is nearly as important as the costs; it is an essential part of this deal. If you can share the risks across the generations, across age groups and across households, you get a much better deal for everyone. These things are obvious, and they are staring the Government directly in the face. It is puzzling why it has taken so long to get a Green Paper, for heaven’s sake. The point was made by the noble Baroness, Lady Fookes, at the beginning of the debate. That suggests to me that there is no prospect of legislation this side of an election. We may have a new Government after the next election, for all I know. You never know what might happen. That Government might say that they need a Royal Commission to start again. The situation is urgent. People may say that long-term care is a long-term policy, and it is, but we are running out of time to enable people to make proper dispositions for themselves and their families and in the future to protect themselves against some of these devastating things that can hit families.

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The demographic trends are known and have been mentioned. I wonder whether people understand just how dire some of the resource problems and care problems will begin to look. Looking at the demographics, by 2050 there will be twice as many people over the age of 85. That has really compelling policy implications, not just in health, care and transport but other things. We need to understand the extent of the problem. I was very encouraged by the speech made by the noble Baroness, Lady Morris of Yardley. We are far too unambitious about what we can do with people who are reaching the end of their natural life.

As someone who spends quite a lot of time in the House of Commons gymnasium, I can tell you that its locker room is an interesting place to be; you learn all sorts of things in strange circumstances there. I learnt from the professional assistants there that every one of us can be a relatively fitter 70 year-old than we were at 60. You can target improvements in VO2, health and that kind of thing even at the end of your natural life.

We need to introduce arts, photography and music and to involve the community instead of doing this care thing in isolation as we seem to be doing. We are heading towards personalisation. I can understand the value of that, but I am fearful that that just means that people are thinking that everyone can do it for themselves. There is a much wider community interest in this subject. We must not lose that in the pursuit of personalisation of care, which is worth having for itself.

We also have to consider that the context in which this debate is taking place has changed from 10 years ago. The noble Baroness, Lady Greengross, who made an excellent speech, with all of which I concur, made the point about human rights now, rightly, being a much bigger part of the equation. Look at what the Government are doing with the Equality Bill, which is being delayed. It looks as if the age discrimination legislation, which the Government are right to advance, is also going to be delayed. Both of these things are intrinsically important to get the dignity and respect agenda properly implemented and enforced. Human rights and dignity, to which we all aspire, are something that the Government need to look to in making their Green Paper proposals.

Noble Lords mentioned quality, which is very important. I can hand on to the Minister for her Easter reading the book by JM Coetzee Slow Man. Coetzee is a very dark author, but he is a wonderful writer, and he describes the circumstances faced by someone who loses a leg in old age, whom he describes as eventually being “unstrung” by the experience. It is a very interesting book, because what he describes more than anything else is the value of the quality of the care rather than the clinical aspect of the package. Some colleagues mentioned that earlier. Sympathy and companionship are nearly as important as the clinical standards that are produced in the package. In the book, he is really saying that you need to care as well as to promote care when you are trying to help people in these dire circumstances.

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1.09 pm

Earl Howe: My Lords, I congratulate my noble friend Lady Fookes on a masterly opening speech in which she very succinctly focused our minds on the importance and the difficulty of this subject. As she said, and as other speakers have implied, this debate foreshadows the forthcoming Green Paper on adult social care and lays before the Government the range of questions which we expect that document to begin to answer.

They are not easy questions. We start from a rather unusual position for a policy review. It is not often that the Government explicitly states of a publicly funded service that it is not sustainable; but that is what the consultation document, Care Support Independence openly acknowledged by citing changing demographics and changing societal expectations. It made the point that those expectations, even now, are often not being met. The document speaks of the need for a,


That may not be quite the right way to put it, and I will come back to that, but the point is that the Government are telling us that the review in prospect is to be no ordinary one.

The background to all this, as noble Lords have said, is that the proportion of older people in our population is growing. You sometimes hear people say that this will not impact unduly on the health and social care budget, because even if people are getting older, they are at the same time freer of illness and disability. Perhaps they are thinking of the noble Lord, Lord Rix, when they say this. Statistically, alas, that is not accurate. 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. In 20 years, at least 1.7 million more people will have a need for care and support of some kind than at present.

What should we be aspiring to? The Government have set out their vision of how a decent care and support system in the 21st century ought to look. The key words are ones we have heard today: promoting independence and choice, high quality care, targeting support where it is most needed and affordability. It is the last of these where the rub lies. There is a funding cake but the cake is not big enough. We know that, because, as the noble Viscount, Lord Tenby, and others told us, rationing is already happening at a local level. Eligibility criteria are being constantly tightened.

Where should the extra money come from? One answer that the Government are looking at is for some sort of compulsory savings scheme to cover the cost of care. Some very persuasive voices out there are saying that this is the only way to go; but to many people, compulsory saving may sound suspiciously like a form of extra taxation from which they may never benefit. Certainly we need to look at such a system and see how it might work; but compulsory saving will never be practicable for those on low incomes or, crucially, for those with learning disabilities or who are seriously

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disabled at a young age. When we look at caring for young, long-term disabled people, I am not averse to the idea of a quite separate structure of public funding, recognising that many of these individuals will not have the chance to acquire financial means of their own.

The injustice that is most often talked about in the current system is that while the prudent and thrifty are penalised in old age by being made to sell their houses to pay for care, the feckless poor have everything paid for them out of the public purse. So far, in 12 years, the Government have said and done almost nothing to resolve this issue, even though Tony Blair highlighted it in 1997 as an injustice. I hope the Green Paper faces the issue head on, either by coming up with a solution—as, I may say, my own party did at the last election—or by admitting that, for now and for the times we live in, it is too difficult a nut to crack. The issue cannot be ducked.

The other injustice in the system, the postcode lottery, was mentioned by the noble Lord, Lord Rix. If we think there is a postcode lottery in the NHS, there is an equally blatant one in adult social care, which is why the consultation paper floats the idea of moving away from the current system, whereby eligibility for care is decided by local authorities, to a nationally based system. Personally, I am drawn to that idea. As Help the Aged and others have pointed out, the usual argument about local decision-making being better because it can respond more easily to local need is in practice a fiction, because most councils can do little more than provide the essentials to those whose needs are the most serious.

The current debate around social care is not just about the funding gap; it is also about what might be termed the care gap. CSCI have estimated that 6,000 older people in England with high-level support needs are receiving no social services and no informal care, 275,000 older people with less intensive needs also receive no care, and 450,000 people receive some measure of support from family and friends, but their full care needs are unmet. Those are disturbingly large figures, but if we then look at the demographic curve over the next 20 years and the projected ratio of workers to retired people, we see another gap emerging between the number of people needing care and the number who are in a position to deliver it. Some 80 per cent of adults of working age are in some form of employment; the available cohort of women carers is reducing. Like it or not, informal care looks set to be a major element of the care equation for the indefinite future. The London School of Economics has estimated that demand for informal care will actually outstrip supply by 2017. By 2041 there will be a shortfall of 250,000 intense carers—people who give care for more than 20 hours a week. In other words, if we do nothing, a quarter of a million fewer disabled people will receive informal care in 2041 than at the moment. How are we going to bridge that gap?

The answer suggested by various think tanks and informed academics is that we need radically to rethink our views about family and community responsibilities. We cannot look simply to families. Increasingly they are becoming dispersed and fragmented. I am one of

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those who believe that we need to look beyond the narrow framework of family at neighbourhoods and voluntary groups. In doing so, a fundamental question is to be addressed about the balance of responsibility between society in its various guises and the individual. The respective roles of government, the community, the family and the individual need to be better defined if we are to reach a consensus on what is fair and practicable for the future. If we believe that the wider community has a potential role in delivering care and support, we need to do some hard thinking about how best those forces might be mobilised, and by whom. The Government have an obvious role in facilitating such a process, and so, I believe, does the Church. What would such facilitation look like?

Unfortunately the clock is ticking and there is no time for me to expand at length on that interesting theme, but the Minister may care to read some stimulating ideas coming out under the banner of, among others, the Joseph Rowntree Foundation. Like my noble friend, I believe that we need to focus public policy much more closely on the role of informal carers and how we might improve their quality of life. Peter Beresford of Brunel University pointed out the irony whereby on the one hand we heap praise on carers for their magnificent and important work, but at the same time we allow their terms and conditions of work to be comparable to, and in many cases worse than, those of supermarket shelf stackers. It is a contradictory attitude. Paid carers are poorly remunerated and poorly trained, and the result is inevitable—high turnover and poor levels of recruitment. Informal carers are, if we are candid, exploited by society as a resource, despite the many things that the Government, to their credit, have done to improve their lot. Good-quality caring requires ability, empathy, warmth and the ability to listen, together with all the things to which the noble Lord, Lord Kirkwood, referred.

I hope that we will have a chance to come back to these issues after the Green Paper is published. I look forward to reading it as a basis for future consensus but, equally, I look forward to what the Minister is about to say in response to the excellent speeches that we have heard today.

1.20 pm

Baroness Thornton: My Lords, I congratulate the noble Baroness, Lady Fookes, on her choice of subject and on the absolutely outstanding way in which she introduced it. There can be few issues more important or wide-ranging than the care of older and disabled people. Today, the noble Baroness has provided an opportunity for this House to debate the crucial questions of how we care for and support some of the most vulnerable members of our society.

I shall not be able to take advantage of the full time allocated to me because I wish to give the noble Baroness, Lady Fookes, time to respond to this wide-ranging debate. Therefore, if I do not reach any specific questions that noble Lords have put to me, I promise to write to them.

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