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We want to ensure that support goes to people who need it most. Those facing the greatest burden are often those on middle incomes who have savings which will last just a year or two. While these people who are currently funding their own care have relatively high incomes for their age group, they are by no means among the most well off in society. Indeed, the main beneficiaries will be those on middle and below-middle incomes. Typically, the people who require personal care services are likely to be more than 75 years old, live alone and be generally in poorer health. This measure is not just compassionate but progressive and redistributive.

The second feature of the Bill is to encourage reablement support to help another 130,000 people after a fall, when their health deteriorates, or following a period in hospital. Reablement may mean physiotherapy and personal support to help people learn how to perform daily tasks again after an illness or injury. This could, in some cases, mean using technology such as alarms or electric pill dispensers to improve safety. Often such measures have significant outcomes. In other cases, there could be adaptations to make a person's home more suitable for them to live there comfortably. In some places this work is already going on and showing its worth.

I give an example from the Wirral, where a lead on reablement is being taken. A 77 year-old woman had been dependent on carers for two years when she was

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admitted to hospital for aortic valve surgery. She had become used to doing very little for herself. She was sleeping downstairs, and used a bowl of water in the lounge and a commode to meet her personal care needs. On discharge, she received three visits a day from the home assessment and reablement team to help with her personal care. They helped her to practise using the stairs and encouraged her to undertake daily tasks such as opening the curtains, putting on the washing and making her own lunch. Over a six-week period, the visits gradually decreased and she is now living independently with no interventions from social services. That intensive support has absolutely paid its way.

In this way, the Bill aims to enable people to retain their independence and reduce costs, with potentially beneficial effects on their health. The Bill will ensure support for people to remain economically active by enabling the provision of support and control which families and carers need to balance work and their caring role. As we know, it is the carers who are often the unsung heroes. As someone's mobility and general health deteriorates, it is they who step in to offer greater and greater support.

We want to build on the invaluable work on prevention and intervention that many councils have already begun to support people to live independently in the community. This is a vital part of these proposals. It must rely on sensible and effective partnership and decision-making between local authorities, by people who need care services and with their care partners. The solutions must be dignified and not imposed insensitively.

The research indicates that investment in interventions across the partnerships for older people pilot programme has produced an average £1.22 saving in emergency bed days for every £1 spent. These projected efficiency gains are on top of the £1 of additional service benefit from addressing older people's presenting needs. By extending a hand to those with lower-level needs, we can help to reduce isolation and keep people active and, by doing so, we can prevent people slipping to the point wheremore intensive care and support is required. This will reduce the costs of care for individuals, including those who continue to fund their own care. It will help people to avoid hospital admissions-and, perhaps, a premature move to residential care-and to stay independent and well in their own homes.

I turn to funding. There has been a great deal of speculation and misinformation about this Bill, particularly on funding. I should like to take this opportunity to explain our approach. We estimate that the measures will cost £670 million in the first full year, £240 million of which will be provided from the Department of Health's central budget-not from the NHS-and the rest by local government efficiencies. We know, as many of your Lordships will, that the Association of Directors of Adult Social Services, or ADASS, has some concerns about that overall figure and has recently conducted a survey. The response that it received was from fewer than half of its members. We continue to have confidence in our estimated figures; perhaps I might set out why.

First, our figures were the result of independent analysis undertaken by the Personal Social Services

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Research Unit at the London School of Economics. To reach those estimates, detailed modelling was undertaken across the population to try and estimate those people who are currently not receiving services. We have always been clear that it is an estimate and that, naturally, there have to be some inherent uncertainties with that. Indeed, in some areas there may be less of a cost impact than we are estimating; in other words, we have erred on the side of caution. For example, the ADASS survey shows that estimated hourly costs of care are lower than those that we have used. We also believe that there will be some reduced demand as a result of the reablement services that we are putting in place.

Along with the scope for further efficiency gains, this will be considered as part of the normal spending review process. It is right that councils should play their part alongside central government to help deliver this commitment to free personal care, and they have been widely involved in the consultation and stakeholder events which have so far accompanied the Bill. I reiterate the point made by my right honourable friend the Secretary of State for Health in another place: it is completely incorrect to say that any of that money is coming from cutting disability benefits, nor is it coming from the cancer research budget. I should like to put that scaremongering to bed right now.

The Bill is about putting more money into the social care system now. The funding is much needed, prudent and targeted at those with the highest care needs, helping them to live at home for longer, which is where the great majority of them tell us that they want to be.

Earl Howe: I am sorry to interrupt the noble Baroness, but I may have misheard her. Could she clarify what she said about the central government contribution in the first full year? I think that she said it was £240 million and that she meant £420 million.

Baroness Thornton: The noble Earl is right; it is £420 million. I spoke that figure back to front, and £420 million will be provided from the Department of Health.

The Bill recognises that those with the greatest needs cannot wait. This Bill is not the whole answer, but it is a bold first step and I commend it to the House.

3.24 pm

Baroness Gardner of Parkes: My Lords, this Bill has given me much to think about, which is why I have added my name to the speakers list for today's Second Reading debate. I had intended to listen to other speakers and welcome the wide variety of points that had been raised, but speaking so early in the debate I am not in a position to do that. It was helpful to meet the Minister and her team last week to discuss the Bill, but that left me with a number of concerns. I intend to present my own personal view, as I have had some relevant experience through local and regional government. I declare a personal interest in that my eldest daughter was diagnosed with multiple sclerosis 28 years ago, so she has a long-term disability.

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It is easy to welcome the concept of free personal care at home, and I do so without hesitation. Everyone is in favour of motherhood and apple pie, so who could oppose the idea behind this Bill? To take any other view would be opposing kindness and humanity. What concerns me is that this is being brought forward in an ill considered way and that the money will simply not be available to honour the promises of the Bill and the expectations that are being raised for the people who stand to benefit. The timing and speed of the Bill are also unfortunate. Bringing it forward at the last moment of this Government raises my suspicions that it is just electioneering.

A long time ago, I was chairman of social services at Westminster City Council and I represented the Greater London Council on the Association of Metropolitan Authorities' Social Services Committee. The relevance of the Social Services Committee, in particular, was that it coincided with the first disabled persons' legislation, championed and introduced by Alf Morris MP, now a Member of your Lordships' House. We were faced with suddenly having to find all the people who would qualify for help under the new Act. It was clearly impossible for us to achieve this 100 per cent at once, as we had neither the staff nor the means. As a first move, we set out to survey 10 per cent of our residents, and during this time many people previously not known to us came forward. It took years and a large part of our budget even to begin the process. It is no different now. Ensuring that those who need help are the people who get it is a perennial problem.

Today, many of the people who would benefit from the Bill would be known to social services, but not all. Those meeting their own costs at present may have been assessed years ago and their cases will have been filed away after it was decided that they did not qualify for free care. It will be a time-consuming process to trace these records, which could be long out of date. The cost for local authorities simply of determining exactly who is to be covered under the Bill will be high. I do not underestimate the work involved and I am concerned that local authorities' budgets are already hard-pressed. Sadly, I am concerned that those who stand to benefit from the Bill will be let down when their expectations are not met.

Members of the House will have had briefings from many different groups which will be closely involved in implementing the law. They mostly seem to welcome the concept, as I do, but they all seem to raise different concerns. I shall quote some of them. Age Concern says:

"We are concerned whether local authorities will be able to achieve a further £250 million efficiency savings without any detriment to services for other people".

I heard on the radio today that it is believed that the cost will be double that estimate. The Royal College of Nursing seeks,

On funding, the royal college asks,

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and adds that,

It asks:

"What will happen if local authorities, whose social care budgets are already under significant pressure, cannot find their share of the budget needed to deliver the Bill's commitments?".

It also says:

"The RCN is particularly concerned about the possibility of unintended consequences caused by the proposed joint funding arrangements".

Again, I recall very clearly from both my social services and my health experience that joint funding was one of the most difficult things ever on which to get agreement.

The Equal Opportunities Commission puts forward 27 points. I shall not go through them all but point 6 states:

"The Commission has some concerns about the practical issues that might arise",


"It is difficult to see how local authorities could meet the cost of this measure from efficiency savings, without any detriment to social care services and other local services".

It is also concerned about reablement, regarding it as unfair that,

I think it should be "raises", but I am quoting from its text, so I am using the word "raise"-

Reablement is clearly a new word, as whenever I put that word into my computer, it rejects it as incorrect.

In its point 12, the Equal Opportunities Commission urges the Government to ensure that the forthcoming White Paper covers,

I agree with its point 17, which states that,

That is what I think is essential: debate and consensus. Why this rush now after so many years of this Government?

I am less happy about the EOC's point 23. It wants to ensure that,

I agree that it should be on an equal basis with others, but what exactly does that mean? Most people do not have unlimited choice as to where they live, so perhaps that phrase does not mean too much. People are constrained in their choice, often by their personal income and, sometimes by access to work or other reasons. Many people like to stay where they are, where they are familiar with their surroundings or have happy memories. Some of those people are now living alone in large properties which are not really suited to their needs. In some cases, the properties cannot have the necessary adaptations made to make them practical for a person in need of personal care.

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In London, in particular, there is a desperate shortage of family-sized social housing, and many, particularly older people, continue to live in large properties with very high costs for heating and maintenance. I suppose we could consider such persons as the equivalent of "bed blockers" in National Health Service hospitals. It is not easy to face moving after decades in a property, but it must be in the local authority's and the community's interest to provide suitably sized units adapted for disabled living or personal care, and ideally with warden supervision. I believe that many people would be willing to move if such alternatives were available. That would free up some of those large homes for families who desperately need them. I have met a number of people who are delighted with how much easier living is when the accommodation is suited to their needs. For those living alone, it is very reassuring to have someone check daily that you are all right.

In Australia, I saw a number of properties where an individual could buy a lifetime occupancy of one such property in a sheltered community, which was bought back by the charity or other owning body on the death of the occupant at an agreed value according to the number of years of occupancy. There was quite a waiting list for those homes. There were similar schemes for rental homes, but some people who have owned their home are very reluctant to go somewhere where they feel that they would lose that ownership. I thought that that scheme was a good one.

To cite Carers UK,

Carers UK has called for greater clarity about the expectations placed on carers, as it believes that in many cases the assessment process makes assumptions about carers' availability and willingness to provide care. It makes the point that,

I frequently meet people whose family members are now in receipt of care. Although they appreciate the help that they are receiving, the often elderly person complains that their carer comes at six o'clock in the evening to help them get to bed. They really want to stay up until they have seen the 10 o'clock news, they have no wish to go to bed so early, but it is the only way to fit them into the crowded schedule of visits that the carer has each evening. A 24-hour service will be necessary to provide care to suit all receivers of care. If it is intended to help people to live in their homes in the way they wish to, and to satisfy the new extra demand, it will be necessary to have a large number of extra carers and nurses. How and when will these be trained? Who will meet these costs and how long will the training take?

Carers UK asks,

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The issue of assessment processes is raised by many organisations in terms of time, reliability and regular updates. It seems that even cases currently receiving benefit will have to be reassessed. How will the Government help local authorities to limit the number of times reassessment will be required? There are so many questions that can be asked and so much need to go into these matters more thoroughly. I have quoted briefly from organisations that have sent me their comments and I am sure other speakers will pick up different points from those briefings. One day in the Commons has not been enough to consider the Bill properly. I hope your Lordships will ensure that it gets the full and careful consideration that is essential.

3.36 pm

Baroness Campbell of Surbiton: My Lords, I am pleased to contribute to the debate on this short but extremely significant Bill. Free personal care at home: who in their right mind would not support this fundamental principle? Indeed, free personal care at the point of delivery has been at the heart of independent living campaigns for more than 30 years.

I declare a personal interest: without state-funded personal care support I certainly would not be here with you today. Moreover, I could potentially benefit from the Bill's provisions directly-and, boy, I could do with the cash that I currently hand over in charges, which are massive.

However, it is not about me today. For me, personal care is not only about getting up in the morning and going to bed at night; it is about my basic human right to live with dignity and equality among my peers-and even my noble Peers. Thousands of people require intense personal care to stay alive, in exactly the same way as they need healthcare. For people like us they are both equally vital to existence. When I am being put on my ventilator or assisted when I am choking, I do not consider whether it is a health or personal care need; it is just essential human support for me. I have never understood why one is free and the other is charged for; after all, we have no choice to say, "No thanks, I'll manage without". Often, to be severely disabled is to be poor, as we are expected to pay for the privilege of doing all the things that most people never even think about-eating, popping to the loo, scratching your nose and even breathing. Does any other noble Lord consider those acts every day? I do, probably about 10 or 12 times a day.

We should welcome the principle in the Bill before we begin to criticise it because it is good and it is right. What else should we welcome-beyond, of course, the attractive free element? I am still thinking about what I might spend the extra cash on. The Bill demonstrates the Government's commitment to enabling people with high support needs to stay in their own homes. It is hard enough dealing with advanced motor neurone disease or Alzheimer's without having to leave the familiar surroundings of your own home and to move to a new and strange environment to get the care you need.

Another reason I welcome the Bill is that it will make it easier for the NHS and local authorities to work together. Again, that line between health and social care really does not exist. Partnership working

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between health and local authorities has been a policy objective for many years under Governments of both persuasions, but means-testing for social care has remained the elephant in the room. It is an obstacle to joint provision and integrated working. For the group covered by this Bill, this barrier can begin to be removed and that is to be welcomed. Nevertheless, partnership has to involve a third party. May I ask the Minister what guidance or regulations will be put in place to make sure that such an integrated assessment will include service users? There is a strong history of user involvement, choice and control in social care assessments which has yet to take off in healthcare.

I will now move on to a few concerns. From my reading of the Bill's intent, people with critical levels of need will be divided into two groups: the critical and the critical-plus. I am still deciding what group I am in. Perhaps noble Lords might advise me. The second group will receive free care. The other may be charged for similar levels of support. There is great potential for discrimination to occur here between almost identical groups. Will the Minister seek advice from the Equality and Human Rights Commission on whether this approach contains an element of discrimination?

As former chair of the Social Care Institute for Excellence and co-founder of the National Centre for Independent Living, I am also concerned that part of the assessment for free personal care will depend on how many activities of daily life you cannot manage without help. The institute and the national centre have been major supporters of the Government's policies for independence and personalisation. They focus on the things disabled and older people can do and encourage them to be as independent as possible. This Bill, I am afraid, puts a financial premium on proving how incapable you are. I call this the "deficit model" because it creates perverse incentives to present as more dependent in order to be eligible for rationed services.

I am now going to hand over to the noble Lord, Lord Wright, as agreed by the usual channels.

At this point, Lord Wright of Richmond continued the speech for Baroness Campbell of Surbiton.

Last year when I was a commissioner at the EHRC, I helped draft its policy statement on social care. We called it From Safety Net to Springboard and argued that the deficit model of assessment should be abandoned and replaced by one which promoted independence and autonomy for everyone in the caring relationship. We proposed assessments for support, which meant that carers and disabled people were no longer caught in a social-care safety net of dependency, but instead given support which promoted active citizenship, like working, volunteering, interacting socially, and so on. I do not think the springboard formula is reflected in this Bill.

However, the Minister may say that the Government have anticipated the problem and plan to offer people with the highest levels of need a period of reablement before assessing their eligibility for free care. This may help them regain abilities that they have lost, but the formula would take them out of the group who would qualify for free care. What evidence do the Government have that shows that reablement works in these

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circumstances? If you fail to reable enough, would you have to repeat the programme? Would reablement monitors be appointed to make sure that the people with the highest levels of need were trying hard enough to regain their lost abilities? Perhaps the Minister could clear the fog on this one. Most people with progressive conditions such as motor neurone disease or my own condition are going only one way. Are we to be seen as reablement failures?

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