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The Bill may be short but the implications are huge. It needs careful consideration and cannot be done on the cheap, otherwise many mistakes will be made and there will be many disappointed people.

5.22 pm

Baroness Turner of Camden: My Lords, I welcome the Bill. For too long we have neglected the care particularly of elderly people but also of the disabled of all ages. This is a great step towards the introduction of a national care service. It guarantees free personal care at home for the most seriously disadvantaged. We are promised a White Paper on the broader issues in the next few weeks.

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I am sure that the Bill is also welcomed by carers. I have been a carer myself. I know that personal care at home is what most of the long-term ill want. Few want to go into a care home. In my own family, I had to promise my mother when she was ill in hospital that she would not be sent to a care home; she wanted to go back to her own home as soon as she possibly could. The same was true of my husband, who was in need of personal care in his last years. In his case, I approached the local authority because I felt that I needed assistance. Someone came to see me. I pointed out to her that we had at that time a scheme entitled care in the community and there was an obligation to assist people in my situation. "Yes," she said, "but it is within available resources. Our resources here are limited, so we'd be obliged if you would do the best you can for yourself". I was willing to pay but they did not have people to do the work, so I did help myself. A neighbour recommended a local woman who had caring experience. I saw her and arranged to pay her. She came every day, and together we looked after my husband until he became too ill and had to go into hospital, where sadly he died a few days later. I tell this story because I think local authorities must have the requisite resources to provide the services envisaged in the Bill-not just money, but also people.

There is also a need for better interaction between the services available and information for families. This is important for people who, perhaps later in life, find that they are faced with having to care for a partner or a relative. I recall being phoned by an old friend whose wife's condition had worsened. He was really quite desperate: "I don't know what to do", he said. I was able to give him some advice, which he took, and I am glad that in those circumstances the local authority has been very helpful, and assistance is being provided to an ageing woman who has a spinal disease and is immobile, and is also blind.

With this Bill, which I have said before is a first step, the Government are ultimately offering us a national service which will be able to ensure that people requiring care can receive it in their homes, plus help for them to be as independent as possible. Savings will be made because fewer people will require residential care.

Care homes are desperately expensive. They are not always of as high a standard as many would like; there have been reports to that effect in recent years. Insurance schemes are currently being advertised so that people of modest incomes can afford such care should they ever need it. Many are worried that this may mean selling their homes. Local authorities only pay for residential care in cases of absolute poverty, and then at the lowest level they can find. The Government believe that arranging for people to receive care in their own homes will be very much cheaper, as well as being much better for the vulnerable people concerned.

Of course, there has been some opposition to the Bill-we have heard some of it this afternoon-mainly on grounds of possible cost. However, we should be prepared to accept the obligation involved in the care of disadvantaged and vulnerable people. This is a first step towards a new national scheme, and it is directed at the care of those most in need. Issues about eligibility

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have been raised, notably by the Local Government Association. No doubt this is a matter that could be further explored; the LGA believes that the number of reassessments is likely to increase, as people who have been provided with care by unpaid family carers will come back into the care system for free. The eligibility system, it says, will increase the work of social care staff, as decisions will have to be taken as to who is and is not eligible for free personal care. No doubt the Minister will respond to that in her reply.

These comments from the LGA highlight how much we rely on family carers providing all the work involved for nothing. I cannot help feeling that this is a bit of an imposition. We know what a drain this can be on family resources. It is not surprising that carers' organisations fully support the Bill, but there is far too much reliance throughout the system on what families are able to do.

I recall that when I was in hospital following an operation some years ago, the floor manager came to see me to tell me that I was going out the next day. When I protested that I was a widow living on my own, and would be unable to cope if I left hospital so soon, her immediate reaction was, "Haven't you any relatives?" I responded that none lived near. She asked me who lived nearest, and I said the nearest lived in Wiltshire-I live in London. She told me she could let me have another day and I could phone my relatives in Wiltshire and get them to collect me. I was able to do that, but many older people live entirely on their own with no relatives able to assist.

We should not base our care services on the assumption that relatives can always be available to provide help. This is increasingly less likely. Family members no longer live close together. The Government's Bill recognises that, and attempts to deal with it. It is a first step towards providing social care, and I fully support what the Government are endeavouring to do in this much neglected area.

I oppose the amendment: it will simply delay the Bill. We know what many organisations think, because they have already told us. Many of the objections, as we know, seem to be about cost. I believe that we should simply get on with the proposals outlined in the Bill; and I welcome the Bill.

5.29 pm

Lord Best: My Lords, I declare an interest as president of the Local Government Association-I here express support for amendments to the Bill that the LGA will be promoting but which time does not permit me to address now-as chair of the All-Party Parliamentary Group on Housing and Care for Older People and chair of the Hanover Housing Association, the country's largest provider of extra- care housing for older people. At this stage of the Bill, I must confine my remarks to my specialist subject of housing.

The Personal Care at Home Bill is predicated on the home being suitable for high-level care to be delivered there. Regrettably, the design and/or construction of many homes makes them quite unsuitable for those with the highest care needs. If you need help with washing, toileting, dressing and so forth, you are likely

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to need a home that is highly accessible. There must be no steps to the front door that become hazardous in icy weather and which are impossible for anyone with a Zimmer frame let alone a wheelchair, and no inadequate heating systems, poor insulation or huge fuel bills that can all render a property too cold or damp for a frailer occupier. Personal care at home is not a realistic proposition in a house with no downstairs bathroom where the recipient of care has to crawl or be carried upstairs.

If the design or condition of the property makes it impossible for someone with care needs to stay there, a move to residential care can become an expensive and usually unpopular necessity, so entirely commendable efforts to support personal care at home must start with an assessment of whether the home in question rules that out as a practical proposition. Of course, the ideal may well be a move to a well designed, light, bright, fully accessible and adaptable, highly energy-efficient apartment with care available if and when it is needed. Such places are far more common on the European mainland, as I saw in the summer when visiting Sweden, Switzerland, the Netherlands, Denmark and Germany as chair of the governmental Housing our Ageing Population Panel for Innovation-HAPPI for short.

We have some excellent examples in the UK, including high-quality extra-care apartments where personal care is on tap as required, and a few retirement villages that can also supply a range of health, fitness and social facilities. I am grateful to the noble Baroness, Lady Gardner, for speaking eloquently on the value of building excellent retirement housing for sale or rent thereby helping younger families by freeing up underoccupied housing.

However, for the great majority of older people it will be by adapting their existing accommodation that personal care at home becomes feasible-such as adding a downstairs bathroom, putting in handrails and easy-to-turn taps, better heating, emergency call systems to summon help, stairlifts and so on. Because we know that the cost of adaptations in these cases can be repaid by savings to the NHS budget, switching more resources from health is well worth while.

Andy Burnham, the Secretary of State for Health, talks rightly of joined-up thinking and integration of providers and provision of health and care, but the third leg to the stool, housing, must also be addressed. Of the £670 million rather loosely estimated as needed to fund the Bill's measures, I note that £130 million is to be set aside for reablement, which is excellent work in helping people, including some of those leaving hospitals and residential care establishments, to live at home. I am told that the pot of funding incorporates something for home adaptations, including installing assistive technology with sensors to monitor those, for example, with early dementia. But I note that the calculation of £130 million is based on each of 130,000 recipients getting £1,000, equating to 30 hours of specialist home care.

On the face of it, that leaves no room for any spending on the home itself and without any such spending there will be considerable difficulty in

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implementing the Bill. My plea, therefore, is for the third leg of the stool-housing as well as health and social care-to receive recognition in the Bill, with proper assessment of the suitability of the home as well as of the individual and with funding for home adaptations, perhaps switched from the health budget, where these are necessary. After all, it cannot be too much to expect the Bill to address housing concerns when it has the word "home" in its title.

5.35 pm

Lord Joffe: My Lords, I was a member of the Royal Commission on Long-Term Care for the Elderly, which reported in 1999, and with my noble friend Lord Lipsey, co-authored the minority report of that commission in which we opposed the case made by the majority for free personal care for all, financed from taxation. The opposition came from us despite our high regard for the chairman of the commission, the noble Lord, Lord Sutherland, and other members of the commission.

While we were naturally attracted by the concept of free personal care for all who needed it, the rationale of our opposition was that, having regard to the constraints on government expenditure, all available funds should be spent on improving the quality and range of care of those who could not afford to pay for it rather than to provide free care for those who could afford it. I emphasise to the noble Baroness, Lady Campbell, that this opposition to the Bill has nothing to do with opposing free personal home care, but everything to do with the equitable allocation of available resources for all those who need such care.

After the commission reported, the Government agreed with our minority approach and in a statement to the House on 2 July 2002, my noble friend Lord Hunt of Kings Heath, then Parliamentary Under-Secretary at the Department of Health, said in rejecting the recommendation of the majority of the commission on this view:

"We chose a different course because we believed that if we instituted free personal care, we should not produce a single extra service as a result but would benefit many better-off people".-[Official Report, 2/7/02; col. 123.]

That has been the policy of the Government for the past 10 years and it is difficult to understand why at this stage government policy is being changed.

When in July last year the Government published for consultation their Green Paper Shaping the Future of Care Together, which was to be followed this year, after consultation, by a White Paper, it seemed that a carefully considered and appropriate process was being followed by the Government to determine future strategy and funding for such care, which in practice covers a wide-ranging, complex and interlocking set of issues. Against that background, the Bill before the House, which piecemeal addresses the single issue of funding free personal care at home for those who can afford to pay for it, cannot seriously be addressed without taking account of the funding for other interrelated parts of social care.

The Green Paper considered in great detail the various funding options for social care, and until a government decision is made on which option is to be

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followed, it is irrational to decide on additional funding for extending free personal care. Indeed, if the funding option for care finally chosen by the Government is insurance, which is one of the three recommended options in the Green Paper, there will be no purpose whatever in having put in place the legislation proposed by the Bill, which seeks to make it free.

The failure of the Bill to be set in the context of a holistic policy of social care will create inconsistency in an area where none exists at the moment, leading to a number of perverse incentives. Presently, people who can afford to pay for care are obliged to do so both for care at home and in care homes. Making home care free will create an incentive to demand such care even where it may not be in the best interests of the individual.

Malcolm Johnson, Visiting Professor of Gerontology and End-of-Life Care at the University of Bath and Emeritus Professor of Health and Social Care at Bristol University, has worked on these issues for 35 years. His research concludes that for old and often sick people towards the end of their lives, going into a care home is often not the worst option. He points out that the majority of such people-some two-thirds-are women living alone. Their social networks will have been eroded, including by the death of contemporaries. They are unlikely to have family members living close enough or willing to visit daily. They may be blind, have lost their hearing, be incontinent singly or doubly, or have lost mobility. Frequently they will suffer from two or more of those disabilities.

Public services typically offer these people little more than six hours of care a week, and nothing at weekends. For such people life is isolated, consisting of large chunks of time sitting around, perhaps in physical and often in mental discomfort, waiting for carers who may or may not turn up on time. One could reasonably conclude from this research that it would be in the interests of some elderly people to be provided with free care in care homes rather than free care at their homes. This issue needs to be considered as part of a coherent care policy.

Other perverse incentives arise from the Government's funding proposals. I will not dwell on the injection of significant additional funding by the Government at a time when their own funding is under such pressure, as so incisively analysed by the noble Lords, Lord Warner and Lord Lipsey. Rather I shall focus on the proposal partially to refund the cost by relying on efficiency savings from local authorities. Many cash-strapped local authorities will be unlikely to find these savings and will resort to perverse incentives such as diverting those with the highest need into means-tested residential care, increasing charges for non-personal care, or limiting free care to those with the most severe needs, thereby denying access to individuals with moderate or in some cases substantial care needs.

Previous experience also suggests that some of these local authorities will seek to make cost savings by decreasing the fees they pay to independent care providers, which provide 80 per cent of care homes for patients. This in turn will impact adversely on their lower-paid workforces, where there is already an annual staff

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turnover of 24 per cent. This will adversely affect the quality of care that the elderly folk in these homes receive.

For these and all the reasons raised by noble Lords who have already spoken, in particular in the eloquent address by the right reverend Prelate the Bishop of Norwich, it would damage the Government's reputation for responsible legislation to proceed with a Bill on an issue that they put out for consultation before the conclusion of that consultation process and which fails to take account of their own overall policy on social care-yet to be determined. I urge the Government not to proceed with this Bill.

5.45 pm

Baroness Murphy: My Lords, I come at this Bill as a doctor who has for some 30 years worked in the community as a specialist with older people. I feel passionately about the serious inequities between the provision of health and social care and the seriously unjust system we have at the moment, so you would probably think that I would like this Bill. I am also quite supportive of the policy objective to allow more people to remain in their own home for as long as possible and to support them with adequate personal care there-although I take to heart the point of the noble Lord, Lord Best, about the appropriateness of the home circumstances.

I collaborated in a good deal of research with the government-funded Personal Social Services Research Unit-the PSSRU-over many years. More than 20 years ago we demonstrated that the policy objectives of this Bill were feasible even for the most heavily dependent, if-I stress "if"- the appropriate personal case management was applied flexibly to each case and if there were real choices available. This is a good moment to pay tribute to the fantastic evaluative research that PSSRU does. However, it has always been careful to point out that fidelity to a successful model is important in getting the right outcome. This Bill is based on no such evaluative project. As the noble Baroness, Lady Gardner of Parkes, and the noble Lord, Lord Lispey, said, it is a piece of electioneering, presented at party conference as something that would rally support. Most older people's organisations naturally support this Bill; after all, who in their right mind would turn down more money to enable the most dependent to stay in their own home?

Yet this is a horrible Bill. It is socially divisive, bureaucratically retrograde, provides financial incentives to choose one sort of care when another might be preferable, moves money from the most financially disadvantaged to the wealthier sections of society and will be a nightmare to implement. Instead of using this opportunity to develop an innovative state/public and personal partnership approach to the business of personal care, the Government have stepped in during the process of their evaluation of the Green Paper and rejected the development of a realistic and practical formula in the interests of headline popularity. As I say, they have not even finished the consultation on the Green Paper which carefully outlined a whole range of options around which we could build a political consensus.

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In the small print of the modelling exercise paper on the costs of this Bill, PSSRU has itself hedged it round with some caveats. The modelling exercise depends on choosing exactly the right levels of assessment of activities of daily living, which I will come on to. I expect that any of your Lordships will have looked at the proposed scheme of assessment which will determine who gets the jackpot and who does not. It looks just like the Poor Law scheme of 1834 to determine the deserving and undeserving poor. In this case we will have a magic lift-off point. If you have four prescribed activities of daily living down then you are eligible; if you have only three activities of daily living down, sorry, but you will not be. As the noble Baroness, Lady Campbell, pointed out, this sort of deficit assessment is a truly divisive and horrible tool.

Apparently there will be a nationally agreed assessment tool, although who knows who will administer it? I suspect it will be the same workforce which does the current fact assessments. Can anyone remember what happened in the last attempt to devise a nationally agreed joint single assessment tool between the NHS and local authorities? It was a nightmare, taking three years to agree and then implement. Does no one remember the eligibility criteria for NHS continuing care? I used to see all the appeals against the final judgments of the tribunals on the contested cases in the north-east London area. Most of the cases were so arbitrarily unfair, particularly against people with dementia, that it made one weep. This Bill will have exactly the same effect.

Let us turn to these activities of daily living. The PSSRU modelling is all based around these assessments. First you have to go through the fair access to care assessment, as now, and then you are subject to the reablement services if possible. I do not know what they are, but I have a pretty good idea. This will be a tool for delay and procrastination, of course, but it has a rationale. Then the ADLs will be assessed. This is crucial. I will mention them all, as they are listed; it is not so much what they contain as what they leave out that is important. The ADLs are eating and drinking, toileting, washing/bathing, dressing, oral care, skin and hair care, plus another, which is the prompting and supervision of a person who is unable to make the decision for themselves about the ADLs on the list. The list excludes cleaning, housework, shopping, laundry, transport, sitting services and so on.

I am detailing these because, although it is true that the number of ADLs that people are unable to do correlates well at population level with demand for care services, they are not good at individual level. A body of research, largely from the United States, has shown how inappropriate these eligibility criteria can be for many people with dementia. For example, a patient with profound Lewy body-type dementia can suffer from serious behavioural disturbance, aggressive and deluded outbursts and wandering and can need 24-hour supervision from relatives who are effectively imprisoned in their home and yet they might not be disabled to the point of having more than one or two activities of daily living points on this scale. What happens in a case like this? It has to be interpreted by very sophisticated, well trained assessors, who are

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willing to use their common sense and to fudge in order to get people into the criteria. Just as hundreds of appeals are upheld every year against mean-minded assessments of night and day rate attendance allowance, this assessment will also generate hundreds of appeals, because the system will be a bureaucratic nightmare and a profound letdown for many who may assume that they will be eligible.

The financial incentive to stay put and not go into residential care will, I believe, be a serious and insuperable difficulty. Families will understand very quickly how to maximise their future inheritance. While it is usually right for people to stay at home, it is sometimes right, as we heard from many contributors today, for people to enter residential care, especially when dementia is advanced. There should be as little distinction as possible in financial burden for relatives between care at home and residential care. Without that, decisions are skewed away from choice made on clinical and social grounds to those made on financial grounds. This Bill fails on these criteria.

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