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Finally, I turn to matters of social equity. My objections are not simply on the large financial costs. Heavens, I have been quite a psychopath in my time about winkling out of social services and healthcare more than my patients' fair share of the budget, so I have no guilt if I winkle out of the Government more than a fair share for this very needy cause. However, I believe that the Bill undermines the mechanisms by which we can reach a consensus on meeting a grave and growing social issue. We must find some fair middle way of funding care that is neither old-fashioned means-testing nor frankly unaffordable universal coverage. We are in a big enough mess with the NHS, which inevitably will have to be addressed at some point. Providing public funds, irrespective of assets and income, for all those living at home will transfer wealth to better-off members of society and their heirs at the expense of those most in need. Already we are aware that many people who receive attendance allowance simply do not need it. Such a proposal as the one in the Bill is extraordinary when the Government are groping towards a welfare system that promotes social equity.

We need a partnership between public and private sectors. That was made clear by Wanless and by extensive research by Julian Le Grand and others and it was ably outlined today by the noble Lords, Lord Lipsey, Lord Warner and Lord Joffe. Elderly people increasingly want the dignity of choosing for themselves the type of care that they receive by buying it rather than by having assessed care packages. That is the brilliance of the Government's approach to personal care funding, whereby people can buy their own. Already a third of elderly people pay for their own care and it is estimated that this will rise to more than a half over the next 20 years. However, not a single penny of this extra state funding would go to improving standards of care for elderly people. The Bill will transfer vast sums of money out of the public purse to those who are currently deemed to be able to afford their own care. Since very little of the preserved assets will be spent by disabled elderly people themselves, the state will secure for elderly people's heirs a better inheritance for the future. Is that the objective? I think not.



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It is very hard to hope that this Bill will fall, because undoubtedly some older people with profound difficulties will be helped in the short term. However, I think that the funding will rapidly come to an end, as the Bill is not practical. I fear that this sticking-plaster solution will act as a deterrent to the creation of a more comprehensive solution to our profound problem. A Bill with this title is needed, but this is not it. If the noble Lord, Lord Warner, presses his amendment this evening, I shall support him.

5.56 pm

Baroness Pitkeathley: My Lords, I declare an interest as vice-president of Carers UK. I want to give a carers' perspective on this Bill, but let me be clear about what I mean when I use the word "carer", as there is an increasing tendency to conflate it to mean both the families, including the neighbours and other informal carers who provide care free of charge, with what I would properly term "care workers", or those people who are paid to provide care. I will talk about the informal sector.

This Bill will, for the first time, provide for people who have savings or an asset such as a house to be entitled to free care from the state. As Carers UK has been campaigning for that for many years, naturally I support it. It will help families to meet the costs of care, which can be very high and which contribute to the poverty faced by disabled people and carers. A survey of 1,700 carers in December 2008 found that 66 per cent were spending their own income or savings to pay for care. It also found that 74 per cent of carers were struggling to pay essential utility bills and that, because of the costs of care, 52 per cent were even cutting back on food.

Carers UK research has always found that carers want to care for their elderly and disabled relatives at home whenever possible. They also want to ensure that the person for whom they care gets the best possible care, which usually means looking after them at home, as that is what both parties want. This Bill will support those wishes. However, realising the desire for people to receive care in their own home should not be based on the assumption that families will provide the levels of care, which may be inappropriate given their circumstances or detrimental to their health or well-being. We need clarity about the expectations placed on carers, as the noble Baroness, Lady Gardner, reminded us.

One in five carers is currently giving up paid employment in order to care, so removing one element of the cost that they face will help families to manage their finances and remove some of the stress of caring. Carers, of course, have strong views about charging for care. They want an element of care to be free of charge. As I said, Carers UK has been campaigning for this since the introduction of community care in 1993. Early research in 1995 found that, as a result of councils increasing charges, one in four carers and their families were experiencing hardship and that around one in seven were cancelling services. In the 1995 research, three-quarters of carers surveyed thought that a guaranteed package of services should be free irrespective of income. I am pleased to say that that

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research was carried out for us by the noble Lord, Lord Warner, who said that,

He costed this at £1.4 billion per year and said that,

He suggested that guaranteed care should be free of charge to carers. The report was very influential and widely circulated at the time. We were very grateful to the noble Lord, Lord Warner.

As we know, criticisms have been made of this Bill. The debate in the House of Commons suggested that families would give up caring in order to receive free care. The evidence published by the Joseph Rowntree Foundation two years ago, after the implementation of the model in Scotland, found very little evidence of this. Most families continued to provide personal care because this is what they preferred to do. The modelling provided by the Government mirrors that.

We consistently underestimate the willingness of families to provide care and overestimate their desire to get out of the caring situation, however hard that situation may be. Carers are the absolute antithesis of what people are wont to call "broken Britain", and politicians would do well to remember that.

To give noble Lords a case-study, Alan has cared for his wife for many years since she had a stroke. He is now in his late 60s. They have applied for continuing care, but have been turned down, and they have spent down their savings to pay for care. The wife is severely disabled-she needs to be moved several times in bed, and regularly stops breathing and needs to be resuscitated. She needs help with all forms of personal care. Alan says, "if I had got free personal care years ago, it would have made such a difference to my life. I am sick of poor quality care and having to pay for it as well".

The Government have said that this Bill is a stepping stone towards the longer term goal of a national care service and I certainly welcome that vision. This Bill is by no means a solution to the problems that we face with social care-I am the first to admit that-but it is a step along the way. The view that I have taken for years about changes to the social care system is that change should be incremental, not revolutionary, and should come-salami-like-in small, sometimes very small, slices. That was the case with all the legislation for carers. The first carers Act in 1995 was not what I or carers wanted, but it was step along the way. It could be used as a launching pad to argue for other, greater rights for carers, and that has proved to be the case.

I know that the White Paper on social care is expected soon. It will be important that the Government look in that at the wider picture, and not just at alleviating stress at the heaviest end of need. For example, would support put in earlier mean that fewer carers would break down and that families would thereby be enabled to go on caring for longer? Would reablement and more independence for older people

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make it easier for their families to continue in paid work? People giving up paid work to care for a relative is a cost to the economy and to business which we can ill afford at the moment. Can the Minister assure me that the White Paper will look at the wider economic impact for families, rather than merely at expenditure with regard to residential and NHS costs?

There is no doubt that carers have concerns about the Bill. The evidence from some councils is that they are poorly assessing disabled and older people by assuming that families will provide care. This is against the current legislation, but it is also short-sighted, since it can lead to families struggling without appropriate help, as I have already said. Most carers want to continue to provide care and will continue to do so. However, they do not wish to be taken for granted and they do want their needs and support to be taken into account when looking at what services will be provided to the person being cared for.

Can the Minister assure me that the Government will ensure that guidance on this Bill clearly states that local authorities should not assume carers' willingness and ability to care, but that they should check with them that they are able to do this? Will the Government stress in their guidance that the sustainability of the caring role must be carefully considered in assessment? If the carer is at risk of breakdown because insufficient support is provided, this will result in enormous costs for several people rather than limited costs for a few. I also seek assurances from the Government that if this Bill becomes law its operation will be regularly reviewed.

Finally, I remind your Lordships that all the significant charities and third sector organisations supporting carers and older people have issued statements in support of this Bill. They said:

"Care charges for those with critical needs are often a crippling cost to families already struggling with the financial impacts of illness or disability. This Bill would mark an historic end to means-testing and charging for some of the most vulnerable people in our society to provide for their most basic care needs. The older and disabled people, families and carers we represent have long called for an end to charging for care services-and",

these people,

There is no doubt, they go on, that,

which we face.

"However the principles set out in this Bill are a vital first step in reforming social care".

I hope your Lordships will remember that.

6.06 pm

Lord Sutherland of Houndwood: My Lords, I confess to a number of interests. I am president of Alzheimer Scotland and of Scottish Care, and I do some work with the English Community Care Association.

That being said, some of us have waited 10 long years. We looked for a response from the Government to the royal commission report on The Funding of Long-Term Care for the Elderly, and response had we

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little. Indeed, it was so little that a rump of Members, after five years, sent a reminder to the Government. The message of the reminder was, generously I thought, "Well, you don't like what we recommended-have you an alternative?" They had, after a fashion, but I characterise it as follows: it promoted a postcode lottery; there were thousands of complaints to the health ombudsman, who in key cases ruled against the Government; resulting compensation payments ran into hundreds of millions of pounds; there was much articulated discontent; and for many real, often silent, suffering and puzzlement because they could not understand and work with a far too complex and unfair system. There was, I would suggest, no recognisable policy, but just a series of unfortunate happenings.

As a result, one has reduced hopes and expectations. Some of us had hoped, hearing that a Bill was coming, that we might at least have half a loaf; better than no loaf at all, as the old saying is. Perhaps the Wanless report offered more than that, but it was turned aside. However, now we have a Bill, admittedly a short piece-indeed, one might say, a modest piece, something of a morsel, perhaps even a crumb. Unfortunately, no longer a crumb from a rich man's table, but I shall return to that. What about this morsel? Is it to be rejected, to be postponed until it is stale, and in its staleness nibbled into extinction by the mice rumoured to be invading the Back Benches of this House? What are we to make of this morsel, this crumb, this "legislative opusculum", as one of my friends put it? In terms of evaluation, I am among those who welcome this morsel, but noble Lords must understand I am a hungry man. I digest the crumbs with alacrity, and I do not want to leave them to go stale for the mice to nibble into extinction.

I hasten to add that the most important feature of this Bill is not on the face of it. I hope that the Minister will speak plainly and put things on the record on the critical element, which is the context and promise the Bill offers of a new direction of travel towards a national care service. I know there are many problems with setting that up-there were problems in setting up the health service-but are they problems to be faced, or to be recounted and the Bill withdrawn prematurely?

I remind the House what a national care service minimally involves. It involves a single point of entry to a system of assessment of need, not to a bureaucracy or clutch of different funds which you might raid if you have expert advice but not if you have not. It involves a single point of entry. When the royal commission sat, this was one of the biggest cries that we heard from those whom we met in large numbers throughout the country. I know that there are dangers-my noble friend Lady Murphy has pointed these out very fairly-but it needs a single set of criteria of eligibility, pointing towards a degree of equity and fairness. Without a single framework, we will be back to a postcode lottery and divisions that we should be fleeing from. Such a service needs a single point of commissioning. I came to realise that this is what all the talk about personalisation of the service means. The person in need of support-the carer-or the person needing care needs to talk to an individual about what is to be commissioned and what the needs are.



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Behind this, it needs a single budget-a budget that will reflect that need. That budget will need to be portable so that you can, if necessary, move around the country. This point was made very well by the noble Baroness, Lady Campbell of Surbiton. The provisions made will then follow you, and you will not enter again the morass of renegotiating on five or six different fronts. It is important to treat the needs of older people equitably, with no artificial distinctions set by the way in which we administer the money and care. There are three different sources of funding for care for older people: the health service, local authorities and the Department for Work and Pensions. Are these flowing in the same direction? I have not seen the evidence, but I have seen plenty of contrary evidence. The Government have been unwilling to tackle a single budget. It is too difficult. There has been sucking of teeth up and down Whitehall as the Government say "How could they suggest such a thing?". I will listen with great interest to what the Minister has to say about what many of us are currently saying to her about the shape of a national care service and its preconditions.

There are plenty of counterarguments; we have heard them all and some are very good. I pay tribute to the noble Lord, Lord Best, who is unduly modest. The sort of schemes being outlined by, for example, the noble Baroness, Lady Gardner of Parkes, are of the type that he was instrumental in putting together when running the Rowntree trust. A very large sum of money-over £20 million, I understand-was invested in creating a care village, effectively, where one could do exactly the sort of thing that the noble Baroness, Lady Gardner, rightly holds up as a good example. The noble Lord knows what he is talking about. What he says about housing is very important; I am completely with him on all of that.

We have heard much about the bad legislative and governmental process. I am no more than a spectator to personal grief within the Labour Party on this. What grief and agony transports between individuals there is a matter for consenting adults in private, rather than in public. Of course the Bill comes from a bad legislative process. Of course it is inadequate. However, it is not the first Bill of which that has been said and doubtless it will not be the last. It must be improved massively-of course it must-but it will not be improved by being put on the back burner. I say to the right reverend Prelate the Bishop of Norwich, who suggested that waiting and considering are important: of course they are. However, we do not all have the biological constitution of Methuselah. We have waited a long time already. Perhaps we would like to see some action that might lead to a policy. There are those who say of such a wait that the amendment that might be tabled is not a wrecking amendment. They have said it in an email that I received, as, no doubt, did the Minister. If I were a cynical man, I would say, "Pull the other one", but I am not so I will not comment.

Those who argue against the Bill rightly raise questions of affordability. This is not affordable; there is much that we are doing that is not affordable. It is suggested that in Scotland we are talking about affordability again. We have never stopped talking about affordability. It has been a constant discussion and so it should be.

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However, if we are talking about what is and is not affordable, why do we seem always to start here? We can whip up a headline about the cost of long-term care of the elderly. I give a few alternatives because affordability is often assumed to be within the constraints of these three sources: the National Health Service, local authorities and the Department for Work and Pensions. This country's financial position transcends that. We should look more broadly at priorities across government, not within artificially constrained government departments.

On affordability, national identity cards are not at the top of my list. These were initially budgeted at perhaps £1 billion to £3 billion but the LSE came up with an estimate of £18 billion. These things are very elastic. There is our current foreign policy and the associated defence costs. I do not suggest that we stop having decent defence, but it is a matter for discussion. Malcolm Rifkind makes that point in the Times today, stating his own conclusion. These are major issues. Are we overextending ourselves or are we not? This should be talked about when we discuss affordability and priorities. The bureaucratic costs, including consultancy in the current health service structures, are massive. Rewards and payment for general practice have escalated without any obvious benefit. I speak as someone who looks for a general practitioner sometimes in vain. The cost of merit increments for consultants is massive for the health service; is it something that we can continue to operate with? I am sorry to any consultants who happen to be present, but it is an issue of affordability. We are talking about priorities. Dare I even add public sector pensions, which doubtless many of us in this Chamber benefit from? Finally, I add to my short list-noble Lords will have their own-an elected House of Lords, which will cost more money but seems to be pushed up various groups' list of priorities.

Cost is now a matter of priorities across government. That is the one thing that we are learning from the huge financial constraints that we find ourselves under. We cannot opt out and say, "Just a little bit here or a little bit there". We have to look again. I am in no doubt that the outlook for the next few years is very sombre. It will be a time of real cuts, but we are looking for a national care service and a means of dealing with all the problems that have been paraded around the House today about how we are not serving the needs of the elderly well-and we are not. If we are looking for a solution to that, I suggest that we incorporate the costs of providing for the needs of the elderly in a single budget, covering the health service, the Department for Work and Pensions and local authorities. Then we sit down and ask where the cuts will fall.

At the moment, folk see the rather tall poppy of care of the elderly threatening to grow again and want quickly to slash it and cut it down. It should be incorporated with other matters and then a decision taken. In my view we cannot afford the health service that we have, but when the cuts come-as I believe they will-they should not start with the elderly before looking at the rest. There should be a rounded discussion. I am not asking for false and unsustainable prioritisation of the needs of the elderly; I am asking for them

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simply to be taken into the same pot. However the decision is made, and by whatever form of deliberation, fairness, equity and rationality should lead the discussion.

I did not want to talk about Scotland but I have been goaded, or prompted, into it. I am sorry; I have to do this for just a couple of minutes. I sometimes think that I hear the following, adapted from Animal Farm: Scotland bad in the area of care for the elderly, England good. Perhaps that is occasionally permissible and, sometimes, I regret to say, justifiable in Wembley or Twickenham, but is it fair to give that impression of what is happening in Scotland? There is not a sense of national catastrophe, as there has been in the hysterical language that we have heard. The myth is that Scotland is a spendthrift country which has become more profligate since devolution. The fact is that at the time of devolution-and, indeed, 10 years ago in 1999-Scotland spent 16 per cent more per head on public expenditure. In 2009, Scotland still spent 16 per cent more. There has been no escalation as a result of that policy of devolution. Scotland operates within a cash-limited budget. English public expenditure has increased by exactly the same amount-16 per cent. It is true that it starts from a different baseline, but it is more or less true that there has been the same increase for Wales and Northern Ireland. The rate of increased spending is no different in Scotland. The idea of profligacy is not correct.

The reason that Scotland spends more is of course due to the Barnett formula, which, as we have learnt this afternoon, was introduced by a Labour Government who possibly were advised by the noble Lord, Lord Lipsey. If you want to tackle the larger expenditure on the public sector, look at the Barnett formula. I am open to that as a suggestion-indeed, I make it. It would be a very odd policy to say to Scotland, "We've got this formula; it's a bit funny but we are not willing to change it. You get all this extra cash, but you may not spend it on social care for the elderly. You can spend it on anything else that you like". Scotland lives within cash limits, just as everyone else does. That means that it has to take decisions not to do things that we are going to do down here.

I shall give a good example. Last year, we improved what I can only call the raising of the school leaving age in England. It was suggested that that will cost £750 million in the first year of operation. I bet that that is an underestimate. While it may be something that England can afford, Scotland cannot, because it is spending its money in other ways. There are other aspects of expenditure in Scotland that I could examine, but I shall not because I have used up my time.

This Bill points forward. It is weak, it is inadequate, and it has been presented at the wrong time-it should have been put through 10 years ago-but it is the best crumb that I have, and I am going to live with it. I commend it to noble Lords.

6.22 pm

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