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Baroness Wilkins: My Lords, like the disability organisations with the main interest in this Bill, I welcome its intention to support severely disabled people to remain living in their own homes and the

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fact that it highlights the urgent need for a national care service that is fair and sustainable to be established. But, like other noble Lords, I have serious concerns about the perverse incentives contained in the Bill. These have been sufficiently rehearsed and I shall not repeat them. I will, however, cover much the same ground as that referred to by the noble Lord, Lord Best, in his excellent speech. I hope noble Lords will agree that it is worth re-emphasising.

The Bill focuses our attention on providing better help for people with high support needs to be able to remain in their own homes. I greatly welcome that. However, what is notable is the absence of any reference to the adaptation of the home in which the person with high care needs is to be supported in order to live. In my view, any new arrangements to meet the cost of personal care at home must also integrate a system for fast, effective provision of home adaptations. That, at the moment, is sorely lacking in many parts of the country. My noble friend Lady Andrews did a great deal to rectify this situation during her time at the Department for Communities and Local Government with the excellent strategy report, Lifetime Homes, Lifetime Neighbourhoods. That work needs to be built on and fully integrated into the health and social care support available for disabled and older people.

As Care & Repair England points out in its latest report, Time to Adapt, the issue which makes the greatest contribution to enabling independent living for disabled and elderly people for as long as possible, and reducing the cost of their care, is housing adaptations. Not surprisingly, making sure that someone can, for instance, get to and use a bathroom, to wash and go to the loo, is often pivotal in enabling people with high care needs to remain living at home. That is the purpose of the Bill.

Adaptations impact directly on the cost of care because they enable the disabled person to do as much as possible for themselves and they make the giving of personal care much easier for paid staff and unpaid carers. It is in the interest of the best use of public finances, let alone in the interest of the dignity of the individual, that adaptations are fully integrated into the proposed system of free personal care.

The research undertaken by the University of Bristol for the Office for Disability Issues in 2007, entitled Better Outcomes, Lower Costs, set out the evidence for this. It showed that timely adaptations and appropriate equipment can produce direct savings to the public purse in terms of the amount of home care required, hospital admissions and delays in discharge. Adaptations also directly lessen ill health among care givers; for instance, by reducing the numbers of strained backs from lifting. That report also showed how better outcomes for the individual can be achieved with the same level of expenditure. For example, if for the same amount of money a disabled person can have frequent visits by a carer to help them to use the loo and wash, or can have an automatic loo and level access shower to use whenever they please, the latter will, for the vast majority of people, be far preferable. In short, if free personal care is to be provided for those with the highest needs, then, in order to make best use of public funds and to ensure that the care at home is

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of the best possible standard for the individual, housing adaptations have to be an integral part of the assessment and provision that is made.

The Government propose that this Bill is,

This is laudable and in keeping with one of the most broadly welcomed proposals in the social care Green Paper-that of clearly defined, universal entitlement. If the Bill is the first step towards a national care service and a move away from the uncertainty of variable local provision, then steps also need to be taken to create an integrated, health and social care linked national adaptations service. The need for such a service was argued by Sue Adams of Care & Repair England at a recent meeting of the All-Party Group on Housing and Care for Older People, and I am indebted to her for her help.

Currently, disabled and older people face a bewildering array of possible local systems when they need help with urgent home adaptations. While there is indeed a national legislative framework in place defining eligibility for help with adaptations through disabled facilities grants, the degree of flexibility for local housing authorities in the implementation of the framework results in highly variable local delivery. As the Audit Commission noted at the same all-party meeting, while there have been improvements in the provision of assistance with small items of equipment and minor adaptations, larger disabled facilities grant-funded adaptations systems are, in a significant number of authorities, simply not fit for purpose.

Many disabled people have to wait years for adaptations help. The result is not only extra costs to health and social care, but suffering for individuals. Older and disabled people face the undignified situations of living, sleeping and eating in a single room with a commode in the corner and being strip washed in the kitchen. Carers are put at risk by having to carry people upstairs and lift them in and out of bed, when, for a few thousand pounds for a stair lift or hoist, their lives would be transformed.

Changes to the disabled facilities grant system, announced in 2008 and phased in over 2008-10, offered local authorities even greater local flexibility. While this will result in improvements in some areas-the Foundations report, Adapting for a Lifetime, cites a number of positive examples-in other areas, DFG help will decline. The ending of the legal obligation to match government funding for DFG has already resulted in some local authorities reducing their DFG budgets. More are expected to do so in the next financial year, despite the very welcome increase in national grant. The adaptation help that a disabled person can expect will become determined by where they live. This is totally contrary to the aims of increasingly universal provision of personal care at home that this Bill heralds.

While home adaptation is not currently in the Bill as drafted, the Bill could still provide the incentive for reform to remedy the current incoherent pattern of provision-a reform that is urgently needed. I hope that my noble friend the Minister will acknowledge the necessity that, in shaping the future of personal social care, the central role of home adaptations must be integrated into any new systems.

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6.30 pm

Lord Low of Dalston: My Lords, I am not sure whether this is a modest or an immodest Bill, but it certainly has much to be modest about. Free personal care at home for those in greatest need sounds like a marvellous idea. As others have said, who could possibly be against that? Yet the moment that you begin to look at what is proposed, it immediately becomes clear that it is not quite what it seems. The more you look at it, the more it becomes clear that it has some quite untoward consequences, which have not been thought through. Although the idea of free personal care at home is initially attractive, I fear that, as enshrined in this Bill, it is overwhelmed by the arguments that have been deployed by the noble Baroness, Lady Murphy, and the noble Lords, Lord Warner, Lord Lipsey, Lord Joffe, and others. It is hard to say anything fresh at this stage of the debate, but perhaps my remarks will come as a handy summary for the Minister before she winds up.

For a start, it is not really free personal care at home for all those who might need it. The Bill introduces a right to free care at home for only a proportion of those whose needs are assessed as critical, because they require help with four or more activities of daily living. Thus, only a small proportion of those who need social care will benefit from the provisions in the Bill. The Bill also provides an entitlement to 30 hours of intensive reablement support over six weeks. What is the relationship of that entitlement to the general right to free care at home introduced by the Bill? For those whose needs are severe enough to put them in line for the free help offered under the Bill, that is hardly intensive. They would certainly need more support, and for longer. The kind of people we are talking of here probably need round-the-clock help; what is offered would barely scratch the surface. What is the position of those who receive reablement support but do not qualify for free personal care after the six weeks are over? Those are just some of the questions about which there needs to be a lot more clarity.

The additional cost of the measure is set to be substantial. On the Government's reckoning it is £670 million a year, with £420 million to come from NHS budgets and £250 million from local authority efficiency savings. However, as we have heard, ADASS has estimated that double that will be required from local authorities. What will be the effect on NHS and local authority budgets, which may already be helping people to stay in their homes for longer? What will be the effect of funding free personal care at home, for those with the highest need, on services provided to those with moderate or even substantial needs? One possibility is that they could incur the double whammy of having their attendance allowance-even their disability living allowance, if aged under 65-taken away to fund social care generally under the reforms presaged in the Green Paper, and having the level of social care support they receive degraded at the same time. In practice, the money will have to be found, in whole or in part, through service cuts or, possibly, charges. That could further fuel the pressure for an ever more restrictive process of fair access to care services.

What about the practicalities of implementation? The impact assessment accompanying the Bill estimates

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that at least 70,000 people who currently do not receive formal social care services will be eligible for free personal care from October. The Royal College of Nursing argues that if the changes are to be successful, substantial and immediate investment in community nursing will be necessary-on top of the Government's estimates that I have already referred to. I suppose that it would say that, but there are worries all the same that, with only nine months until the measures comes into force, there may simply not be sufficient numbers of properly trained social care and nursing staff to deliver the commitment to free personal care in the Bill. The college's worries on that score would seem to have some force.

The complexity of the assessment process is also a major concern. Once the existing fair access to care services rationing process is combined with the new personalisation arrangements and the personal care at home criteria have been added, the assessment process will consist of six interlocking stages of Byzantine complexity. That is all too likely to lead to confusion among practitioners, and service users will be baffled and alienated by the experience of Kafkaesque bureaucracy. Extremely careful guidance and excellent staff training will be necessary if chaos is to be avoided. The draft guidance issued so far is not reassuring, displaying as it does far too little clarity and precision regarding the assessment process, its multiple stages and the relationship between them.

There also stand to be some very untoward consequences, as we have heard from other speakers in the debate. The impact assessment makes it clear that the wealthiest old people will be the main beneficiaries. Because care in a residential home can be charged for according to the ability to pay, the requirement to provide care at home free will also give local authorities a perverse incentive to pressurise better-off people into going into care homes, where they will contribute to the cost. That could have the effect of forcing people into care homes even when that is not the best thing for them.

Finally, the process is seriously flawed. The Government were in the middle of a consultation on the Green Paper that discussed, inter alia, a national care service, partnership between the state and individuals in paying for the costs of care, and a system of insurance to enable individuals to insure against their care costs. The announcement of free personal care at home for those in greatest need in the middle of that consultation cuts right across it. Indeed, it clashes directly with the Green Paper, since all the options canvassed in it ruled out free care at the expense of the taxpayer. The Government say that this is just a stepping stone or building block on the way to a national care service, but the measures in the Bill are not a subset of the vision set out in the Green Paper. That is really the answer to speakers such as the noble Baroness, Lady Turner of Camden, and others who have welcomed the Bill as a down-payment on implementing a comprehensive and more wide-ranging strategy for social care.

The Government have stated that the policy of free care at home will need to be reviewed after 18 months. We need to be reassured, therefore, that this potentially

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temporary measure will not adversely impact on the plans for longer-term reform that all parties recognise is needed, and which may help many more social care users, and that those who will benefit from the free care at home provided in the Bill will not lose out following the 18-month review. That may prove a very difficult line to tread.

Only a small proportion of those who need social care will benefit from this Bill. The wealthy will benefit most; funding it will be difficult; and raiding the pots that the Government have fingered will have unpredictable consequences for those who fall outside the immediate scope of the Bill. What is proposed is full of perverse incentives. The Government have hardly begun to get to grips with the problems of implementation and the labyrinthine assessment process will be a nightmare. If that does not constitute a case for the Government to do some serious rethinking, I do not know what does.

6.39 pm

Lord Carter of Coles: My Lords, as we have heard in this most interesting debate, this is a very difficult issue. The Government's proposals obviously have within them a paradox, which many noble Lords have examined. I think that we all recognise the importance of care at home. However, we should also recognise that it is but one aspect of the precarious journey sometimes known as the "continuum of care" that many elderly or disabled people have to make. Of course, we should note that only 18 per cent of people die at home. Tackling the funding of one part of that continuum and, in effect, privileging one element of the journey will create a multiplicity of problems which I believe will have serious consequences in the years to come.

In speaking on this matter, I should declare an interest as the chair of the Co-operation and Competition Panel of the NHS and chair of the international operations of McKesson, a distributor of health and social care information systems.

I spent 15 years of my life organising care for the elderly in some detail. In that time, it became very clear to me that there were three key issues: first, quality and appropriateness; secondly, choice; and, thirdly, funding. I think we all accept that quality is not negotiable, but it will become a very pressing issue as the current financial pressures start to bite. For that reason, I welcome the proposal to expand the role of the Care Quality Commission in regulating all aspects of elderly care, wherever it is carried out. However, we need to make sure that the frameworks, assessments and regulation are all properly in place before we proceed.

With regard to choice, in 30 years we have come a very long way in offering a range of services for the elderly. One of those has been the growth of home care-letting people stay where they want to-and all the research points to that being the main preference. None the less, as we have heard from many noble Lords, sometimes that is not practical.

However, it seems to me that the most pressing issue remains funding. As my noble friends Lord Joffe and Lord Lipsey said in their seminal note of dissent in the 1999 report of the Royal Commission on Long-Term Care of the Elderly, to which many speakers

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have referred, the key issue seems to be the balance between what it is reasonable for the state to provide and what it is reasonable for individuals with resources to pay for themselves. That question has been asked, yet it has remained unanswered-at least for these 10 or 11 years. It was therefore very encouraging to see the excellent government Green Paper, Shaping the Future of Care Together, which sought to examine this issue.

Like many, I am concerned that the Government are taking forward this Bill without the benefit of consultation and, in my view, hastily addressing some but not all of the issues of the current system. I know we feel that we should be able to find the money to meet these aspirations but it is worth reflecting for a moment about the amount of money that we have in this system. In this current year, care of the elderly one way or another will total £21 billion. Of that, individuals already find £8 billion and the state £13 billion. Given the demographic projections, and in particular the rise in the over-85 population, it is clear that by 2030 there will be 2.8 million people in that cohort, placing enormous demands on both home care and care delivered in residential settings.

There have been many speculations about what it might put on the standard rate of income tax if the Government were to bear the whole of that burden. Therefore, at a moment when we are facing such financial challenges in the public sector, it is surprising that we should come forward with these plans. Even if, as many have argued-and I have some sympathy for the argument-we could afford to spend that amount of money, would we be able to contain costs going forward at that level? We have heard many arguments, including on the situation in Scotland and so on, but we have to ask a serious question. What is a sustainable level of funding that we can find to take this proposal forward? The suggestion that we can divert people from residential care is one of the great myths and simply defies the demographics that we face.

Therefore, the question of how the cost is shared becomes critical. Those who have to pay for themselves will have to make a choice about meeting care expenses from savings, property or insurance. Various things have appeared in the Green Paper and in the proposals from the Opposition: free care, mutualisation schemes, insurance schemes and so on. However, most of these proposals suffer from perverse incentives. I shall not revisit that as we have already heard a lot about it today, but of course with many of them the whole question of funding remains unanswered-how are we going to pay for this?

Having worked closely with the elderly for many years, I can say that the greatest fear among those who had money was that they would run out of it. Generally people with assets accumulated in their lifetime accept that they need to spend some of those assets on old age. However, we have encouraged people to be prudent, and at the end of their lives people do not want their lifespan to outlast their assets; frankly, it is demeaning.

I shall not dwell on the many alternative schemes that have been proposed and on how to mutualise them, but I was very taken with the proposal in the 1999 royal commission report by my noble friends

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Lord Joffe and Lord Lipsey that there should be some form of state reinsurance so that people can plan to find the money to cover either home care or residential care.

As many noble Lords have said, in considering how to spend the money, we need to step back and look at the whole picture. Addressing a part of it is not enough. I was very taken with the points made by my noble friend Lady Pitkeathley on supporting carers. The fact is that throughout the western world 70 per cent of all long-term care is provided by informal carers. I do not like the word "informal"; I think it is pejorative. We are talking about people delivering care, and we should look at how to help them more. Those of us who have delivered care personally know the great moments of panic that carers experience when faced with the unpredictable.

The challenge now is to find an equitable funding balance between the individual and the state, and I think that here lies the paradox. On the one hand, I was very taken by the point made by the noble Lord, Lord Sutherland, about the crumb. On the other hand, like many other noble Lords, I was very struck by the problem of having to build an integrated system to avoid the "hand-offs" and perverse incentives which arise from a non-integrated scheme.

Funding for long-term care is the elephant in the room. We are normally told that the best way to eat the elephant is piece by piece, but in this case I think that we have to get a picture of how to deal with the whole elephant. When the Minister replies to the debate, I look forward to hearing how, in forming a view on this, we can strike a balance between taking what is on offer, which is clearly important, and understanding how that will fit into a national care service.

6.48 pm

Lord Turnbull: My Lords, I cannot match the fervour of the analysis of the Bill made by the noble Baroness, Lady Murphy, but I start by saying that it is doubly objectionable. It is objectionable in process and it is objectionable in substance.

The issue of how long-term care is provided and financed has been controversial for more than a decade. The Department of Health, working with the rest of Whitehall, is to be commended on a substantial piece of work which was edging us towards a consensus in the country and across parties. A set of well considered options was laid before Parliament in July, with a consultation process which was due to end in November last year. At a time when the Government have been criticised for weakness in dealing with cross-departmental issues, the Green Paper was a model of its kind. It was signed by seven Secretaries of State, plus the Prime Minister. That must be a record. However, what then happened? Even before the consultation process had ended, one of the signatories, the Prime Minister, in a political forum-the party conference, not Parliament-repudiated the consensus, unilaterally striking out with a new proposal, which cut across the options developed in the Green Paper. The Green Paper had rejected taxpayer funding but this Bill reintroduces it and confines it to one sector, and one sector only, of the care universe without regard to the rest.

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My noble friend Lord Butler and I have attended or written briefing for dozens of Cabinet meetings immediately before party conferences. They always contain a sermon from the Prime Minister or the Treasury about avoiding new announcements to conference which are not costed and collectively agreed. Rather than making us wait 20 years, I wonder whether the Minister will tell us whether this proposal went through that process. Not only is the option in the Bill ill considered-I will give an example of that shortly-it illustrates something that is going wrong with governmental processes.

By chance, on Friday, this House's Select Committee on the Constitution produced a report on the Cabinet Office and central government. One of its conclusions-you will find it in paragraph 97-was that the increase in the power of the Prime Minister had not been kept pace with by the accountability mechanisms on the Prime Minister. This is a perfect example. The Prime Minister has launched a proposal whose genesis was not in the lead department but from his coterie in No. 10. The responsibility for defending this has not rested with the Prime Minister, but has fallen, under our parliamentary system, to the Secretary of State in the Commons, and to the Minister in this House. The Secretary of State has been undermined, left trying to defend something not of his making and, to judge by his performance on the radio this morning, he was finding that difficult.

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