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The Bill is a classic Gordon Brown dividing line. It is not drawn up on merits but has been chosen to set a trap for the Opposition, who either oppose it and are accused of being heartless, or accept it against their better judgment. Looking at the density of population on the Opposition Benches, they have obviously elected to sidestep this challenge, although that means that they are unable to enter into the substance of the debate.

The proposal is equally objectionable on substance. Let me illustrate that from the experience of my family. It is an example which, I believe, has quite wide applicability. My mother-in-law, now 94, has lived on her own for more than 20 years. In recent years, she has been growing frailer, but was coping. Then, as is often the case, she suffered an illness which set her back. The family managed, however, with the help of the NHS and social services, to get her back into her own home, supported by a local care agency, paid for by her. That worked well for 18 months, until she had a fall and broke her arm. That so reduced her mobility that independent living, other than by provision in her home of 24-hour care, became impossible. That is the moment that all families dread, but there was no realistic alternative to her moving out of her home into a home. Happily, she is much better cared for, and she is living much closer to us.

The point of that example is that, at the very moment that her care needs went up from, perhaps, 30 hours a week to 168 hours a week, her eligibility for financial support went down. That cannot make any sense. Crucially, it fails the test set out by the Minister when she said that those with the highest needs must receive the greatest help. It is that injustice, even more than the issue of cost, which I find so objectionable.

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We are being asked to vote on a Bill whose details are still unclear and which has received perfunctory scrutiny in another place. It is often the case that a Bill is fleshed out by the details of regulation, but in this case, key principles, which should be in the Bill, are still missing. What is the basis of assessment? Is it the four ADLs-activities of daily living-which do not seem to include cooking, incidentally? What is the true duty of the social services department? Is it to provide care or merely to fund it? What does it cost? Is it all a cruel deception in which hopes are being raised way beyond our ability to deliver?

The effect of the Bill is to pit people's pockets against their better judgment. In many cases, increasing the care to extend living at home will be the right answer. Many others have correctly argued that. It was for us for a time, but for others, as the example I have given shows, there will come a time when it is no longer the right answer. A financial obstacle is being erected to prevent decisions being taken which are in the best interest of the elderly person.

The Bill, in my view, is so badly constructed, so poorly costed and so weakly scrutinised that if, as is traditional, it receives a Second Reading, I hope that the House will subsequently not allow it to proceed until the unanswered questions are answered. We can then return to the better-thought-out proposals in the original Green Paper.

6.55 pm

Baroness Gale: My Lords, as one of the last speakers in this debate tonight, I am very pleased to say that I support the Bill. I was just as delighted when the Prime Minister announced this Personal Care at Home Bill at the Labour Party conference.

I am very pleased to have the opportunity to contribute to this important debate, and will focus my speech on the impact that the Bill will have on people with Parkinson's. I am confident that the Bill is an important first step on the road towards improving social care support for people with Parkinson's. However, it is important to recognise, as other noble Lords have tonight, that it is only a first step towards achieving a much-needed national care service.

I declare an interest, as I chair the All-Party Parliamentary Group on Parkinson's Disease. I am pleased that Parkinson's has featured so prominently in both the Bill and the debates about it. Last July, the all-party parliamentary group published a report on services for people with Parkinson's, which clearly highlighted inequalities that people currently face when trying to access health and social care. I am hopeful that the Bill will address some of the major gaps in social care for people with Parkinson's, as illustrated in our inquiry, because one of the key issues highlighted in our report was inequalities in social care services across the country.

I am particularly pleased to see that the consultation documents published alongside the Bill indicate that a standard assessment tool will be developed. That is an important step towards ensuring consistent implementation of the Bill across the country. I am equally pleased to see that the Bill will introduce a period of reablement. Preventive intervention, such as

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therapy services and aids and adaptions in the home, are proven to be cost-effective in the long-term, and can make a huge difference to the lives of people with Parkinson's.

However, I raise a concern about waiting lists for aids and adaptations in the home, which are currently not mentioned in any of the regulations and guidance for the Bill. The Bill aims to reduce unnecessary admission to care homes, but to achieve that, it is vital that waiting lists for aids and adaptations be addressed. Although the Bill offers additional funding for equipment, which would be provided as part of the reablement process, without a clear requirement for that equipment to be delivered promptly, the Government will not be able to achieve their stated aim of reducing avoidable admissions to care homes. Is it a clear commitment that the regulations under the Bill will address that important issue?

I am also concerned that the focus of the Bill on those with high needs may have the unintended effect of diverting therapy resources from those with less severe needs. It is extremely important that preventive interventions, such as physiotherapy, are available to people at the earlier stages of Parkinson's disease. Our inquiry showed that those services are extremely patchy and difficult to access. Provision of those services is cost-effective, and capacity needs to be increased urgently to meet the demand.

There are also a few concerns about the assessment process. In Clause 1, new subsection (4C) authorises local authorities to make a person's eligibility for free personal care conditional on that person undergoing an intensive intervention or reablement package. Although the focus on prevention and reablement is extremely welcome, the compulsory nature of it appears to go against a personalisation agenda in some ways. Again I ask the Minister whether she can give assurances that this matter will be dealt with sympathetically.

The Bill is understandably limited and I recognise the reasons why carers' services are not covered under the proposals for personal care. However, the APPG report found that far too many carers are struggling to get the support they need, not only to continue caring but to remain fit and healthy themselves. Can the Minister confirm that the guidance will explore ways in which carers can be supported in the rehabilitation phase of the assessment process-for example, through support such as respite breaks, training in moving and handling and in medication management?

I said at the beginning of my speech that I welcome the Bill. I certainly do and I will be supporting the Government tonight.

7.01 pm

Baroness Barker: My Lords, I thank the noble Baroness, Lady Thornton, for introducing the Bill. Everyone who heard the "Today" programme this morning will have recognised that she will not have an easy task. If it is any consolation to her, summing up on behalf of the Opposition when the noble Lords, Lord Lipsey and Lord Warner, are in the vanguard is not exactly a picnic either.

"The present situation cannot go on much longer. People are entitled to security and dignity in their old age and so we must

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find a way in which to fund long-term care which is fair and affordable, both for the individual and for the taxpayer".-[Official Report, Commons, 4/12/97; col. 489.].

Those are not my words; they were said by Frank Dobson MP when he announced the setting up of the royal commission.

Since the royal commission the Government have not stood still. They have brought forth a raft of research reports, policy papers and legislation. I pick out highlights, as noble Lords have done already, such as Sir Derek Wanless's report in 2006, the Government's Green Paper in July 2009, the dementia strategy and the Community Care (Delayed Discharges etc.) Act 2003. Along the way we have had rafts of research and policy papers, the National Service Framework for Older People and the falls prevention strategy. However, today we are no clearer and no nearer to answering the question the royal commission was set up to answer.

The most dispiriting thing about the Bill is that it takes us back to talking about a narrow, focused part of social care. The great tragedy is that the Bill's production has meant that work on the costing models for the Green Paper had to stop. When we discussed this matter in the Queen's Speech debate there was general consensus that, whatever one thought of the detail in the Green Paper, the financial modelling was crucial. The Bill has delayed that. Why is that so important? It is important because, as the right reverend Prelate the Bishop of Norwich said, this is a political issue of some importance. I congratulate the charities and the groups that have worked so hard to make this a key issue for the election.

In truth, all parties are struggling with the issue of the funding of long-term care and this important debate could not come at a worse time. We all know how bad the outlook is for the public services and public service finance. Had we had this debate 10 years ago, the atmosphere would have been different. The Conservatives have brought forward their pledge for the election-a voluntary insurance scheme which would enable people to pay £8,000 in order to meet some of the costs of going into residential care. There has been a great deal of talk about perverse incentives and there is a great deal of concern that such a policy would encourage relatives to put people into residential care before they should be.

As the noble Lord, Lord Warner, said, the Liberal Democrats have put on hold our commitment to free personal care-a decision we did not take lightly. At the same time, we also put on hold our long-held policy of funding free nursery education for all three year-olds. Passionately committed as we are to enhancing the life chances of children, I hope noble Lords will understand that the need to defer both policy commitments has come about because we are in such a difficult financial situation.

I echo the speeches of the noble Baroness, Lady Murphy, and the noble Lord, Lord Sutherland. Debates on long-term care are always a mix of high principle and devilish detail. We will support the Bill going forward, not because we think that it has general overall merit in the greater scheme of things for putting us onto a sustainable future for long-term care but because in the draft regulations and guidance we go

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one step forward towards something which has been lacking throughout all the debates on personal care-a definition of what it is. The noble Lord, Lord Sutherland, is right: we have known for more than 12 years that we need a definition of what constitutes social care and what will be the state entitlement that is sufficiently clear to enable individuals, by whatever means, including insurance, then to bring in their own resources to top that up. That is why there is a value in this.

The noble Baroness, Lady Campbell, referred to the question of assessment and whether we will have a critical plus band for services and, if we do, how people will be assessed. The noble Baroness loves talking about assessments-so do I. Last week I addressed the AGM of Counsel and Care, where one of my fellow speakers on the panel was Imelda Redmond, the chief executive of Carers UK. She reported that at the moment, in some local authorities, if a person turns up with the person for whom they care to an assessment meeting, the person being cared for can have their eligibility assessed as 50 per cent less than someone with similar care needs solely on the basis that they have a carer, and without that being mentioned to the carer at any point during the interview. Does the noble Baroness agree that that is wrong; that if it is happening it must stop and stop now and does not have to wait for this legislation? I should like assurances that the assessment of need will not include a carer's contribution but that carers can be taken into account in working out a care plan.

Other noble Lords referred to the activities of daily living, but I shall not go into them because that is a matter for the Committee stage. However, I will ask the Minister for clarification about what needing significant help with those activities will mean because it is on such small details that the daily fate of hundreds of thousands of people rests. The noble Baroness, Lady Murphy, made an eloquent case for saying that we have come to a time when we have to acknowledge that assessment of people who have dementia is different and, therefore, we have to have parallel assessment criteria for them. What somebody who has capacity can manage is not the same for somebody who lacks capacity. It is helpful to have the list of qualifying services set out in the guidance.

In her introduction, the noble Baroness, Lady Thornton, talked about the criteria for NHS care. In her reply, can she say how the criteria for this policy will work with the criteria for continuing NHS care? It is not that long since local authorities and the health service were playing games with one another to see who would pick up the tab for individual people. That stopped when there was an increase in funding. It will reoccur the moment the pinch begins to fall on the public purse. A propos a point made by my honourable friend Norman Lamb in another place, reablement is a good thing and we are all in favour of it, but does the Minister agree that people who need palliative care should not be put through an assessment for reablement? That is simply a bureaucratic nightmare for people and their families when there is no need for it.

On the issue of budget allocation, the right reverend Prelate the Bishop of Norwich talked about local authorities trying to implement this policy and having

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to cut services for other groups of people. I think it will be different and that social services departments will sit down and look at cutting other services for older people, who are by far one of their biggest client groups. That is the tragedy of having to debate such a small and narrow-focused element of social care. Were I in the unenviable position of being a chair of social services faced with this Bill, I would have to look at the work of my department and say, "Am I going to cut the wardens in sheltered housing? Am I going to cut the transport? Am I going to cut the lunch clubs and the shopping services?" These are all services which help thousands of older people and their families to get by. Given the lack of clarity about the number of self-funders and the capacity of councils to meet the obligations which this Bill places on them, does the Minister agree that this policy needs to be reviewed earlier than the 12 to 18 months proposed, so that we can see very quickly the extent to which it is, or is not, meeting its aims? I share the curiosity of the noble Baroness, Lady Masham, as to which Department of Health budget will be cut in order to fund this Bill.

Finally, there is the proposal of the noble Lords, Lord Lipsey and Lord Warner. I have immense respect for the noble Lord, Lord Lipsey. Over the past 10 years we have done battle on this subject many times. He has consistently taken the approach that he does out of a passion for ensuring that the quality of services for older people in this country improves. I admire him for that. I am afraid we will not be supporting him on these Benches tonight. I have advised my colleagues to abstain for two reasons. The first is a technical one. We on these Benches do not intend to vote either at Second Reading or in Committee unless a matter is of exceptional importance, and I do not believe that this Bill falls into that category. The second reason is this. The Government have raised a whole raft of questions on a pretty thin evidence base. I have never read an impact assessment like it where the word "unknown" appears time after time. But having raised the debate just before a general election, the Government's proposals deserve greater scrutiny than they received in the House of Common-although, having read Hansard, I would say that one clause got far more scrutiny than usual down another end. However, it needs to be taken much further apart.

We can all argue about the principle and wonder about the economic climate and what we would do if we had the money, but when it comes to a national care service, we are not talking about reordering providers or establishing branding and all that which goes with the NHS, but about entitlement and funding. This Bill does not address funding but it begins, in a very small way, to address entitlement. I believe noble Lords have a right and a duty to examine that in very great detail, so I wish to go forward to Committee stage in order to do that.

7.16 pm

Earl Howe: My Lords, it is quite clear from everything we have heard today that, rather like one of those trick diagrams where one sees either a pair of human profiles or, alternatively, the outline of two candlesticks, this is a Bill which can be viewed and appreciated from a

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number of different angles. One of those angles is that which the Government invite us to adopt as we consider the Bill's proposals, and I would be hard put to disagree that the perspective of the noble Baroness, Lady Thornton, is a natural starting point in this area of policy. Like other noble Lords, I do not think that anyone could cavil at the principle of enabling people living at home who have critical personal care needs to receive such care free. It is a laudable aspiration. It is equally laudable to try to devise ways in which those who need personal care can avoid having to go into residential care, or at the least can delay doing so. Who among us, especially those of us with elderly relatives of our own, could take issue with that aim?

I begin by commending the Government on their worthy instincts. It will however be clear to the Minister that the Bill represents something rather more complicated. The Government have taken 12 years to reach this point. The Royal Commission on Long-Term Care for the Elderly, under the able chairmanship of the noble Lord, Lord Sutherland, contained some extremely valuable analysis of demographic trends and their implications for social-care delivery, and a great deal of the commission's thinking is relevant to our deliberations today. However, one of the things that the Government took away from that report was the conclusion reached by a minority of the commissioners that free personal care for all was not an idea that was either practicable or, in terms of its net benefits, politically defensible.

The Green Paper published last year restated that conclusion on the back of some home truths. The first home truth is that the current system of social-care funding is under considerable strain. If nothing is done, it will come under progressively greater strain as we move into the future as a consequence of demographic trends. Over the next 20 years we are going to see the proportion of the working population diminish in relation to the number of people of retirement age. To fund personal care solely from taxation would inevitably mean placing an increasing financial burden on those people who are working. The problem with that is not just one of affordability but also one of fairness. A fully tax-funded system would entail a shift of resources from the young, who have relatively fewer means at their disposal, to the old, who have accumulated wealth over a lifetime. It was not surprising, therefore, that the Green Paper explicitly ruled out a wholly tax-funded system and proposed instead a number of options resting in one form or another on co-payment. The paper states:

"We think that the Partnership option should be the foundation of the new system".

The Bill before us has been heralded as one of the building blocks of that new system, yet its proposals, as we have heard from so many noble Lords, run completely counter to the partnership option. What on earth can account for that? Neither in the Prime Minister's speech at the Labour Party conference nor at any time since have we had an explanation as to why the Green Paper's carefully formulated arguments, based in essence on principles of social justice, should have been ignored in a Bill that is meant to represent the very first step along the road to comprehensive social care reform. It is not as if those wider principles

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of fairness magically disappear. If we look at those older people whom this Bill will benefit, we see that no fewer than half are currently paying for social care, either in part or in full from their own pockets; in other words, people who by definition are not in the poorest bracket of society. Given that the windfall that those people will receive is in large measure to be funded out of general taxation, we are looking, exactly as the Green Paper said, at a large slug of public money going into the pockets of those with means at their disposal. At a time when public funds are under serious strain, it is hard to see the social justice in that.

It is equally hard to see the justice in the discrimination which underlies the Bill. One group of people with critical care needs who happen to be living at home will benefit; those whose needs are equal if not even greater, but who happen to be in residential care, will not. The Government go to some lengths to justify this distinction, but, in truth, their explanations sound pretty hollow. If it is compassion and people's level of need which have motivated the Government to act in the way that they have, why have they not tried to produce a package that would be fairer to all in greatest need, instead of just some?

Let us take the Bill on its own terms. Its key aim, as the Explanatory Notes tell us, is to enable,

The key phrase there is "more people". In other words, there is a test, as there always is, of value for public money. The more people who benefit from reablement and from personal care at home who are currently not in receipt of those services, the greater is the value for money. We need to look quite carefully at how many more people will actually avoid going into residential care as a result of the Bill. In a full year, the number of people in the highest category of critical need who will receive personal care at home is budgeted at 277,000. Of those 277,000 people, only a tiny fraction, under the Government's assumptions, are not currently in receipt of such care. In fact, the figures, even by the Government's own admission, are a matter of uncertainty, because nobody knows how many people there are whose needs are currently not being met in any form. If we take the £537 million that it is going to cost to deliver personal care in the home as a result of the Bill, it is clear that the net additional benefit conferred by that money will fall, first, on the 2,000-odd people who it is assumed will switch from residential care; and, secondly, on the 5,000-odd people who will stop receiving informal care and switch to social services; in other words, a very small number of additional people set against a very sizeable sum of public expenditure and therefore a very large dead-weight cost. What is the justification for that? It looks like a very poor deal for the taxpayer.

Not for a minute would I wish to belittle the value of reablement, which is the other part of this package. Reablement is a good concept, although it is perhaps just as important for us to focus on prevention as on reablement; sadly, the Bill says nothing on that topic. Nevertheless, as regards value for money, I am fully prepared to believe that, per pound spent, reablement is capable of achieving very considerable benefits. The problem with reablement, as envisaged, is the way in

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which it has been costed. As we have heard, just about every single figure used in the Government's impact assessment comes with a giant health warning, but the figures underpinning the reablement calculations look particularly shaky. One hundred and thirty thousand people at £1,000 a head is suspiciously broad-brush. Those whom I have spoken to in local government say that the underlying cost assumption of £30 an hour for 30 hours is likely to be a gross underestimate of what will actually be required.

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