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Personal Care at Home Bill
Committee (Continued)
4.13 pm
5: Clause 1, page 1, line 4, at end insert-
"( ) In subsection (1), after "charge" insert "or charged at a prescribed rate ("preferentially")"."
Earl Howe: My Lords, I will speak at the same time to Amendments 6, 14, 16, 27 and 40. One of the main concerns about this Bill which emerged at Second Reading was the deeply unsatisfactory way in which its provisions cut across the key arguments and principles articulated in the Government's Green Paper of last July, Shaping the Future of Care Together. For my own part, I found that Green Paper to be an extremely helpful analysis of the issues that should be uppermost in our minds as we consider the long-term reform of social care provision. Two conclusions from the Green Paper were inescapable. The first was that, as a nation, we cannot afford to deliver free personal care to all who need it and fund this out of general taxation. Any attempt to do that will not prove sustainable over time because of the demographic trends which are already in evidence. Therefore, as the paper says, the foundation of the new system lies in the partnership option-that is to say, in co-payment of one sort or another.
The Government are holding fast, as far as I know, to the conclusions of that Green Paper, but they are at the same time bringing forward a Bill which is completely at odds with it. The Bill is said to be a "bridge towards" a fully reformed social care system, but it is hard to see that phrase as anything more than just words. If the Government had been a bit straighter with us and said that the Bill was designed as a temporary stopgap in advance of long-term reform, that might have been a more credible and accurate description. I would have liked the Bill to point a clearer way towards the vision set out in the Green Paper; in other words, to be a genuine bridge and a genuine building block to long-term reform.
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To be that bridge, the Bill needs to open up the way to a much more varied and flexible set of options. We have already considered some of the pitfalls that look set to await us as a result of the lack of clarity in some of the definitions that will determine eligibility for free care. In any decision about eligibility, so much will be at stake that people are unlikely to take a refusal lying down. I genuinely fear an explosion of complaints, appeals and litigation.
The obvious way forward is to preserve the core idea of a more generous deal for those in critical need of care, but to cut the cake differently so that there is a more graduated scale of preferential charging and therefore much less incentive for people to dispute the results of an assessment. The difference between having substantial needs and having critical needs will often be quite narrow. The difference between requiring help with four activities of daily living and requiring help with only three may be equally narrow. Therefore, I ask the Minister what thought the Government gave, as an alternative to offering free personal care to all those people with critical needs, to the idea of a graduated preferential scale of charging under which local authorities would be able to take into account not only the acuity of a person's need but also their personal financial means.
I mention means-testing here with no apology. The cost-benefit analysis contained in the impact assessment seems to me the loudest warning bell, if any were needed, that we are in danger of creating an unsustainable system. People who can afford to bear some or all of the cost of their personal care cannot in the current climate be considered a more important priority than those without financial means whose need for care may be only very slightly less acute. I am no advocate of the postcode lottery, but I believe in local authorities having discretion to manage their finances in ways that they consider fair and affordable. The Bill takes that discretion away from them in a material sense, and it does so, as we will debate later, in a very unstructured and ill planned way.
I have spoken up till now about the short term; the longer term should concern us equally. What are the ingredients of a sustainable and fair system of social care provision over, let us say, the next 100 years? To my mind, they are these. We should aim for a personalised service to enable people to buy the care that suits them best. One of the problems with the Bill, despite what the noble Baroness said earlier, is that it seems to cut right across the personalisation agenda, which, up to now, the Government have done rather well at. We need consistent national standards for the assessment of care needs. The Government are right about that, and I shall support them in their efforts to introduce them. We need to help people stay in their homes for as long as they can-again, the Government are right about that. We need also to find a way of protecting people from having to sell their homes to pay for long-term care. I should like to think that there is no disagreement between my own party and the Government on any of those four principles.
I do not want to exacerbate the public spat which has been going on between members of my own party and Ministers in another place, but I would simply say
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A national care service is a great idea, but if you mandate the service from the centre, and fund it centrally, it becomes inflexible and depersonalised. I do not think that that is the way to go. Equally, a compulsory state insurance scheme takes us in the wrong direction if we believe in empowering people through choice. It also acts as a strong disincentive to informal care, and I worry greatly about that.
If this Bill is to act as a bridge towards a flexible and personalised system of social care, under the banner of a national care service, it needs to offer a greater range of possibilities than it does at present. It needs to factor in the likelihood that people will wish to provide for their critical care needs by means of voluntary insurance, and to allow for those who wish to engage in preventive health programmes, not simply reablement. To incentivise the take-up of those programmes, it needs to protect those who cannot afford to pay for personal care, while at the same time giving due recognition to those who are prudent enough to provide for part of the cost of their care from their own resources. It also needs to recognise the value of informal carers. In general, it needs to be more enabling towards local authorities, and less prescriptive in terms of the structure of care services which they commission and fund. It is against that background that I beg to move Amendment 5, and I hope that the Minister will feel able to move at least a little way in my direction.
Baroness Campbell of Surbiton: My Lords, I speak to Amendment 29, and I would like to thank the noble Earl, Lord Howe, for allowing me to pop in on his amendment group. This is a much better time for me, and I thank him.
It is a privilege to have this opportunity to again raise the vital issue of social care portability. It is so fundamental to the basic human rights of disabled and older people. Many noble Lords will remember the very positive debate that we had when my amendment on portability was debated during the passage of the Health and Social Care Act. Strong cross-party support then led directly to the commitment in the recent social care Green Paper to work towards a national care system with portability at its heart. I promised noble Lords during that debate that I would give portability my forensic attention. I am therefore very glad that I am today able rather modestly to place an amendment to make that commitment a reality for 280,000 disabled and older people with the highest support needs who are anticipated to qualify for the new free care provision.
The effect of my amendment would be to ensure that the new free personal care provision is portable between local authority areas. People who qualify for free personal care in one local authority area would be entitled to move to another, in the certainty that they would continue to receive that free care without anxiety, disruption or delay. The amendment achieves this by
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It is vital that those with critical-plus needs receive seamless support if and when they move home to be near relatives. Delays as people wait for a new assessment could at worst be fatal and at best lead to grave health crises, putting disabled people and their families under enormous strain.
The Government have pledged that the new free care offer will be underpinned by a common assessment framework that will help to iron out inconsistencies between authorities. Some say that this negates the need for a portability clause in the Bill. However, a common assessment framework will not guarantee that the transition from one authority to another will be seamless. A receiving authority will be required to reassess people who previously qualified for free personal care, even though their needs will not have changed. I will now hand over to the noble Baroness, Lady Wilkins, to assist me.
At this point, Baroness Wilkins continued the speech for Baroness Campbell of Surbiton.
It is widely accepted that local authorities fail in their responsibilities to deliver seamless support to disabled people who move between authorities. Continuity of support is treated as an aspiration rather than as a necessity. Many people I know are too terrified to move for fear of their support falling apart. If they do move, they face huge stress and hardship as they struggle to renegotiate vital care and support. It is these fears and this hardship that my amendment seeks to address, albeit only for those with the highest level of need.
A major inspiration for the amendment, apart from a desire to address the harrowing experiences that disabled and older people face when moving home, is of course the desire to see human rights standards brought to life. The UK Government recently ratified the UN Convention on the Rights of Persons with Disabilities, which spells out that disabled people must be able to choose where we live on an equal basis with others, and that we have the right to work and participate in our communities and to be free from exploitation, violence and abuse.
The amendment has strong support from the Equality and Human Rights Commission, which states that,
- "current arrangements place an unfair and inequitable restriction on freedom of movement and, at the very least, are very much against the spirit of the right to private and family life as set out in Article 8 of the European Convention on Human Rights ... the Commission supports enshrining portability within primary legislation. Any other approach would continue to restrict this fundamental human right".
At this point, Baroness Campbell of Surbiton resumed.
I am pleased to report that there are now local authorities out there itching to implement portability. I recently had the pleasure of being on the interview panel for the Department for Work and Pensions' Right to Control trailblazer sites. We were tasked with choosing eight local authorities to test the new Right
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My amendment is short, sweet and to the point. In many ways, it is cost neutral-we are not asking for more funding. As time is short, I will just say two things on the detail. The first is that disabled people are very aware that the exact level of direct payments and type of services available will differ from one local authority to another. We are realistic about that. We understand continuity of support to be about creating a support package that meets our needs, rather than replicating identical services. Secondly, I want to emphasise that it will be particularly important to spell out in regulations and guidance the need for user and family involvement in all arrangements made to support someone in picking up their new life in a new place.
If the Government accept the need for action today, it will send a strong message of hope to thousands of disabled and older people in England that they may move without fear of reprisals. It will also keep the costs of this Bill down by ensuring scarce resources are not wasted on reassessing people whose needs have not changed. We have a momentous opportunity to test this out and make a start on portability, and I urge noble Lords to grasp it. I beg to move.
4.30 pm
Lord Eden of Winton: My Lords, I support the amendment moved by my noble friend Lord Howe. In doing so, I confess to a certain amount of confusion in my mind. There is a possibility of conflict here between, on the one hand, the need for local authority autonomy and the ability that each local authority rightly has to administer and control its own budget as far as possible, and, on the other hand, the requirement-as put forward so ably by the noble Baroness who has just spoken-that there should be portability in the benefits or awards of assistance received by the individual in the event of a move from one local authority area to another. Will the Minister be able to clarify this for me? I am very much in favour of both but I do not quite see how we can have both.
The operative word that seems to be missing throughout much of our deliberations is "flexibility". There must be flexibility in identifying the needs of the individual, in allowing for that individual to move from one area to another and for the local authority to manage its own financial affairs. These are the issues that need to be ironed out because if we ultimately go the full course and achieve in this country what the Government are evidently aiming for-the establishment of a national care service-that predicates a degree of centralisation, of central control, of central direction and of central
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Baroness Turner of Camden: My Lords, I speak as somebody who supports the Bill and I am therefore somewhat confused by this group of amendments, although for a different reason from that given by the noble Lord who has just spoken. I do not support the amendment moved by the noble Earl, Lord Howe, but I support Amendment 29, which provides for a transition between one local authority and another. I think that was part of the Government's original intention when we discussed the Bill earlier. However, the rest of the amendments in the group, and particularly the Question whether Clause 1 should stand part, cut right across the general intent of the Bill, and I certainly would not be in favour of that. As I said at Second Reading, I support the intention of the Bill; I support what the Government want to do for these-mostly elderly-people who are in the neediest group. This is, I understand, a first step towards a much bigger national care programme, which I think many of us in this House would fully support. In the mean time, I support the Bill and therefore cannot support the amendments in this group, except Amendment 29.
Baroness Barker: My Lords, on my way here today I tried to work out how I would explain and justify to people what I had spent my afternoon doing. I set myself a goal: I would go through today's proceedings as though I were somebody who needed social care services, a carer or someone in the unenviable position of trying to organise this for a local social services department. I would try to get to the end with greater clarity and understanding about what the social care system in this country is. However, I have to say that it is not looking good at the moment. In fact, it is becoming more confused. That is an inherent problem when people talk of such things as a national care service without clarity about what it means. It is not about unanimity of provision; it is about agreeing about what care services are, who is entitled to them and how they are funded.
That leads me directly to both of these amendments and to ask a question. I can see the intent behind the amendments of the noble Earl, Lord Howe, and I have a great degree of sympathy with it. We are, after all, talking about a system which has never met-and never will meet-all the social care needs of the country, and about trying to find an equitable way of ensuring that such resources as we have are best applied to people who have needs. My question for the noble Earl, Lord Howe, is: who would set the preferential rates for services? When we talk about care services, by and large we talk about people carrying out care tasks for individuals. The cost of employing people does not vary much, whether they are in the private sector or the public sector, or whether they are in different areas of the country. It might vary ever so slightly. What is the rate for a care attendant in one area of the country? It may differ, but only very slightly, in another. I ask the noble Earl, Lord Howe,
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I draw the attention of the noble Baroness, Lady Campbell, to the issue of portability. She said that we are not asking for more money. Care, in the terms of the Bill, applies not just to people providing care for others but to adaptations. The capital expenditure of adapting somebody's home might well be doubled if they moved. Both the noble Baronesses, Lady Campbell and Lady Wilkins, said, in relation to this amendment and Amendments 2 and 4, that personalisation and self-directed support now has a body of evidence behind it that proves that it is cost-neutral and cost-effective. I wonder whether they could both point me to that, as I have not yet seen evidence as strong as that. The IBSEN report on the pilots did not go that far.
Given that cost is at the absolute heart of this debate, I should very much appreciate seeing the evidence behind both those statements. That will help noble Lords when we come down to doing what we ultimately all have to do-to work out what we believe to be the best use of finite resources for the best benefit of the most people. Noble Lords who listened to the "Today" programme with as much attention as I did this morning will know that my colleagues and I have concluded that this Bill does not represent that. We would use the resources in other ways that we think would be to the greater benefit of the greater number of people. In that context, I believe that these are fair questions and I would appreciate some answers.
Lord Tebbit: My Lords, I wonder whether the Minister can help us, or at least help me. I refer to the proposals made by the noble Baroness, Lady Campbell, and the number of people who might move from one local authority to another, as there is a tendency for people to do in their old age, or relative old age, or when they become disabled. Quite a lot do so, either from a high-cost residential area to a lower-cost one or nearer to relatives and things of that kind. Therefore, there is bound to be a certain number of people washing backwards and forwards across local authority areas.
We can only guess at those numbers but it would help us if we had at least an idea of what was in the minds of Ministers as to the cost per individual involved in this scheme. How many people do the Government think will benefit? The Government's estimate of the cost of the whole thing is that it will be less than £650 million. I must confess that my reaction to that is "Come on, pull the other one". If the Government are going to stick to £650 million, how many people will be involved? That will give us an idea of how many of those people might be transients washing backwards and forwards across the boundaries.
Is there a cap? The noble Baroness, Lady Barker, added the cost of changes to homes to make them possible for people to live in. It might not be just the cost of a stairlift; it might be a substantial lift at a cost of £15,000 or £20,000. The cost of a bathroom being adjusted can be £2,000 or £3,000. That is apart from the recurring costs. We have to have a better idea of what the Government think will be the cost per head
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Lord Sutherland of Houndwood: My Lords, not surprisingly, many of us had anticipated that as we probed into the details of the Bill we would find ourselves in a bit of a quagmire. It is quite a small Bill and quite a small area of quagmire, but my impression is that the depth is considerable and one gets out of one's depth very quickly.
However, I want to support Amendment 29 put forward by the noble Baroness, Lady Campbell of Surbiton. I supported the principle of this at Second Reading and I have seen no reason to change my mind. Here, there is at least one bit of hard ground on which we can walk where there could be a significant benefit from legislation that we might advance this afternoon. The benefit would be in three contexts. One is the individual. By and large, people who need substantial care packages do not move for frivolous reasons. If they are moving from one authority to another, there will probably be a good reason, normally to do with folks who are relatives and potentially informal carers. The benefit there is clear and significant.
4.45 pm
However, there will also be a benefit to the local authorities involved. If someone with substantial care needs comes into a new area and has to be reassessed completely, that will involve significant time and the cost of their assessment, including professional time. One can be fairly sure that if significant capital costs are involved-which may well be the case, and that is a legitimate point to query-the move will, by and large, not be for frivolous reasons and there will not be a large number of people to whom this applies. They would not be moving if the capital costs were likely to be great, because the care needs would be equally great. The move would be for good reason.
Thirdly-this point has been made-some of us believe that one of the more important features of the Bill is that it moves towards a national care service, involving a degree of equity between different postcode areas and local authorities. That would be one way of establishing equity in a very specific way. Costs borne by a new authority are running costs-I accept not capital costs-lost by another authority. Surely it would not be beyond our powers of intelligence to devise a way of transferring money if the costs were significant and substantial. I support the amendment.
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