Funding of Care and Support
(13 years ago)
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Baroness Pitkeathley
That this House takes note of the report of the Commission on Funding of Care and Support and the future of social care.
Baroness Pitkeathley
My Lords, it is a pleasure and an honour to introduce this debate about the future of social care and to move the Motion that the House takes note of the Dilnot commission report. I am grateful to all noble Lords who have put their names down to speak and I hope they will not mind me calling them, in the context of discussing social care, “the usual suspects”. I mean that as a term of the greatest respect. However, it is a disappointment that there is no speaker from the Conservative Benches apart from the Minister.
Certain reports are so significant in the development of policy that they are known by a single name. Your Lordships will think of Beveridge or Wolfenden. In the field of social care, the names that spring to mind are perhaps Seebohm, Griffiths and Laming, and certainly many of us believe that Dilnot should join that illustrious number. I pay tribute to the Government for setting up the Commission on Funding of Care and Support and the future of social care, and to Andrew Dilnot for his extraordinarily important report. I include thanks, too, to his colleagues Dame Jo Williams and your Lordships’ very own Lord Warner—my noble friend—not only for their contribution to the report but for their continued work to have it accepted and implemented. Their diligence and sheer hard work are enormously appreciated.
The commission was set up to investigate the problems of the current system of adult social care in England and to develop ideas for reform. So what were the problems that the three musketeers, as some have called them, were to investigate? The current system of care and support is seen to be in crisis, severely stretched or broken, depending on where you sit. All agree that “something must be done”.
Of course, it is not the first time that such feelings have been expressed. Let us remember that social care has never been free at the point of delivery as healthcare has been, and the question of who pays—the individual, the family or the state—has occupied politicians for years. Twelve years ago, my own Government set up a royal commission on the subject and recommended that all care should be free. I am delighted that the noble Lord who chaired that commission is to speak in this debate—his second outing of the day—as is one of his dissenting members, and I look forward very much to hearing their views.
The problems in summary are as follows. The system is not fit for purpose. It was set up originally for a country in which men died at the age of 66, shortly after retirement, and women died before they were 70. The new statistics—for example, that 11 million people alive today will live to be 100—are of course a cause for celebration, as is the fact that so many more people are living longer, albeit with greater degrees of disability. This means that we are spending inadequate amounts on care and support, both publicly and privately.
Social care funding has failed to keep pace with demographic change. Since 2004, while spending on the NHS has risen by £25 billion, spending on social care has risen by just £43 million. To cope with rising demand and static resources, councils have increased charges for care services and rapidly raised eligibility criteria, with the percentage of councils providing support to those with moderate needs decreasing from 50 per cent in 2005 to 18 per cent in 2011, as eligibility criteria were raised to cover only those with substantial or critical needs. This has been compounded by recent local government spending reductions, with social services directors reporting £1 billion cuts to services this year and warning that the same level of cuts or even greater ones will have to be made next year. Our public provision is largely seen as providing poor services for poor people, and there have been several examples of this in recent months, most notably yesterday’s distressing report from the EHRC.
However, we should never forget that much good care is still provided to individuals within the system because of the dedication and skill of thousands of workers. Those workers and their agencies have had some success in recent years with the personalisation of services, promoting independence and early intervention. There are pockets of great service to be admired, and we should always remember that, but in general the care and support system is perceived to be starved of cash, failing to meet the volume of need, unfair and a lottery, especially for people with middle incomes, for the simple reason that if you die neatly without needing to use care services, you pay nothing, but if you become disabled through a long-term illness such as Alzheimer’s, you may need expensive services at full cost for many years, involving thousands, sometimes hundreds of thousands, of pounds. So people who own a home and have modest savings are hit very hard. The system is also extremely confusing. It is difficult to find your way around, different in different parts of the country, not portable when your location changes, and so on.
Moreover, caring families as well as the individual needing care suffer at the hands of the system, which for them is too complex, costly and unfair. Family members end up sacrificing their careers, finance and their own health in order to provide care to disabled or older loved ones, getting little or no help from a social care system and finding that services are of poor quality and expensive. However, if you have a carer you are luckier than the frail older person living alone whose total social care is a 15-minute visit once a day—twice if they are very lucky—which is not enough to keep them clean and comfortable, let alone cared for. These problems are only going to get worse if nothing is done. Within 20 years the number of over-85s will double and the number of people living with lifetime disabilities will grow too. Relatively fewer people will be working and paying taxes to help pay for support.
Apart from the practicalities of money and how it is all to be paid for, we have other changes in society that affect what we expect from social care. People want and demand greater choice and control than is often offered by our current system, and people’s expectations about standards of care are rising. The Dilnot proposals were published on 4 July and they aim to change the way that social care funding is raised and spent, extending entitlement to public funding for social care in a way that is acceptable and sustainable to taxpayers.
The key recommendations will be familiar to your Lordships. The contribution of an individual to their social care in their lifetime, which is currently unlimited, should be capped. After the cap is reached, individuals should be eligible for full state support. It is suggested that the cap should be between £25,000 and £50,000. The means-test threshold over which people are entitled to full costs should be raised from £23,000 to £100,000. Further, there should be national eligibility criteria, and portable assessments should be introduced. All those who enter adulthood with a care and support need should be immediately eligible for full state support without a means test. A new information and advice service should be set up to guide families through what they need to know.
The cost is estimated to be about £2 billion, although that figure is disputed. Of course, it is a large sum but not if you compare it with the £170 billion that social security costs or indeed the £119 billion which carers contribute to the coffers every year. In these difficult financial times there is of course a question of how money is to be found, but perhaps a better question is what will happen if that money is not found. We shall certainly see more reports of the kind which the noble Baroness, Lady Greengross, presented to us yesterday.
The unanimity of support for the Dilnot proposals is as great as I have ever seen. In my Second Reading speech on the Health and Social Care Bill, I reminded your Lordships that if you want to bring about change you have to build a consensus. There is no doubt that such a consensus now exists. That consensus is that it is inescapable that the future funding of social care has to be based on a combination of individual and state responsibility and contribution and that these proposals offer the prospect of a lasting settlement based on a partnership approach. That is not to assert that there is unanimity on every aspect of the Dilnot proposals. People are concerned about the level of the cap, about the fact that hotel costs are not included in the calculations, and about whether the life insurance product market will really be stimulated. I have no doubt that other noble Lords will speak about these concerns. Nor should we assume that the commission provides a total answer to the social care problems I have outlined, but these reservations do not detract from embracing its general thrust. The consensus that now is the time and that the general direction of the Dilnot report is right surely cannot be gainsaid. It would be sad and a failure of all of us involved in these important discussions if we allowed disagreement about details in the report and the valid arguments that are put forward to get in the way of action.
If you want to bring about change, another thing that you have to do is to make people, individuals, Governments, political parties and society itself see what they are going to gain as a result of the changes. What will they get out of it? That surely is clear. We will spend existing resources better. It will improve the integration of health and social care systems. When people’s need for social care is not met, they will turn to the NHS, resulting in increased numbers of emergency admissions or delayed discharges. The inconsistency between fully funded NHS care and means-tested social care the delivery of an integrated care system. Recent statistics from the Department of Health show an 11 per cent rise in the number of hospital bed days lost to bed blocking—I thought we had seen the last of those terms—so the costs have risen from £483,000 to £537,000 per day. In addition, if we adopted these proposals, the rights and responsibilities of individuals and agencies would be clear to the public. If people were clear about their future personal liability they could plan how they would meet care costs up to the level of the cap, wherever that was placed. We would also stimulate the care market to provide more choice for families and incentives for business.
The government consultation process on the report is under way and is to be commended. The engagement process is about to conclude. It has been helping people to put their views, and the leaders of the discussion streams will indicate the priorities for change. I hope that the Minister will be able to tell us more about the process of putting those priorities into action. I know that the Government are committed to a White Paper in the spring, but it cannot be stressed too strongly that action is needed, with the greatest possible dispatch, to take advantage of the near consensus around this issue at the moment. We hear rumours of the Treasury having misgivings about the cost of the proposals. Will the Treasury be involved in the decisions about putting the identified priorities into action? I hope the Minister will tell the House the answer.
Another cause for concern is how the Law Commission proposals on social care, which again have been widely welcomed, will be dealt with. I do not have time now to go into these in detail, but they would create a stronger legislative framework, are compatible with the Dilnot proposals and together would form the basis for a White Paper and subsequent legislation. Do the Government intend to combine their response to the Law Commission proposals with their response to the Dilnot report? The chance to do so has been called a once in a lifetime opportunity. It would be tragic if the opportunity were missed. Therefore, it is vital that we harness not only the consensus in the care sector clearly set out by the 52 organisations in the Care and Support Alliance but the willingness of political parties to cross party political divides in the interest of finding a solution to the social care dilemma. We must find political consensus. My own party has suggested ways of facilitating this. My noble friend on the Front Bench will say more about this and I hope that the Minister will respond to these suggestions.
In conclusion, the Minister for Social Care, in a debate on 10 November in another place, said that,
“when the decisions are made … I hope we will be in a position to legislate at the earliest opportunity. Social care has languished … in the ‘too-difficult-to-do’ box for far too long. We are the Government who are committed; we see the urgency and the need. I hope that together we can get the cross-party lead that results in the changes which are long, long overdue”.—[Official Report, 10/11/11; col. 181WH.]
Amen to that. I hope that the Minister today will give an equally strong commitment. We must not fail to grasp the opportunity that Andrew Dilnot and his colleagues have given us. I beg to move.
Baroness Barker
My Lords, I thank the noble Baroness, Lady Pitkeathley, not only for the characteristically thorough way in which she introduced the debate but for securing it in the first place. She is absolutely right that the timing is of the essence. Many noble Lords have buried themselves deep in the Health and Social Care Bill. I was going to observe that perhaps today was light relief for some of us—but it is not. Everything that we will discuss today has an impact on the National Health Service. We have known for so long—and it has been confirmed by every report that the noble Baroness talked about—that if we do not sort out the system of social care, which we know does not work, it will inevitably build up costs for the National Health Service. As ever, it is a great shame that while people are passionately vocal about changes in the NHS, there has been something of a silence on social care, which never gets the same level of reaction despite being so important.
I will not go into great details on the reports. I will focus for my seven minutes on things that have to happen now. It is clear that the public know that they are likely at some point to need social care. However, they do not know the likelihood of that happening to them. We know that for people aged 85 and over, of whom there are a growing number, the figure is three out of four. According to an ABI survey, 51 per cent of the public do not know who will pay for their care; 21 per cent think that their family might pay for it; and 19 per cent think that the Government might pay for it. They have no idea where to go for independent advice. Those are the key issues that we must work around.
We must recognise that this is a generational issue. One’s ability to afford social care depends entirely on whether one has property. That is the determining factor. There is also an age factor. People aged 85 and over at the moment will have to pay for social care from their savings or capital. Those who are 65-plus and already retired will have to try to secure an annuity. As we know, the private market so far has failed to develop appropriate products. People of working age who want to plan for their future social care needs will either have to come to some kind of annuity arrangement or hope that in future insurance products will be made available.
As the noble Baroness, Lady Pitkeathley, said, it is crucial that politicians come together now to agree which parts of the Dilnot report they will accept, and the criteria and level of funding, so that individuals can know with some degree of certainty what the likely state contribution to their care will be, and private companies can come up with forms of insurance that are sustainable. That will take considerable time and is an urgent matter.
The noble Baroness, Lady Pitkeathley, mentioned in passing the Law Commission. She is absolutely right. The Law Commission report is critical to this. It calls for two things: a new statute and regulations that set out community care criteria and eligibility, and the process of assessment for individuals. The importance of community care assessment is something that people in the world of community care understand, but nobody outside it does. It is fundamental to this issue. If individuals cannot tell at what point their care needs will be recognised, accessed and taken forward, we cannot begin to build insurance products that will help people to plug the funding gap.
I will make a further point that has not come out in either of the documents. It is crucial that there is a system of care assessment that runs alongside but is completely independent from any form of financial assessment. In future, people will have to undergo both processes, but one must not contaminate the other.
I mentioned property. It is inevitable, given the generational distribution of property ownership, that equity release and the ability of individuals to release resources that are tied up in capital will become increasingly important. At the moment we do not have equity release products that are deemed to be safe. Nobody who wishes to go down the route of funding their own care in that way knows where to go for reliable advice. I ask the Minister whether the work done on equity release by the Joseph Rowntree Foundation in 2006 is being revisited, and whether the Government are engaging with the FSA on how they might build an equity release market in future that people will be able to trust.
Members of your Lordships' House conducted a seminar in which Andrew Dilnot introduced his report. He spoke to a pretty tough crowd. One political point was raised by the noble Lord, Lord Campbell-Savours, who is not in his place. He challenged Andrew Dilnot on whether his report was not a subsidy to people who were well off. That is the outstanding political point. Andrew Dilnot made the fair rebuttal that healthcare in the NHS is a system of pooled risk and we do not draw the distinction. That is the only substantive political point that was raised against the Dilnot report. I hope that if the noble Lord, Lord Campbell-Savours, agrees that the system that has been devised is equitable across the piece, all parties should be able to agree.
We have been here before. We have been very close to reaching agreement. Some weeks ago Ed Miliband said that he would be willing to take part in cross-party discussions. It is very easy to make such a statement and then find some reason, process or proposal that you cannot agree with. This requires political consensus and courage from all parties. It will take a degree of sustaining. It requires all politicians to convince the media that this is the correct way forward. If we do not agree this now, we will be back in 20 years debating the same issues, and the situation will be worse for the individuals concerned.
Baroness Bakewell
I, too, support the Dilnot recommendations and ask for a White Paper in the new year and action from the Government. I thank my noble friend Lady Pitkeathley for bringing forward the debate. I am sure that we will learn many intricacies, given the expertise in the House.
I will explain from my own experience why this is so important. I recently made a “Panorama” that told the story of someone in her mid-50s who had moved into the family home to care for her mother. Her mother's health deteriorated and she went into a care home. The family home had to be put up for sale and the dutiful daughter was left without either a home or an inheritance. These stories have proliferated in the media and have outraged people who wonder how such things are allowed to happen.
Before the Dilnot commission, there was a very unattractive political skirmish when the previous Government proposed a tax on an individual’s estate. It was denounced in the press and elsewhere as a death tax, and the proposal died. This proposal must not die. It has to be faced. It deals with issues of death and inheritance. Perhaps that is why we have shirked it and spoken less absolutely than we need on the matter. The old fear loss. They fear the loss of their contemporaries. They fear the loss of their capabilities, and they deeply fear the loss of their home and their savings. They fear these things more than other generations that have not got there yet, but such worries impact on the health and well-being of an older generation, and that is a consideration for the health of the nation generally.
There are several popular misunderstandings about this situation that get perpetuated by the press—I am sorry if I am guilty of that, and I hope I am not. When I go to make programmes, people often say to me, “I’ve paid taxes all my life. Why am I not cared for when I am old?”. This refrain has given it a very high profile in the media. It was always understood that the National Health Service provided, as the phrase had it, from the cradle to the grave—to the grave, not to the old people’s home. Social care was mistakenly seen as part of that contract with the state, and it still is. Social care, housing, feeding and dressing were things that, as citizens, we have paid for all our lives, but when it comes to being frail, as well as old, we need help in them, so they bridge a social convention—that we pay for housing, food and health—and the medical convention of the National Health Service. We are back to: “I paid taxes all my life”.
Dilnot’s most high-profile recommendation is that there should be a cap on an individual’s contribution to social care of somewhere between £25,000 and £50,000. This is high-profile because it strikes at this very unease felt by a generation of older people who, I have to say, have assets. We are asking taxpayers to fund the safeguarding of those assets. It is a long explanation to make that plausible to people who do not have such assets and wonder why people better off than themselves are asking people in the lower tax range to fund them. We are a property-owning democracy. Citizens are motivated throughout their lives to own their home and, what is more, it is a widely held impulse and part of our culture to have something to pass on to our children. Whether we approve of that or not is not germane to this argument. It is a widely held cultural belief.
Dilnot seems to me to walk a tightrope in asking that care is funded by a shared responsibility between the individual and the state. That is a new and understandable contract. It is as fair as can be devised and honours the aspirations of as many citizens as possible. Adjacent to this proposal are recommendations urging people to plan early in their lives and to be informed of the financial packages that are on offer to meet the sums they could be called on to pay, but the central proposition is a good one. I urge the Government and the Minister to move on this.
Lord Sutherland of Houndwood
My Lords, I thank the noble Baroness, Lady Pitkeathley, for introducing this debate in such a comprehensive, clear and incisive manner. I thank her, too, for the reference to the usual suspects. I am happy and proud to join her as one of them. Looking around the Chamber, most of us have form in this area. Remember “Butch Cassidy and the Sundance Kid”? In the film, as they are pursued by the Pinkerton men, Butch and Sundance look back and Butch, seeing the cloud on the horizon, says, “Who are these guys?”. We are these guys. We will not give up. We will continue the pursuit because this is such a critical matter. I thank Paul Newman and company for that. I shall group my remarks under a heading borrowed from Al Gore's influential book An Inconvenient Truth. I may use other catchphrases, some of which are stolen from MBA speak, such as “the elephant in the room”, but I want our minds to focus on “inconvenient truth”.
Today we address the Dilnot report, a good report, as one would expect from that stable. I have no hesitation in giving it my very warm support. Contrary to basic belief, we did not profligately recommend the free expenditure of money; we recommended a form of co-payment. I accept that the co-payment line has to be different today, and that is why I find it easy to support what Dilnot proposed. We address the report, but we do not address a government response. That is interesting and important. We have been here before—a situation where apparently the Government take longer to read the report than the excellent team took to write it. From past experience, this is not a good sign.
Occasional possible sightings of Dilnot have been reported, but they are usually accompanied by a pursing of Treasury lips and mutters about the state of the euro and that spendthrift bunch who were in government before. But of the report, there has not been a clear, authenticated sighting. Perhaps we should put David Attenborough on to it. It is perhaps in some frozen grotto in the north awaiting revival.
However, my simple thesis is this: the Dilnot report represents an inconvenient truth—none the less true for being inconvenient. The problems to which it points and the reasons for which it was commissioned—yes, it was commissioned, to the credit of the current coalition Government—have not gone away. It is not that the report has not gone away, but that the issues have not gone away, which is why some of us are here again. They will not go away. They will become more and more pressing the longer we ignore them.
What are the reasons for the delay in the Government’s response? They are the usual ones: “We need more time and information” or “We are consulting”. One thing successive Governments are not short of is advice. There is no need for further consultation. Think of the range of reports I could drop before the House today—I thought about bringing them in, but I would get back strain lifting them: the Joseph Rowntree Foundation report; the Wanless report from the King’s Fund; a report from the LSE by Raphael Wittenberg and colleagues; the 2006 report from the Audit Commission, the Healthcare Commission and CSCI; Her Majesty's Government’s 2006 report Opportunity Age; and their 2009 Green Paper Shaping the Future of Care Together. There was also an IPPR report; I could go on. The Law Commission has already been mentioned. There is plenty of advice. It is decisions that are needed. We need a policy.
All of those reports presented inconvenient truths to successive Governments. We have 13 years of history of this. For example, a government report in 2005 pointed out that by 2051 over 25 per cent of the population will be over 65. Wanless pointed out that the cost of care of older people will rise from £3.7 billion to £8 billion with the net cost to government rising to £1.7 billion. Wittenberg has equivalently devastating statistics. We all know them. I look around the House. Noble Lords know these statistics, and I do not need to repeat them. There is a constant litany on demographic change in this and in other countries. My favourite statistic is that in the course of this debate, if we all keep to time, noble Lords’ statistical life expectancy will rise by 30 minutes. That is not a cashable cheque, but statistically that is the rate of demographic change. These are facts. They are true, but they are inconvenient.
There is a litany of further inconvenient truths: our systems for coping with demographic change are getting worse rather than better. We should note the report that was published yesterday, of which mention has been made, about the failings of care at home; the continuing drip, drip of stories about the failings of residential care and care of the elderly in hospital; and the way in which money allocated to local authorities for these purposes, because it not being ring-fenced, is not visible at point of delivery.
I had a letter last week from someone who runs care homes, which, as far as I can see, are run very well. She reports that the price local authorities are willing to pay is £200 per week under the real price. The homes deal with it, not by cutting staff, which is the inevitable route taken by many, but by raising the money elsewhere. I say, good for them, but not everyone has that capacity. The drip, drip, drip, the points to note and the failures of the system are inevitably reported to us. They are the inconvenient truths.
A further inconvenient truth is an unplanned, unco-ordinated and inadequate system, which is approaching the point of breakdown. Ministers should beware because they will be to blame. MPs should beware because older people vote and will hit them in the ballot box, which is the only place that they have left. Governments may contrive to ignore this but they cannot. These inconvenient truths will not go away.
There are convenient ways in which the Government operate which set these aside. I shall list them. Do not upset the Treasury applecart—it has a system for limiting expenditure and no exceptions are allowed. Do not tamper with the historic power of departments—their budgets should be subject to only marginal change. Especially, do not tamper with the fortifications which separate the budgets for healthcare and social care. We do not recognise the elephant in the room. I put it to the Government that it is time now to recognise it and to deal with these inconvenient truths.
Lord Lipsey
My Lords, I declare an interest as president of the Society of Later Life Advisers, which trains independent financial advisers specialising in elderly care. I want to concentrate on the role of the private sector. I strongly endorse, as every speaker has, the key features of Dilnot, which build on the minority report of the 1998-99 royal commission of which the noble Lord, Lord Sutherland, was such a distinguished chairman. Sadly, however, four months after Dilnot, his core proposal, a cap on care costs, is in danger of going down the pan; first, because of the cost and, secondly, because the Government are chary of opening up this wicked issue. The job of the House today is essentially to save Dilnot.
On private insurance, there are only about 30,000 insurance policies for long-term care extant at the moment. There are so few largely because of a lack of demand. People do not know about care costs and too many assume that the state will pay, which is why the work of SOLLA is so important; why local authorities need to do more to help self-funders understand their options; and why a state information campaign—call it a national care service, if you like—is essential. However, that does not apply just to the demand for policies, but to the supply.
The main reason why insurance companies have been so chary of getting into this area is the fear that people will live longer and longer—we have just heard from the noble Lord, Lord Sutherland, about how fast the expectation of life is increasing—and that the costs of that care will bankrupt the companies. Without a state-funded cap which limits the liabilities of insurance companies, mass private insurance is a dead duck. With a cap, one can envisage a huge expansion in policies, many of them funded from the proceeds of equity release on people’s valuable houses. Enhanced annuities are another promising avenue; for example, a pension that increases if an individual becomes disabled later in life and needs care. In Asia, policies have been developed whereby a sum of money is set aside which can be used for a person’s care if they need it but can be left to their children if they do not, and so on. However, without a cap at some level or other, none of those schemes is likely to develop on any scale.
What should the cap be? I have just one criticism of Andrew Dilnot’s admirable report. As a cap on the costs that an individual must bear, £35,000 is too low for three reasons. First, it would cost the state too much—£3.4 billion by 2025-26. At a time of austerity, that will not happen. Secondly, it gives too much benefit to the better off. Let us remember that the poor will not get a penny of this money because their care is free now. Therefore, it goes entirely to middle to upper income people or, rather, their heirs. I do not say that they should not get any of it but if it is too high a cap, too much will go to the better off. Thirdly, because the cap is too low, most people will not bother to insure privately. They will say, “I can run to £35,000 out of the proceeds of my £300,000 or £400,000 house. I won’t bother”.
What should the level of the cap be? I am afraid that I do not know but that is not due to a lack of assiduity on my part. On 11 July, I asked in a Question for Written Answer what the cost of a £100,000 cap would be. The Minister replied with what I think these days we should call a “Baroness Trumpington”. In private communication the Minister has been his usual helpful self, but we still have no figure of a £60,000, £75,000 or £100,000 cap. I take with a pinch of salt his department’s contention that this is a hard calculation to do—with a ruler I could get quite near it myself. We will have to see what a freedom of information request can do to get an answer out of the Government.
But the more fundamental argument that the Minister uses against a higher cap is that the financial services industry does not want it. He cites the Government’s consultation on Dilnot, which favours a £50,000 to £60,000 cap. My own consultations with the financial services industry—I am in quite close touch—suggest a more mixed picture. Some companies want a low cap, say £35,000, and some want a high cap, say £75,000. However, the crucial point is that nearly all financial services companies agree that we need some cap. The Government’s consultation, cited by the Minister, states that support for the cap is overwhelming. The point is that the choice is not now between a £35,000 cap and a higher cap because the Government will not fund a £35,000 cap in present circumstances. The choice is between a higher cap and no cap at all. If there is no cap, there will be no role for private insurance. It is as simple as that. A cap is what we must get.
What do we want from this process? We want a settlement that will endure and enable private insurance to play its part alongside state provision and state funding in a deal on the matter. When do we want it? We want it, if not now, at least by the time of the White Paper next April, before another generation is condemned to inadequate care and crippling financial anxiety.
Baroness Tyler of Enfield
My Lords, I rise as a very recent recruit to the usual suspects and as someone still very much serving her apprenticeship but very proud to be a member of this group. First, I congratulate the noble Baroness, Lady Pitkeathley, on securing this hugely important debate. I do not think that I am exaggerating when I say that, despite all the challenges the country faces, the funding and the future of social care is the greatest social challenge facing the country, which we know we will all face in a very personal way as we move through our lives. I very much agree with the noble Baroness that it is a matter that has been put into the too-difficult-to-deal-with in-tray for far too long.
I should like to explain why this issue must be at the top of the political agenda. It is impossible to escape the fact that chronic underfunding of care has led to a crisis in our social care system and is putting huge pressure on existing care services, the NHS and, in particular, on families providing care. As we think of the challenges we face, a couple of statistics have really brought that home to me. The first is the fact that the number of over 85 year-olds is set to double over the next 20 years. The second is that 11 million people who are alive today will live to the age of 100. The third is that the number of carers is expected to rise from 6.4 million in 2011 to 9 million in 2037.
The extent to which social care funding has failed to keep pace with demographic change—in marked contrast to NHS funding—has already been well covered, so I do not intend to repeat those comments. Instead, I want to say a word or two about who is really feeling the burden of this underfunding. First of all, there is the cost to families. The result of demographic changes outpacing spending is that growing pressure is placed on family members who provide care. I was interested to see that statistics produced by the NHS Information Centre show that the proportion of carers providing over 50 hours of care a week has doubled in the last 10 years. That has all sorts of implications for people’s health, finances, their availability for work and, indeed, for the economy.
I turn next to the issue of the cost to businesses, which we hear less about. The peak age range for caring is 45 to 65, which often represents employees’ peak of training, skill and experience. Employers are at risk of losing these employees at short notice if the social care system cannot enable families to juggle work and care, and the average cost to businesses of recruitment, training and lost productivity is around £11,000 per staff member lost. As we know, there are many enlightened employers who are working hard to try to promote flexibility and workplace support for employees who are juggling work and care responsibilities, but flexibility in the workplace cannot compensate for poor quality, unreliable or inaccessible social care, and over 40 per cent of carers who have given up work say that they did so due to the lack of sufficiently reliable or flexible services.
Lastly, I mention the cost to the NHS. As we all know, an insufficient supply of social care in the community also results in additional pressures and unavoidable costs for NHS services, particularly through things like emergency admissions and bedblocking—a term that I absolutely hate, but recent statistics show that these issues are currently getting worse.
Like many other noble Lords, I am attracted to the recommendations made by the Dilnot commission. I notice that they have also attracted the support of many influential bodies in the sector and beyond. I believe that, if implemented properly, the recommendations have the potential to help people to prepare and plan for a better older age and take away the terrible fear that so many have. I will not run through the individual recommendations in detail because others have done so, but what is important is protecting families from catastrophic care costs by capping lifetime care bills, and we have already heard very interesting arguments about the level at which the cap might be set. I also welcome the commission’s clear recognition of the need for additional resources for social care to overcome the historical shortfall, as well as the proposed national system of eligibility and portable assessments in order to create a more standardised system across London and across England. That will help families if they move to different parts of the country. Another recommendation has been made which perhaps is not very sexy—we have not heard about it so far today, but I think it is potentially very important—is for a new awareness, advice, information and advocacy strategy to help families plan for care and to access private, state and voluntary sector support.
So where is the money going to come from in the very difficult current climate? I shall highlight a couple of possible areas. First, those of us who are involved in the consideration of the Health and Social Care Bill have heard a lot recently about the importance of the integration of health and social care, and I thought we had a good debate on the subject earlier in the week. The Bill is entitled “Health and Social Care”, which is very good, but I have to say that we do not talk that much about the social care aspect, and it still often feels like the country cousin. It was said earlier this week that it will require a really big shift of existing resources from the NHS to the social care system to make a reality of integration, and that is going to require huge political will at both the national and the local level.
There is also the issue of investment in more preventive work, which covers all sorts of things these days. We have reablement packages, telecare and the like that can make a big difference to older and disabled people and their families in terms of enabling them to remain in their homes. That is very welcome, but where is the money for these preventive services going to be found? Is it really going to be made available from ring-fenced public health budgets? We also need to do more to stimulate the care market and to think carefully about what these proposals will mean for current providers. It was interesting to note that a poll carried out in February 2011 of the social providers of community care showed that 25 per cent of them expected to face closure before the end of this year because of cuts in local authority fees. Finally, we need to do more to improve the quality of care available, in particular by supporting the development of a skilled, flexible and valued workforce. The point about members of the workforce feeling valued is so important.
I shall finish by saying that I believe we must be brave both as politicians and as a political class, and here I offer my apologies to the Cross-Benchers. We need a real political consensus on this. The report sets out the basis for a lasting and long-term settlement, and as a class we will not be forgiven if we duck the challenge because it is too difficult.
Lord Rix
My Lords, like others I welcome this very important debate and I commend the noble Baroness, Lady Pitkeathley, for affording her fellow Peers the opportunity to discuss this issue at such a timely moment. I also declare a personal interest as president of the Royal Mencap Society, an organisation that is greatly concerned about the current social care situation facing many people with a learning disability across the whole of the United Kingdom. In the context of the recommendations made by both the Law Commission and the Dilnot Commission about the reform of social care, there is clearly a demonstrable need and appetite for a change to the system to be achieved as soon as possible. While Government austerity measures have significantly reduced settlements to local authorities, it is important not to overlook the pre-existing underfunding that the social care system has experienced.
The Government spend around £16 billion per year on the provision of social care support, in comparison with £110 billion on health and £180 billion on welfare. Despite the vast number of individuals who rely on social care support to ensure their independence and dignity, these figures suggest that it has become something of an afterthought which merely succeeds in papering over the numerous cracks in the provision received by some of the most vulnerable members of society. I dare to suggest that extra funding awarded to social care, evenly distributed around the country, would reduce the NHS budget by a similar amount.
Matters are only likely to worsen. The number of people using social care is increasing and, within this demographic, the number of people with a learning disability is expected to increase by almost a third over the next 20 years. This is a group which is often highly reliant on social care support. Indeed, adults with a learning disability constitute 24 per cent of the social care budget, and so it is essential that their needs are met. However, this is increasingly not the case as the upward curve of social care need jousts with the downward spiral of funding per head in the system. Organisations such as Mencap and the Learning Disability Coalition warn that the consequence of this is that effective and appropriate social care provision is often increasingly out of the reach of a growing number of people with a learning disability.
According to recent research conducted by Mencap about local authorities’ eligibility criteria, 83 per cent of councils are only supporting people with critical or substantial needs, an increase of 10 per cent on the previous year. This reflects a wider culture of “tightening” eligibility criteria so that only those with the “greatest needs” are able to receive support, whereas those with milder or more moderate needs, who nevertheless still require social care support, stand to miss out. It indicates that, sadly, the funding situation for social care is worsening. Indeed, only two weeks ago, the courts ruled that plans by the Isle of Wight Council to provide assistance to those with critical needs and only for some people with substantial needs, was unlawful for failing to give due regard under disability legislation, alongside other reasoning. While it is encouraging to see that such action is being curtailed, there is the wider point that some councils feel obliged to make such contentious decisions as a result of the limited social care resources that they have at their disposal.
The real costs of underfunding become all the more quantifiable when individuals are affected. Susie is a 47 year-old adult with a severe learning disability, which means that, for all of her life, she has been the recipient of social care services and was able to attend a day centre five days a week. She was then offered the option of having a personal budget, which she accepted and, on reassessment, the council gave Susie a financial budget which amounted to only one and a half days’ worth of services.
What that case represents is the corner cutting that is happening throughout the country. But this is not a problem without a solution. What it does not require is yet more papering over the cracks. Instead, action is needed to bring about fundamental reform of the whole system in a way that does not shrink from making difficult decisions. It also requires a fundamental overhaul of the various processes, the various duties and the various means of support associated with social care provision.
This would help overcome the current postcode lottery of care that exists throughout the UK and which dictates that people with equal needs can receive wholly different outcomes purely as a result of where they live. Essentially, this brings together the recommendations of both the Law Commission and the Dilnot commission reports. The latter points out that the current system of funding of care and support,
“is not fit for purpose, and has desperately needed reform for many years”,
while the former urges that a wide of social care overhaul is required as:
“There is no single modern statute to which local authorities, service users, carers and others can look to understand whether services can or should be provided”.
While I fully appreciate the limitations of the current natural climate, the Government would do well to consider the wisdom of RH Tawney in the context of the future of social care when he wrote in The Acquisitive Society:
“As long as men are men, a poor society cannot be too poor to find a right order of life, nor a rich society too rich to have need to seek it”.
Lord Desai
My Lords, first, I must say that Andrew Dilnot has written a good report, but I am going to be more critical of the proposal than most noble Lords have been so far. That is not because I do not recognise that there is a great and growing need, and that a civilised society should of course take care of people in need. But we have to face the fact that we are at a juncture where we have severe problems in our public finances. It is not just the coalition Government who have done this thing. We have undersaved for practically a generation. We—not just the UK but the developed economies as a whole—now face a serious crisis in that, unless we tackle undersaving, we will not be able to survive further into the 21st century. Our dependency ratio will rise. Noble Lords have already pointed out how many more people will be aged over 65 and how many people will live to 100. That is all very good, but the working population in proportion to the people to be taken care off will be small, and if we continue to have this ludicrous policy on immigration, it will not get any better internally.
My noble friend Lady Bakewell said, as often people say, “I have paid taxes all my life, why can't I be taken care of?”. The bad news is that your taxes are not adequate to take care of you when you need help. I am sorry about that. That is the reality. We find the same crisis in pensions. The pension that you have accumulated over a working life is no longer adequate to pay for the long after-work life that you will have. Once upon a time, when Beveridge put in his proposals, the working man lived three years beyond retirement. It was easy and the pension funds were flush with money. Now, you probably work for say 35 years and live for another 25 to 30 years. It is difficult to devise a system of pensions unless you have saved a lot of money to begin with, which will make it feasible for you to have a comfortable life later on. Somebody has to be the hard man and I will choose to be the hard man here.
At the very least, the cap should be indexed. I will come on to what my noble friend Lord Lipsey said, but we should make it quite clear that the cap of £35,000 cannot be kept constant. It will have to be indexed either to prices or earnings; whichever the Government find more money-saving.
Secondly, my noble friend Lord Lipsey said some very good things about this. There is a market failure in the social care insurance business. Of course, as many noble Lords have already said, it is because people confuse social care with health and they think that health is taken care of. Therefore they think, “Why am I not looked after for this?”.
We have to incentivise the buying of social care insurance at a very young age by people. The way to incentivise it, although I have not worked it out, would be that the amount of cap you get later would be related to how much preparation you have made earlier. If you have actually taken care of some of your needs, then we will help you along. That is not to say that we will not help other people, but ultimately this proposal, as many noble Lords have said, is benefiting the better off. To the better off we will say, “Prepare early on. You may be only 25 now, but if you recognise that you will face problems when you are 70, there will be schemes and there could be some government help for you”.
One of the other problems that we will have is that while we have not saved very much, we have been beguiled into thinking that buying a house is buying an appreciating asset. If you buy a car, you do not think that the car will appreciate as an asset. Why do we all think that a house should appreciate because of inflation? Asset price inflation will not go on. A house will not be the kind of wealth that will support you. It ought not to. We ought not to be living with the continuous asset price inflation that we have seen. Equity release will not be a way out in the future.
Given all these problems, I hope that the Government will accept some version of Andrew Dilnot’s report because we cannot again kick the problem into the long grass and come back to it in several years. That is not possible. We have to start with Dilnot and examine whether £35,000 is the right amount and whether we should index it, or whether £100,000 is the right amount and should we reduce it, especially given that the rich not only have more assets than the poor but they live longer. Both ways, there is this kind of regressive redistribution.
Therefore, we have to be very careful and examine the long-run economics, and the projections in Dilnot are not enough. The long-run economics in the general macroeconomic context are what we can afford and who will pay what in a carefully humane way. But let us not get carried away and let us not land ourselves with yet another bankruptcy-making proposal.
Lord Pearson of Rannoch
My Lords, as previously in debates of this nature, I declare my interest as the father of a 31 year-old daughter with Down’s syndrome, who is fortunate enough to live in a Camphill community. What I have to say therefore particularly concerns those many people with learning disabilities.
For them, personalisation should offer greater opportunities to tailor services to their individual needs; some real choice, in other words. But you cannot have choice that actually means anything—real freedom of choice—unless you have the freedom to move if you want to. Unlike the rest of us, who can decide to move without losing our entitlement to, say, NHS services, people with learning disabilities who wish to move into another authority, even if it is a couple of miles away in the next town, do not have the same freedom. Somewhat understandably, authorities are only too happy to place residents elsewhere because they gain financially by the transfer. But the responsibility for fresh reassessment, care planning and, of course, funding is then transferred to the receiving authority, with no commitment to replicate it. Not surprisingly, individual receiving authorities do not always accept people who move into their area. These people must have their needs reassessed by this receiving authority, which can be a lengthy process. Most importantly, they have no guarantee whatever of receiving the same level of support.
The rules of ordinary residence mean that costly and wearing disputes between authorities leave vulnerable people in limbo while they thrash out who shall take responsibility. This causes great anxiety and suffering to them and to their families, and leaves providers who would be willing to accept them unable to do so because they do not have the funding available. For instance, Camphill life-sharing communities exist in only a few authorities, so if someone chooses such a way of life, it usually means that they have to relocate, which then brings all the problems I have just mentioned. The rules on the process of resolving funding disputes were recently clarified, but unfortunately this still does not get away from the disputes themselves. In a recent briefing from the Voluntary Organisations Disability Group, its chairman, Bill Mumford, the chief executive of McIntyre, said that one of the chief obstacles to the potential success of personalisation is the postcode lottery, which is,
“confusing and complicated for purchasers of services”.
The Dilnot report, which we are discussing, goes some way towards addressing this problem. It supports the Law Commission’s recommendation that assessments should be portable. Like other noble Lords, I urge the Government to implement this as soon as possible. It would be a step in the right direction. However, I fear that it does not go far enough. What is also needed is portable funding; funding, in other words, which follows the individual. I can but urge the Government to look into ways of ensuring that funding, as well as assessments, becomes portable across local authority boundaries. Perhaps we need a centralised system of funding.
This would prevent the use of money intended for the learning disabled, which is no longer ring-fenced, being spent on other local needs. It would get around much of the unfairness, particularly the postcode lottery which is endemic in the current system. It would ensure real freedom, which is—or should be—at the heart of personalisation.
Finally, in these times of stringent cuts—and here I trust that the noble Lord, Lord Desai, will agree with me, in view of his earlier remarks—every penny would be spent at the frontline, actually supporting people in the way that they choose and that best suits them, rather than on costly and wasteful disputes between authorities as to who will pick up the bill.
I look forward to the Minister’s reply.
Baroness Wilkins
My Lords, I thank my noble friend Lady Pitkeathley for initiating this timely debate. The noble Baroness, Lady Campbell of Surbiton, had hoped to take part but, sadly, she has developed a chest infection and I know that all noble Lords will want to join me in wishing her a speedy recovery. She asked me to speak to the points that she wished to make, which I share, and to thank Marija Davidson of RADAR for her help.
The noble Baroness, Lady Campbell, particularly wanted to speak on future policy for people below pension age who need personal care, people who are either born disabled or who become so in their younger years. Her main points focus on the issue of human rights and the place of the precious, long-fought-for concept of independent living in future policy on social care.
The proposals of the Commission on Funding of Care and Support rely heavily on building the ability of people to plan and prepare to contribute financially. This is, of course, sensible for those who have had years of employment which allowed them to save for their inevitable decline. But many disabled people do not have that opportunity. Only 50 per cent of disabled people of working age are in work, compared to 80 per cent of non-disabled people, while 23 per cent of disabled people have no qualifications compared to 9 per cent of non-disabled people. The average gross hourly pay for disabled employees is £11.08, compared to £12.30 for non-disabled employees.
All this does not bode well for our ability as disabled people to save and pay for our social care support, whether early or later in life. For those born disabled, the odds against them are stacked even higher, as they will never be able to accrue enough capital to purchase the big things in life, like a property, or to start a business. Disabled people do not start from a level playing field, and it was pleasing to see that the Dilnot report recognises this inequity in its recommendation 3:
“People born with a care and support need or who develop one in early life cannot be expected to have planned in the same way as older people. Those who enter adulthood already having a care and support need should immediately be eligible for free state support to meet their care needs, rather than being subjected to a means test”.
But what will that “free state support” consist of? How will our precious concept of independent living fare in this new world?
An inquiry is currently being undertaken by the Joint Committee on Human Rights, of which the noble Baroness, Lady Campbell, is a member, into Article 19 of the UN Convention on the Rights of People with Disabilities, which concerns independent living. Three things have become clear during the evidence sessions. First, there has been a decline in opportunities for independent living due to decreasing financial resources. Secondly, there is a continued reluctance of local authorities to embrace choice and control for disabled people so that they can exercise independent living. Thirdly, there is buck-passing. It seems that as soon as money gets tight, the urge to snatch back power and control is overwhelming. The increase in charging for social care over the past decade has been matched by a decrease in disabled people's freedom to live independently.
A Social Care Institute for Excellence report published in February highlighted that social care budget holders are losing control over their budgets, as councils require accountability for every single expenditure. Just over a year ago, disabled people receiving social care support through direct payments had the flexibility to spend their payment in the way they deemed best to meet the agreed objectives in their support plan. It is now being asked whether this is a luxury that local councils can afford. However, what they are calling luxury is Article 19 of the UN convention. The positive effects and benefits of independent living, which basically mean choice and control over how one’s personal support money is spent, are legion. Not only does it mean that disabled people can work, volunteer, support families and be active but by providing social care in this way, service users will create new markets through their individual choices. However, local authorities still do not see it that way. In their desperate efforts to control spending, councils are mistakenly snatching back our control, which will undermine the very markets that we need for 21st-century social care. Are we past the heyday of direct payments, which were hailed as a life-starter by disabled people, just when they have barely started to roll out across the country?
Disabled people report a full-steam reversal on supported independent living in the community, always on the grounds of cost. Many disabled people who have had high levels of need are now being asked or, in some cases, cajoled on to continuing care, where there is no right to control your personal budget.
We have to face the fact that there is a cost to disabled people enjoying their human rights, as there is to most human rights—the right to a fair trial, for instance, the right to education and so on. Surely that is a price worth paying collectively, as the whole of society will benefit, not just disabled people. The evidence to the JCHR Article 19 inquiry has demonstrated this starkly; and we have ever-present evidence in this House in the noble Baroness, Lady Campbell, who writes:
“Without another human being by my side, 24/7 to help me function equally, I cannot exercise any of my fundamental human rights”.
Disabled people have serious concerns whether independent living is being eclipsed in the current debate on social care reform. Will the Minister give an indication of the Government’s thinking? For example, are the Government considering allowing personal health budgets to be controlled far more by disabled people? Of course, there is also the issue of portability, just spoken to so eloquently by the noble Lord, Lord Pearson of Rannoch—the right to disabled people’s freedom of movement. The Minister in the other place has expressed a keen desire to make portability a reality. However, it seems that this Government are talking about portability of assessments. Most people can already take their assessment with them; the issue is whether they will be satisfied in the new area. It is portability of outcome that disabled people are seeking. That is what the noble Baroness, Lady Campbell, is seeking in her Private Member’s Bill and we hope it will receive government support.
Independent living is a great good for disabled people and society at large. We are seeking reassurance from the Minister that the right to independent living will take its rightful place in underpinning the future of social care and in its funding.
Lord Low of Dalston
My Lords, I too congratulate the noble Baroness, Lady Pitkeathley, on securing this extraordinary and interesting debate and on the comprehensive and compelling review that she gave us, which has stimulated so much creative and critical thinking from those who have followed her. I can remember three debates on social care and related issues during my first year in your Lordships’ House—so much so that I observed that social care and the importance of social work had become something of a leitmotif running through the proceedings of the House. This does not seem to have been the case so much of late. Unless I have missed something, the last debate of this kind took place on 9 December last year. It is high time we had another one.
The debate is also very timely. The Government received the Dilnot report last July and are now consulting on it. There also seems to be some disposition for cross-party talks on both sides in advance of the promised White Paper in the spring. If we could get to the point where it was possible to move forward, on a basis of consensus, with reform of the law on social care, the upgrading of social care itself and reform of social care funding, that would truly be a consummation devoutly to be wished.
The debate also does not come a moment too soon, in the sense that hardly a day goes by now without our ears being assailed by further horror stories of the neglect, abuse, dehumanising treatment and downright inhumanity to which the most vulnerable on the receiving end of social care—those in greatest need in our society—are habitually subjected. In the summer we had Winterbourne View; and only yesterday, as has been mentioned, the EHRC was reporting evidence of what it called a “systematic failure” across the country, which amounted to a breach of elderly people’s human rights. Examples that they considered amounted to cruelty included people being robbed, left hungry and unwashed, and food being placed in front of deafblind people without telling them it was there, or putting it in an inaccessible place—something, I have to tell you, that blind people routinely complain about in hospital. On the strength of this, the CQC announced the previous day that it would step up its programme of inspections of homecare services, saying that people who use homecare services often find themselves in vulnerable circumstances and the operation of homecare is not as transparent as care in hospitals and other sectors because interactions happen behind closed doors in people’s homes. The Care and Support Alliance, a consortium of more than 50 organisations representing older and disabled people to which the noble Baroness, Lady Pitkeathley, referred, has recently stated that the social care system is in crisis, unable to meet the needs of growing numbers of older disabled people and those with long-term conditions.
Since the day when I entered this House, and I am sure for some time before, we have been talking about a crisis in social care; now it has become a scandal that many predicted if action was not taken. In some ways, that is a good thing—not that we want anyone to be subjected to inhuman and degrading treatment, but it seems to be the thing that gets Ministers’ attention. Up to now, there have not been any Victoria Climbiés or Baby Ps among the elderly and disabled. My fear is that, when the funding for the deprived and disadvantaged, the most marginalised and dispossessed in our society, is cut or they are subjected to inhuman and degrading treatment, they simply disappear beneath the radar.
Coming towards the end of the debate, I speak after such big-hitting luminaries as the noble Lords, Lord Sutherland, Lord Warner and Lord Lipsey, who all, as the noble Lord, Lord Sutherland, acknowledged, have form on this subject—not all the same form but, nevertheless, considerable form. In their presence, I cannot expect my contribution to be anything more than modest, so I shall content myself with trying to drive home a few key points that seem to me pretty well ungainsayable but cannot be said too often.
We have already mentioned the crisis. As everyone has said, the Government must really bite the bullet on Dilnot now. As has become clear, there is room for a range of opinions on the precise form that the bullet should take, but bite the bullet the Government must no doubt do. Labour did some good things with social care when it was in office, but the past decade, as the noble Lord, Lord Sutherland, reminded us, has been littered with too many reports and policy statements that have remained unenacted. It was to the coalition’s credit, therefore, that it moved quickly to set up the Dilnot commission and it will be even more to its credit if it can build cross-party consensus around it and get on with implementing it. I do not disguise the fact that it is a formidable challenge; expenditure on social care has increased, though not as much as on health and education, but it has not increased enough to keep pace with rising demand stimulated by people living longer, and it needs to increase still further. That is a hard saying at a time of financial stringency, but with the number of 85 year-olds set to double in the next 20 years the level of demand will only go on rising relentlessly. I am afraid that that is just the problem that the Government have to deal with; if they do not, they will attract the opprobrium that rightly attends allowing a scandal to balloon out of control without making any serious attempt to deal with it.
Time is running out. Reforming the funding of social care is not the same as undertaking the upgrading of social care that is needed, so Dilnot is not enough. There will be more to do. I realise that it cannot all be done at once but, in addition to Dilnot, it will be imperative for the Government to commit to embracing a wider agenda. Workforce development is critical, but the proportion of care delivered by the private and voluntary sector has gone up from 56 per cent to 84 per cent in the past 10 years. Much of this will be concerned to keep costs to the bare minimum in order to turn a profit. The noble Baroness, Lady Bakewell, devastatingly laid bare, in the Second Reading of the Health and Social Care Bill, how this issues in a jumbo scandal of its own, with the Southern Cross debacle. This poses real challenges in recruiting a sufficiently high calibre of staff.
Finally, Dilnot’s fourth recommendation says:
“Universal disability benefits for people of all ages should continue as now”.
With the Welfare Reform Bill, that kind of joined-up thinking would appear to have gone by the board already.
There is need for some serious rethinking here. It is not yet quite too late.
Baroness Wall of New Barnet
My Lords, I, too, congratulate my noble friend Lady Pitkeathley on achieving this opportunity for us to debate a subject that is growing more and more important. There is no doubt that Dilnot is a good thing but I suggest that it is not the complete solution to all the problems faced in the delivery of social care. The problem is a major issue for us all and, I suggest, the responsibility of us all, certainly those of us involved in commissioning and delivering services to people who need this care and are entitled to it.
Although I have suggested that the issues are major, I also think that they can be described simply. There are ever increasing demands on social care budgets as the population ages. A little like the noble Lord, Lord Low, I feel that I am repeating everything that everybody has said, but it is more and more difficult for each speaker not to do so in putting over the context and importance of this debate. Councils face a much tougher funding settlement than the NHS, councils’ eligibility criteria and funding levels vary and the public are confused about charges.
All of the above can lead to an imbalance and dysfunction between the health and social care systems, which need—or ought—to operate seamlessly if patients are to receive joined-up care and travel efficiently and safely from the health to the social care system. Dilnot tackles this in various ways, including by proposing standard eligibility criteria and the transferability of assessments between different local authorities. A number of noble Lords have referred to this, and the evidence is very clear that that can cause a great deal of distress for people.
Dilnot also talks about capping an individual's liability for charges. Again, other noble Lords, including my noble friend Lord Lipsey, have spoken in much more detail on the cost of that. My understanding is that this would require between £1.3 billion and £2.2 billion of central government funding, so that those individuals do not lose their home if, for example, they need continuing care. The report suggests that,
“the Government should review the scope for improving the integration of adult social care”,
and do so with other services involved,
“in the wider care and support system”.
Can the noble Earl please share with us his views on this and how he thinks that the Government, working together with all parties, can achieve this? The report continues:
“In particular, we believe it is important that there is improved integration of health and social care in order to deliver better outcomes for individuals and value for money from the state”.
I shall raise some points in this context. First, this is important because it will stop councils putting in place higher eligibility criteria than their neighbours and ensure a consistent standard of approach across the country. Transfer of assessments is an efficiency gain and will reduce the number of repeat assessments, as patients move to different authorities. My understanding from talking to people is that it would also remove much of the anxiety that people have in repeatedly having to go through those.
Secondly—this is also important, I suggest—it benefits individuals and families rather than the social care system. Although Dilnot says more funding is required for social care, simply replacing co-payments by individuals with government funding does not by itself, in my view, bring additional resources.
My third point, which is important for trusts such as mine in Barnet and Chase Farm, is that we need to work as an integrated health and social care system. That is something I have believed for the past five years as chair of that trust. I have urged it to happen and we still do not get there. If we do not do this, we will end up with people lying in expensive hospital beds who do not want or need to be there and who, through no fault of their own, prevent others being able to receive the treatment that they require, perhaps in that bed.
Integrated health and social care delivery does not necessarily mean single organisations providing health and social care. It can be achieved through joint commissioning, joint planning and, dare I suggest, pooled budgets. I would guess that suggestion is too radical for some people, but I believe it is true. That has been the aim of many Governments, and people have made many suggestions. The previous Government had this aim and worked hard to achieve much of it—other noble Lords have referred to many of our achievements in this area—but, because the health system, and I particularly include PCTs in that, have never worked closely enough with local authorities, we allowed the gap to remain into which many vulnerable and needy people fall. They are still falling into it now, and that is worsening.
I suggest that there are some gaps in Andrew Dilnot’s recommendations, particularly regarding where the extra funding is going to come from—which is a big question—and whether even what he recommends goes far enough. The story is not complete, and some of the issues still remain. However, as others have said, this is the most sensible set of proposals that we have seen for some time. They must be supported and worked on by all involved to ensure as seamless an approach to health and social care delivery as we possibly can for very often the most vulnerable of people whom we are dealing with. We must do this with urgency.
Lord Adebowale
My Lords, I support the debate initiated by the noble Baroness, Lady Pitkeathley. I congratulate her on ensuring that, at this critical time, social care is given the attention that it deserves. I should also declare an interest as CEO of the health and social care enterprise, Turning Point. I apologise in advance as I certainly do not match the expertise or the eloquence of the luminaries who are taking part in this important debate.
Like many others, I support the work of the Dilnot commission for creating a once-in-a-lifetime opportunity to resolve the anxiety created by the current position of those in need of social care. The noble Baroness, Lady Bakewell, has already mentioned that the deal between the individual and the state to provide care in older age is one of the pillars of this debate. Her position is a reasonable one to take, in expecting those with assets to contribute to the cost of care, although with a cap. The noble Baroness set out the argument with admirable clarity and I need not keep the House further by saying any more than that I support her arguments and those of the noble Lord, Lord Lipsey. Indeed, I am going to get a T-shirt made of his credible call to arms: “What do we want? A cap. When do we want it? Some time after the full response of the Government to the Dilnot report has been published”.
The noble Lord, Lord Desai, made the point that if you want cradle-to-grave care, you have to pay cradle-to-grave taxes—a point that would indeed make of the Minister a brave man if he were to agree to it during the course of this debate, which of course I invite him to do. No, Dilnot may not solve all the problems of the future, but it is a good place to start.
However, it is not just the fact that the general population are living longer that means we have to resolve this issue; it is also that those who have complex needs across substance misuse, mental health and learning disabilities live longer. Turning Point is working with many elderly people who have addictions, mental health challenges and learning disabilities. While I acknowledge Mr Dilnot’s recommendation that the cap should be zero for someone who enters adulthood with already established care and support needs, we need to do more.
My concern in the matter of adult social care is that we should more clearly acknowledge the needs of those people who do not fit the stereotype of the elderly in care—or, as someone in one of Turning Point’s services put it, “My worry is that everyone talks about care for the elderly as though everyone will be Mrs or Mr Marple. What about my mum who has been drinking, anxious and chaotic for the last 15 years?”.
It is essential that we ensure that the integration of health and social care is built into the design of social care policy. As the noble Baroness, Lady Barker, pointed out, this debate is not a break from the Health and Social Care Bill; it is mission-critical to its success. If people fall through the care gap, they either keep on falling or they land on the often very painful and expensive health spike. The critical need for new technologies and approaches, as mentioned by the noble Baroness, Lady Tyler, is essential. Where the money comes from needs to be considered in the context of the fact that cuts now will not always save money in the not too distant future.
I support the remarks of the noble Lord, Lord Rix—I said I would—with regard to people with learning disabilities. The fact is that desperate measures are being taken to resolve short-term challenges. Susie’s story is being repeated up and down the country. To use the noble Lord’s phrase, Susie has started to fall into the crack. We need national eligibility criteria as a first step in at least acknowledging that this crack exists.
This needs to be addressed alongside the point made by the noble Lord, Lord Pearson of Rannoch: surely in a modern society the idea of a postcode lottery of care is simply unacceptable. We need funding to follow the funded, along with their care passport. This policy supports the remarks of the noble Baroness, Lady Wilkins. If we do not have a right to care, regardless of location, we cannot have independent living. Why should those with care needs, however complex, not have the right to move and to be economically active, as many wish to be?
I, too, hear the disappointment of those who expected to be given the resources to create a bespoke pattern of care for themselves and who are being denied that opportunity. These people might create a solution to their complex needs, as opposed to being shoehorned into a convenient budget heading. Surely, the horror stories recounted by the noble Lord, Lord Low, might be addressed by empowering care customers to demand better care.
Policy on care for the elderly cannot be separated from other areas of government policy. We are aware that the Government’s White Paper on social care is being designed as we debate this matter. The paper must be cross-departmental in scope and cannot work in isolation from other policies, such as the Welfare Reform Bill, already mentioned by the noble Lord, Lord Low. The impact on this client group needs to be at the centre of our concerns.
I often state somewhere in nearly all my speeches that the future is decided by the undiscussable. All parties—the Labour Party and the Conservatives in coalition with the Lib Dems—have contributed to making social care discussable. The baton of leadership in this area has now passed to the coalition Government. As has been pointed out by the noble Baroness, Lady Tyler, and others, failure to grasp the nettle now in both funding and need will allow fear of need in old age and disability to dictate the future for us all.
Lord Warner
My Lords, I, too, congratulate my noble friend Lady Pitkeathley on securing this debate and on her excellent speech, after which I felt that I should like to make her an honorary member of the Dilnot commission. I also pay tribute to the coalition for setting it up. I declare my interest as a member of that commission, which was so ably chaired by Andrew Dilnot.
I do not have time this afternoon to go through all the issues that were raised in the commission’s report; I want to concentrate on a few key issues. First, I emphasise that we formulated our recommendations only after an exhaustive consultation with a very wide range of interests, encompassing commissioners and funders of care, providers across the different sectors, the financial services sector, carers and many others with experience and expertise in this area. These groups were united in the view that the system of funding long-term care needed urgent reform on a sustainable basis that had cross-party political support. This issue will require the leaders of the three parties to oversee a political concordat on a solution. It must not just be left to the health teams to sort out, particularly since, if I may say so, some of the current health-post occupants have form on this issue.
The other thing that was clear from our work was that, however much some people still hanker after a wholly tax-funded solution to the issue of funding, there is now widespread recognition that we must move forward on the basis of a partnership between the state and the private citizen in funding adult social care but—and it is a big “but”—with the state covering the cost for the poorest groups and those incurring high, unpredictable costs at the end of their lives. Only through a partnership of this kind will a sustainable system of mixed funding sources be built and new financial services products developed. The commission has created a wide measure of public agreement on this vexed issue, as the reception of our report on publication has demonstrated. I hope that the elected political class will not casually waste the consensus that has been created.
If I may put it as bluntly as this, the funding system for social care is bust. Despite the additional £2 billion announced by the Government in the previous spending review, for which they deserve huge credit, the King’s Fund estimates that there will be a funding gap of at least £1.2 billion by 2014. Despite their best efforts, local authorities are having to continue to tighten eligibility criteria and face more legal challenges for doing so.
We are seeing a growing number of reports of poor care of elderly people at home, in care homes and in hospitals. Too many of the staff undertaking this care are poorly trained, poorly paid and poorly supervised. A shrinking social care funding pot will inevitably produce more scandals and load pressure on expensive and inappropriate NHS in-patient care. That is the stark reality that we face as a country.
We have to start the process of increasing the size of the adult social care funding pot as a matter of urgency. This cannot all be done by implementing the Dilnot proposals but they are critical to showing commitment to building a more sustainable funding solution. If I may say so to the Government—I make this as a helpful contribution—there is nothing to stop them taking powers in the Health and Social Care Bill to implement Dilnot by regulations subject to affirmative resolution procedure. In the spirit of helpfulness for which I am famed, I have put down an amendment on these lines to test their appetite for a bit of decisive government. They could still complete their consultation on the details to be covered in regulations and the timing and cost of implementation. I suggest that this would give a clear signal to the sector and the public that change and improvement are going to happen.
I recognise that in this difficult financial climate the Government face difficult financial choices. I am sure the Minister will say that even just another 0.25 per cent of GDP—that is the cost of the Dilnot proposals at £1.7 billion—is difficult to find. However, it would be unlikely that all these costs would be incurred in one go, or immediately. I make another constructive suggestion. The Government could implement the proposals in stages of their own choosing. They could halve the cost by raising the cap to something like £65,000 rather than £35,000. I, for one, would be sympathetic to moving in that direction just to establish the principle of the cap, as my noble friend Lord Lipsey said.
While I am in radical mode, I bring one of the Health Secretary’s favourite subjects to the House’s attention—the so-called death tax. The reality is that many people in my generation have seen a remarkable increase in the value of our housing assets. Some would see these as windfall profits. There is no reason why some of those assets should not be collected after death to pay for care. Indeed, as we said in our report, some local authorities already do this but do not charge interest on the effective loan of the care costs. Why do the Government not accept our proposal to have a national scheme to allow more people to meet care costs from their estate if the property value is sufficient and up to a capped limit, and let local authorities charge interest at an agreed national rate? If we have a state student loan scheme, why cannot we have a state long-term care loan scheme? On that constructive note, I end by saying that if we do nothing about this, as the King’s Fund has shown, the cost of the current inadequate scheme for public funding of adult social care will rise from £6.7 billion in 2011 to £12.1 billion in 2026. That is a pretty expensive way of doing nothing.
Baroness Thornton
My Lords, I thank my noble friend Lady Pitkeathley for initiating this debate and pay tribute to Andrew Dilnot and his colleagues, including my noble friend Lord Warner, for the report which they produced in July this year. I am sorry that no Conservative Members on the Benches opposite are present to take part in this debate because the band of “usual suspects” to which reference has been made includes members of the Conservative Party. Their voices have been missed in this debate.
I am grateful to all noble Lords who have taken part in the debate for their insights. We felt that it was important that those on these Benches should initiate this debate as we seem to be at a standstill, or making slow progress, on many social care fronts, and in some areas are possibly moving backwards. That is a matter of grave concern. I echo the final words of my noble friend Lord Warner that we cannot afford not to do anything.
We can all agree that the need to secure a sustainable funding settlement for social care has never been more urgent, with local government and NHS finances under significant pressure and demand for services increasing as the population ages. We all agree that the NHS will never work properly without a sustainable approach to social care funding. The Dilnot report therefore offers a credible and costed way forward. We believe that the Government must move quickly to undertake detailed work on the report’s recommendations and honour their pledge to publish a White Paper, followed by legislation in 2012.
The adoption of the capped cost framework recommended by Dilnot offers a fairer and more transparent way of sharing the costs of care between the individual and the state. This will make it easier to tackle the deeper problem of underfunding that has led to the tighter rationing of services and escalating levels of unmet need, which have also been mentioned by several noble Lords, including my noble friends Lord Lipsey and Lord Warner, and the noble Lord, Lord Sutherland.
The much mentioned budget deficit is no reason for delay. The questions of affordability go beyond the current economic situation, and the additional public spending needed to fund the proposals, as we have noted, is less than 0.25 per cent of GDP. The social care system is widely regarded as inadequate, unfair and unsustainable. Under the current means-testing arrangements, anyone with assets of more than £23,250 must pay the full cost of their care. This leaves one in 10 people over 65 facing costs of more than £100,000. Eligibility criteria for council-funded services have been tightened whereby in most areas only those with very high needs now qualify for help.
The squeeze on local authority budgets over the next four years will widen the gap between needs and resources, despite the additional £2 billion announced in the spending review and the best intentions of all local authorities to protect social care. As my noble friend Lord Warner mentioned, the King’s Fund estimates that a funding gap of at least £1.2 billion could open up by 2014 unless all councils can achieve unlikely and unprecedented efficiency savings.
In addition, only this week, the report of the EHRC, led by the noble Baroness, Lady Greengross, shone a light on the too often invisible experiences of older people receiving care at home. It reveals a service stretched to the limit and older people denied the dignity and respect they deserve. It is shameful and unacceptable for elderly people to be left for hours without food and drink and not properly cleaned.
We know that the Dilnot report called for the improved integration of health and social care. Evidence suggests that this can improve outcomes for individuals and deliver cost savings. We know all this, and we have been talking about it not only for the past 40 years but in the past few days during the proceedings on the Health and Social Care Bill. However, despite notable successes, the progress has been limited, with less than 5 per cent of NHS and social care budgets being subject to joint arrangements and wide variations across different parts of the country in the quality and achievement of joint working. Indeed, part of our scrutiny and testing of the Health and Social Care Bill is whether it will make that situation better or worse.
Nor should we forget that Dilnot did not claim to have the whole answer to the challenges that we face. He claimed that his report was part of the process and addresses very importantly, among other things than those I have mentioned, the injustices of portability of care assessments. The Government’s response to the Law Commission report is most important and was mentioned by my noble friend Lady Wilkins and the noble Lord, Lord Pearson of Rannoch. The Minister should be able to respond that progress is being made on this and other matters.
The proposals for carers are also important in the Dilnot report, as is the establishment of a national source of advice. The commission recommends that better advice should be complemented with a national awareness campaign on the cost of care and a new funding system. I look for that to be part of the Government’s response to this report. Indeed, the assessment and provision of services will be available using the same system as for older people, but the funding cap will work differently for younger adults and the report sets out how this might be achieved.
We must not forget that the need for timely, effective social care not only involves the long-term disabled, those in old age and people with long-term conditions. I thank Macmillan for its briefing and for reminding us that integration across health and social care is also vital in helping to meet the practical, emotional and financial needs of people living with cancer and those reaching the end of their lives. Macmillan welcomes the findings of the Dilnot commission, as it believes that the report also represents the foundation for a fairer funding system for social care.
I have mentioned all the things on which we agree, and I have done so quite deliberately. We all agree that we urgently need a long-term solution for the funding of social care, and that is why Labour offered cross-party talks on this issue from the outset. I urge the Government to get round the table so that we can tackle the care crisis and find a fair and sustainable solution for the future.
I hope that what I have to say now may help the scepticism of the noble Baroness, Lady Barker. Indeed, when I explain how we would like to proceed, I hope that she will nudge her own Government into conceding on this and making faster progress than they have done so far.
As the Minister will recall, when the Dilnot report was launched in early July, my right honourable friend the leader of the Labour Party welcomed it and offered cross-party talks on the future of social care, using the report of the Commission on Funding of Care and Support as a stepping stone to secure a better, fairer system of care for older people and the disabled. I understand that there was an exchange of letters in September and October, and most recently a letter to the Secretary of State dated 8 November.
There are some outstanding questions that the Government need to address in their commitment to this process, and I should be grateful if the Minister would indicate to the House whether progress on them has been made. There are four points. First, securing agreement on funding and implementing the Dilnot proposals clearly goes beyond the remit of the Department of Health and the Secretary of State for Health—it should involve all the departments affected. Given the public spending implications of both the Dilnot proposals and the rising costs and needs, the engagement of the Treasury in this process is crucial. Does the Minister agree with that, and is there agreement that that is how we need to proceed?
Secondly, the Government should nominate an independent person to chair the talks. Again, does the Minister agree with that, and when might it happen? Thirdly, we would like to see established an independent secretariat with the specialist expertise to provide equal access to the negotiations as required. Fourthly, there should be a party leaders’ meeting to agree a clear timetable to demonstrate that we are all equally and seriously committed to talks at the highest level.
Those commitments do not stand in the way of the process: rather, they will facilitate it. I put them on the record now, as they have been put to the Secretary of State for Health, and say that I think it would help the House and the process if the Minister would take the opportunity to respond on this matter. Finally, I thank all noble Lords for taking part in the debate.
Baroness Barker
I thank the noble Baroness very much—I did not know about the correspondence. However, can she explain why an independent chair is necessary for the process? I understand the other three points but I do not understand that one. What is the reason?
Baroness Thornton
We think that having an independent chair is a sensible way to move forward. We have not suggested that we should appoint the chair; we have asked the Government to suggest the name of the person who might chair those talks. I do not think that any of those things is a barrier to progress in this matter.
Finally, we on these Benches think that this is one of the most important issues facing our society today. It is one that we cannot neglect or leave in the long grass, and it is one that we are determined to resolve.
Earl Howe
My Lords, I thank the noble Baroness, Lady Pitkeathley, for calling this debate on a topic that I know is not only close to her heart, but close to the hearts of all those who have spoken, as well as mine. This is also a very well timed debate. It will helpfully feed in to the Government’s consideration of these extremely important matters.
Before I talk about reform, I would like to respond to some of the points that have been made here and in another place about the current funding situation for social care. In these challenging economic times, there is pressure on all areas of government spending. We, as a Government, have had to set our priorities and make some difficult decisions. One of those decisions has been to protect social care funding. In the last spending review settlement, we provided an extra £7.2 billion over the four years to 2015 to protect social care, partly through councils and partly through the NHS.
That additional funding will help to alleviate pressures on the adult social care system in the context of a challenging overall funding settlement for local government. We believe that this settlement will protect services, and our view on this is supported by independent research. The King’s Fund has said in its report, Social Care Funding and the NHS, that central government have put enough money in to protect adult social care services. But times are tough and I am not going to pretend otherwise. Although nationally, I can present a relatively positive picture, there are areas where cuts have been made to front-line adult social care services that are really beginning to bite and that must concern all of us.
I turn now to the reform of social care and what needs to happen in the future to improve the way in which we, as a society, support people with care needs and their families. The noble Baroness, Lady Pitkeathley, set out the position extremely well. In this country, our population is ageing as people live longer. This is to be celebrated and not seen as a burden. My noble friend Lady Tyler reminded us of some of the statistics. Last year, we had 13,000 centenarians. I saw that one of them, Fauja Singh from London, recently completed the Toronto marathon, so I hope that that will be an example to many. Most people who are 65 now will live well into their 80s and the number of over-85s is set to double between now and 2026. These are all things that we, as a country, should be proud of, but I can only echo the noble Lord, Lord Low, and the noble Baroness, Lady Wall, in saying that it is also a fact that, as we live longer, we will have a greater need for social care to ensure that we can continue to lead independent and fulfilling lives.
Demand will rise. This is one of the uncomfortable truths mentioned by the noble Lord, Lord Sutherland. We have an outdated social care system that in some respects has more in common with the principles of 19th-century poor law than it does with the needs of people today and as demand for social care increases, the cracks in this system grow ever wider.
The noble Baroness, Lady Pitkeathley, invited me to signal how strongly the Government feel about this. Our belief is that we urgently need reform, both to the way in which social care is funded and to the legal framework that supports it. The noble Baroness, Lady Bakewell, was absolutely right: many people currently think that when they need social care it will be provided free, just like the NHS. Unfortunately, for most people, this is not true, a fact that people often discover only when they, or their relatives, need care. Many people without direct experience of social care are not aware of the unfairness of the current system and the urgent need to modernise it. We need people to realise that they face a huge financial risk and that this can be met only by reforming the system and by individuals taking greater responsibility for planning and preparing to meet some of these costs.
Social care costs are unpredictable and can be very high. Although a quarter of all those currently aged 65 will not need any significant social care, one in 10 will have costs in excess of £100,000. This can be catastrophic for people and their families. Andrew Dilnot’s report proposes one way in which the problem can be addressed. It is an excellent piece of work and a significant contribution to the debate on social care funding.
I listened with great care to all noble Lords. I will mention the different themes singled out for analysis and comment by the noble Lords, Lord Rix, Lord Adebowale and Lord Low. We now need all those involved with social care, and all sides of the political spectrum, both in your Lordships' House and in another place, to engage in an open and honest debate about the priorities and trade-offs in the area of long-term social care. The engagement on social care that the Government launched in September will provide a forum for the debate and will inform the White Paper and progress report that we intend to publish next April. This will set out our response to Andrew Dilnot's recommendations on funding.
I say to the noble Baroness, Lady Thornton, and to all noble Lords, that this is not an issue that we will shy away from. More than one noble Lord suggested that the Government were, in common parlance, dragging their feet. That is absolutely not the case; social care reform remains a priority for us and we recognise that the current system is unsustainable. However, the matter is complex and we will have to answer a number of related questions. The Dilnot commission's recommendations have significant costs attached to them. As we said in our response to its report, we will need to consider that aspect carefully against other funding priorities and calls on constrained resources. We also set out six tests that we will need to consider in coming to a judgment on the recommendations. Before we set out our plans for major reform of social care, we want to talk to stakeholders about the priorities for reform. That is why we launched the Caring for our Future exercise on 15 September.
The noble Lord, Lord Sutherland, was sceptical about the need for further consultation. He is of course absolutely right that much work has already been done in this area. The Dilnot report builds very capably on that foundation. However, I put it to him that it is also right that we engage with stakeholders on the priorities for reform in the current economic climate. Our commitment to legislate at the earliest opportunity is undiminished.
The noble Baroness, Lady Pitkeathley, asked whether the Government in their White Paper will respond to the Law Commission. The answer is yes. We have committed to legislate for adult social care at the earliest opportunity and we will need to take the Law Commission report as our foundation for that work.
The noble Lord, Lord Desai, took us to the subject of the cap and asked whether we felt that it should be index linked. The Dilnot commission recommended that it should be. The range suggested for the cap was between £25,000 and £50,000. It recommended that ideally the figure should be around £35,000. We are looking very constructively at the suggestion of index linking.
The noble Lord, Lord Lipsey, suggested that I had “done a Baroness Trumpington” in my reply to his question about the cap. I am sorry that he thought that: it is not my style, as I hope he knows. The commission’s report set out detailed costings in its evidence and analysis. These included costs for different levels of cap. The level of the cap is an important variable. We are considering the implications of the different levels. As part of the Caring for our Future engagement, the department discussed the cap with the financial services sector. In particular, we discussed the principle of a considerably higher cap than Dilnot recommended. A key conclusion of the discussions, which we published on the engagement website, was that a high cap such as £100,000 would seem unobtainable to people and would not stimulate the development of financial services.
That brings us to the question posed by my noble friend Lady Barker of whether we are looking at the possibility of improving the equity release market. The engagement is exploring the role for financial services in helping people with care costs. That will include any improvements in equity release that we can see for the future. I do not agree with the implication of the noble Lord, Lord Desai, that equity release is not a potentially useful mechanism for us to explore.
The noble Lord, Lord Warner, put forward his constructive view that the Government might consider setting up a loan scheme so that people can use housing wealth to pay for care. We are aware of the commission’s recommendation for a universal deferred payment scheme, and we have been considering it along with other recommendations as part of the engagement.
My noble friend Lady Barker indicated that assessment of needs has to be independent of the financial assessment. I agree that that is an important issue. The Law Commission’s recommendations make clear provision for that. Following on from that, the noble Baroness, Lady Pitkeathley, talked about the need for information and advice when people use care and said that that has to improve, which was again a theme picked up by Dilnot. We completely agree that information and advice are extremely important. Our publication A Vision for Adult Social Care, which came out a year ago, made it clear that people should have good information. The Law Commission has made recommendations in this area, as I am sure the noble Baroness knows. We are again looking very seriously at this. It is a major issue coming out of the engagement.
I say to the noble Baroness, Lady Wilkins, that we completely agree that disabled people need to have choice and control to live independently. The Government’s A Vision for Adult Social Care makes clear our commitment to more personalised support. We want to see greater rollout of personal budgets that give people choice, control and independence. I think it is unrealistic to believe that we can do that sooner than around 2013, but we are working hard on it.
The noble Lords, Lord Pearson of Rannoch and Lord Adebowale, and the noble Baroness, Lady Wilkins, spoke powerfully about the idea of portability. We recognise that enabling portability of assessment could mean that people moving to a new area and the professionals supporting them would not have to go through unnecessary multiple assessments of their needs. This can be particularly important for people who want to maintain employment and pursue career opportunities. The Government support this in principle. We are considering the practicalities in the light of the recommendations of the Law Commission and the commission on the funding of care and support. We have recently launched an engagement process with stakeholders to bring together the recommendations of these two commissions, as I have mentioned, and to consider what our priorities should be. The White Paper will set out our conclusions. I think it would be wrong at this stage for me to pre-empt that process, but I take on board the points that were made about portable care packages rather than simply assessments.
Lord Pearson of Rannoch
When the Government go through this process, for which I am sure all of us are very grateful, will they bear in mind the cost savings which would emerge from portability, as we are looking for cost savings in this area?
Earl Howe
I am sure that is a factor that should be taken fully into account. If I can tell the noble Lord more about that when I return to the department, I shall be very pleased to do so.
The noble Lord, Lord Warner, whom I thank for his work on the Dilnot commission, talked about portability and flagged his intention to debate this when we go back into Committee on the Health and Social Care Bill. As I have just indicated, we intend to signal our response to the Law Commission’s report and the Dilnot commission in this area when we publish our White Paper. I feel that the Bill that we are debating in Committee at the moment is not the right vehicle into which to shoehorn a recommendation like this. It needs the right legislative vehicle. Nevertheless, I am not shying away from the kind of debate that the noble Lord signalled he would introduce.
Integrated care has been mentioned by a number of noble Lords, including my noble friend Lady Tyler and the noble Baroness, Lady Wall. We recognise the importance of integrated working between the NHS, social care and public health, and the benefits that this can have for individuals and their families. It is important for good outcomes and for achieving value for money, as a number of noble Lords have indicated. We have debated this theme more than once during Committee stage of the Health and Social Care Bill. We want to ensure that local authorities and NHS bodies have the flexibility that they need to work together at a local level. The health Bill will ensure that key flexibilities, such as support for pooled budgets under Section 75 of the Health Act 2006, are translated into the reformed system.
My noble friend Lady Tyler referred to telecare, which is an exciting area. The previous Government instigated the largest randomised control trial of telehealth and telecare anywhere in the world—the whole system demonstrator project—which will provide the gold standard evidence for which everyone is looking. It has been one of the most complex studies ever undertaken by the department but the early results are very promising. Evaluation is ongoing but we are nearly ready to publish headlines that will help decision-makers here and across the world.
My noble friend also spoke about the need to ensure that we have a high quality social care workforce. Of course, she is right. The department is spending nearly £300 million on the training and development of the social care workforce this year. The ONS labour force survey shows that 67 per cent of people working as care assistants and home carers have a level 2 qualification or above. Data show a steadily improving picture with regard to the number of people who hold level 2 or above qualifications. In the current financial year, the department is providing approximately £28 million of funding to Skills4Care for the training and development of the adult social care workforce.
My noble friend Lady Tyler once again referred to the importance of supporting carers. We fully agree with her that the carers’ strategy refresh document prioritises future actions to ensure the best possible outcomes for carers and those they support. We have made available an additional £400 million to the NHS over four years to provide carers with breaks from their caring responsibilities to sustain them in their caring role.
A number of noble Lords have expressed the view that a broad political consensus is emerging on long-term care reform. I genuinely hope that that is so. I can say to the noble Baroness, Lady Thornton, who put the question about cross-party dialogue, that we remain committed to a process of dialogue with the Official Opposition, given the importance of this issue, which is why the Secretary of State wrote to the shadow Secretary of State for Health inviting him in his new role to continue in this dialogue.
As she mentioned, the Secretary of State has received a response from the shadow Health Secretary and the shadow Minister for Care Services stating their commitment and intention to continue with the process. We very much want to seek to build consensus around an issue as important as this. We will of course ensure that sufficient resources are provided to support talks. But, as the noble Baroness will recognise, Ministers must remain ultimately responsible for the decisions that we take. She also mentioned the letter that my right honourable friend wrote to Andy Burnham on 8 November. On the same day, a letter was received from Andy Burnham and Liz Kendall. It outlined their commitment to resuming talks, which we welcome. We are considering the questions and conditions in that letter. I hope that my right honourable friend will be in a position to reply formally very soon.
Of course, there are a number of other priorities for social care. We need to improve the quality of care that people experience to ensure that those with care needs have the best possible outcomes. Services need to be more personalised, more people need more choice about their care so that social care is designed around the needs and wants of the individual, not around the convenience of systems, and we need to push for better integration, as noble Lords have indicated. We need to support more prevention by early intervention so that we can avoid people deteriorating unnecessarily and allow them to remain independent as long as possible, and we need to create a more diverse and responsive care market so that people can buy the services that best meet their needs. All these are our priorities. I hope that the engagement we are now in will find the solutions to those. This is an issue for our times as our society gets older. How we look after people with care needs will become ever more important. We now have an opportunity to get this right, and we must not miss it.
Baroness Pitkeathley
My Lords, we have seen great enthusiasm for the Dilnot Commission in the course of this excellent debate while acknowledging that it is not the whole answer, and while acknowledging its shortcomings. Even my noble friend Lord Desai admitted that it is the best chance we have. However, if the objective of the debate was to save Dilnot, as my noble friend Lord Lipsey proposed, I am not sure we can be confident that we have succeeded, judging by the Minister’s response. Even so, I know that as ever the House will be grateful to the noble Earl for the way in which he has responded and, indeed, confronted some of those inconvenient truths about which the noble Lord, Lord Sutherland, reminded us.
My noble friend Lord Warner robustly reminded us that doing nothing is not an option. As ever, the wisdom and expertise shown around the Chamber has been extraordinary, and there has been universal agreement that we need a lasting settlement based on a partnership between the individual and the state. We have also seen that we must have honesty and, above all, we must have political consensus, which will require a degree of bravery. I know that the usual suspects who have taken part in the debate—these guys, as we all are—will continue to apply pressure, as well as offer advice and consultation to stiffen the resolve of the Government and the Opposition to be brave, to bite the bullet and make this a watershed moment in the history of social care by responding to the call to arms. I thank all noble Lords who have taken part in this inspiring debate.