The Minister of State, Department of Health (Paul Burstow)
I am very grateful for the opportunity to speak in this debate. I start by thanking the Backbench Business Committee for granting it and my hon. Friends the Members for Truro and Falmouth (Sarah Newton) and for Stourbridge (Margot James) for securing it and leading it so well.
I have chosen to speak early in the debate because I want to spend the majority of it listening to colleagues. I undertake to respond to their questions in writing if necessary to ensure that we have a clear record of the Government’s position on these issues.
I pay tribute to the Care and Support Alliance. The lobby that it organised this week was a truly powerful event, because of the testimony of individuals who made the journey to Westminster to lobby their MPs. I had the pleasure of spending an hour being cross-examined by a large number of people on that lobby, and I found it a really useful opportunity to talk about social care.
I have been a Member of Parliament for more than 15 years and raised the issue of social care reform throughout that time. For far too long, it has been left in the “too difficult to do” drawer, and it is now due attention from the House and the Government. We must not make the mistake of putting it back in that drawer, which would be dangerously short-sighted.
What does high-quality social care mean? It means helping people to stay healthy, independent and out of hospital. As the hon. Member for Worsley and Eccles South (Barbara Keeley) said, it means reducing pressure on the NHS, but above all it means helping people to live the lives that they want—long, safe and comfortable lives with the maximum possible independence. That is why the coalition Government are determined to tackle social care, and we have already set to work on doing just that. We established the Commission on the Funding of Care and Support, chaired by Andrew Dilnot, to make recommendations on how we could develop an affordable and sustainable funding system for social care. My hon. Friend the Member for Truro and Falmouth outlined those recommendations.
Kelvin Hopkins (Luton North) (Lab)
There is constant emphasis on the importance of independence and of people living their own lives, but many people who depend on care want company. Some would prefer to live in decent, appropriate care than to be left on their own in their home and not cared for appropriately. Is the Minister not aware of that?
Paul Burstow
I am most certainly aware of that. Social isolation is a huge burden on the individuals affected by it and has huge consequences for health care. That is why, when I talk about independence, I also mean interdependence—the recognition of the value of family support and carers, and of the fact that people need to be active in their community throughout their life. Social care has a role to play in enabling people to do just that, rather than become institutionalised in their own home or a care home. I absolutely agree with the hon. Gentleman about that.
The Dilnot commission made a number of recommendations on the development of a system such as I mentioned, and my hon. Friend the Member for Truro and Falmouth described them well. In the spending review, we allocated an additional £2 billion by 2014-15 —£7.2 billion over the spending review period as a whole. In November 2010, we also set out our vision for social care reform, including the roll-out of personal budgets and greater personalisation. I agree that we need to ensure that that is genuinely about how we enrich people’s lives, not just an opportunity to reduce the available resources to individuals. We are also investing £400 million over four years to help to give carers much needed breaks. We are ensuring that the NHS is held firmly to account for delivering the money in the coming year by making sure that it has to account directly to carers’ organisations locally, and agree with local authorities the plans to provide breaks, spell out how many there will be and the size of the budget for that purpose.
It is also important to dispel a myth about social care, which has been hanging around for far too long—that, in some way, it is just like the NHS and free. As my hon. Friend the Member for Truro and Falmouth said, it is not free and never has been. If people assume that the state will pick up the bill, they are unlikely to prepare themselves. If they do not prepare and they need help, the impact can be truly devastating for them and their families: life savings wiped out, family homes full of memories sold off, and thoughts of a comfortable retirement turned to dust.
We therefore recognise the problem, which is getting worse. Our population is ageing, and that should be a cause for celebration. Too often, debates about ageing in our media are couched in terms of demographic time bombs and the like. However, the current care and support system is not fit for purpose. I agree with the Care and Support Alliance about that. It is broken, and patching and mending it is no longer acceptable.
However, reforming social care will not be easy. As has been said, it will require bold thinking and difficult decisions. The Dilnot commission shed much needed light on the reality of social care funding. Soon, we will publish a White Paper and a progress report setting out our response to the recommendations.
Barbara Keeley
Perhaps the Minister will enlighten us on what is meant by “spring”. There is speculation that spring might extend to May, June or July. When I was in government, I spent a lot of time answering questions about what spring meant in relation to Government reports. Will he tell us what it means now?
Paul Burstow
On that basis, the hon. Lady knows the answer that I would give and I shall therefore not tire her by saying what she would have said if she were in my place. We are anxious to publish a White Paper as soon as we can in a way that ensures that we have successful dialogue with the Opposition on funding. Those two matters are interdependent.
We are considering not just funding reform, but the legal structure that governs social care, which must be updated. The Law Commission has done a sterling job of making recommendations for replacing the patchwork that has built up in the past 60 years with a legal framework fit for the 21st century. A new social care law will bring clarity where today there is a complicated and confusing system, facilitate personalisation and support staff, service users and carers.
Beyond that, we need high-quality, integrated care, which focuses on early intervention, prevention and the needs of the individual. Better care is about not just spending more money, but spending it much more wisely. The Health Committee made that point powerfully to us. Some councils do that well; others could do it better. That is why the Government are jointly funding with the Local Government Association work to support councils to release savings while improving the care and support they provide.
The Health and Social Care Bill will foster far greater integration between the NHS, social care and, importantly, other public services. Health and wellbeing boards will bring together democratically elected local councillors, directors of children’s services, adult social services and public health services, clinical commissioning groups, and, importantly, the public through Healthwatch, to improve services in our communities. They will identify local needs now and for the future and, importantly, be accountable for setting the strategy to meet those needs. The unprecedented transfer of money from the NHS to social care is creating new opportunities for joint working.
However, we have a long way to go to improve the quality of social care, especially for older people. Clinical audits on fractures or continence care; the parliamentary inquiry into the human rights of older people in health and social care; and damning reports by charities such as the Alzheimer’s Society and Age UK all point to the fact that health and social care in England is far from universally excellent. In too many cases, it is very far indeed from being excellent. There can be no excuses and no mitigating circumstances. Yes, there are excellent staff working in our services, but some staff need to be challenged, and some need to leave the profession because they do not do the right thing. We need to be honest. We need to applaud the good, but to shine a light where there is no good.
It is not a matter of not having enough staff. In some places—
Paul Burstow
I will in a moment, because I made a point in direct response to my hon. Friend.
In some places, full staffing complements perform badly, while places under considerable staffing pressure perform exceptionally well.
Paul Burstow
I will give way to my hon. Friend, who I know works hard on these matters.
Andrew George
I am very grateful to the Minister, whom I respect. Poor standards need to be rooted out wherever they exist, whether among the lowest-paid care workers or the highest-paid managers, but does he accept that the care system is based on workers who work antisocial hours, who are often untrained and unsupported, and whose salaries are appallingly low?
Paul Burstow
I accept that we have a largely untrained work force—or they are not as trained as they should be. This is the first Government to set down the need for training standards for health care assistants and care assistants. We have signed off the funding to allow Skills for Care and Skills for Health to do that essential work for the first time.
On transparency, we need to know what is happening within caring organisations. Transparency is vital to improving the quality of services on offer and to holding providers and commissioners to account. As is happening already in the NHS, we need more information and data to improve the quality of social care. Without those, how can local authorities, individuals or their families hold providers to account?
That is why we published the adult social care outcomes framework last April, which was developed in partnership with the Association of Directors of Adult Social Services, the Local Government Association and others. I thank all those involved in developing that new tool, which has the potential radically to improve the quality of social care in England. The outcomes framework will enable local authorities to hold providers to account, and in turn enable local people to compare and contrast performance on social care in one part of the country with performance in another, and to hold their councils to account.
In the past, the emphasis has been on patients and people who use services bending to the convenience of service organisations. That must change, and it must do so faster than ever before. By focusing on the individual and integrating services around them, we can begin to break down institutional barriers that for too long have held back the improvements in care that the country needs.
Many people’s lives could be so much better. We are right to celebrate the fact that our population is living longer, and often living longer better, but we can do much more to ensure that we add quality to the extra years that the success of our health and other systems have delivered. That is why the best social care means the difference between a life of dependency and life lived with independence and dignity—the difference between a life endured and a life enjoyed, or a life in which potential is not realised or unlocked and a life in which it is.
Social care is among the most pressing issues facing us today—I believed that when I first came into the House. I hope that, during this Parliament, this Government, working in partnership with others and the Opposition on funding, can reach a consensus that can be delivered, and that we can translate that into sustained action. That is how we can do something that has not been done for 60 years.
We have inherited laws that are out of date, which make it impossible for some people to navigate their way around our social care system. It is time to change. That is why the Government will publish our White Paper and set out our plans for legislation. I look forward to more debates on adult social care as time goes by, but today I look forward to listening to colleagues, and will respond to further questions.
Andy Burnham (Leigh) (Lab)
I, too, congratulate the hon. Member for Truro and Falmouth (Sarah Newton) and my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley) on bringing this important debate to the House. They make an impressive and persuasive double act for this most important of causes, and are right to challenge both Front-Bench teams as this is without doubt the biggest unresolved public policy challenge facing the country. So far, between us, Parliament has failed to face up to it, and as others have said the result is a developing care crisis in England.
We must all bear our share of the responsibility for allowing that to happen, but the best response is to resolve to find lasting solutions. This century of the ageing society demands it, and the earlier we do it, the better. If we do not, to Beveridge’s five giants of the last century we might add a sixth for the 21st century: fear of old age. We cannot let that happen, and people are looking to us all to put point scoring aside and to work constructively to find a solution. In that spirit, I welcome much of what the Minister said.
I commit the Opposition to doing the same, and as a sign of our intent, the Leader of the Opposition has appointed a member of the shadow Cabinet with specific responsibility for these matters. I refer to my hon. Friend the Member for Leicester West (Liz Kendall). The House might have noticed that she is not here today. I send her apologies. [Interruption.] The Minister of State, Department of Health, the right hon. Member for Chelmsford (Mr Burns), is absolutely right. She has a good excuse: she is in Leicester with Her Majesty the Queen at the commencement of the diamond jubilee celebrations; otherwise of course she would have been here. I hope that I am an acceptable substitute.
Andy Burnham
Thank you.
I wish to demonstrate today Labour’s commitment to this issue. The House might remember, as my hon. Friend the Member for Worsley and Eccles South said, that I made reforming social care my top priority as Health Secretary, and I did that for a very personal reason: I have never forgotten my grandmother’s dispiriting journey through England’s care system and the battles that my mum fought to preserve her dignity. The day I visited her in a nursing home near where I lived to find that her engagement ring had been wrenched off her finger and stolen was the day that I knew something was seriously amiss with how we looked after our older people.
We all have our own personal experiences, and we all know that we have to do much better. Looking after other people’s relatives, particularly the most vulnerable in our society, should be one of the most highly valued and respected callings there is, but sadly the reverse is the case. England’s care provision is too often low status and low wage, with about 70% of the work force having no qualifications and many earning at or around the national minimum wage.
With every year that passes and every year that we do not achieve a lasting and better solution to the funding of adult social care, the cruel unfairness in the system gets worse and the quality of service diminishes even further. People are paying higher charges, and the most vulnerable, as the Minister said, are losing everything. Families are being wiped out physically, emotionally and financially by the situation, carers are under intolerable pressure and councils are struggling to cope with the demographic pressures.
But there is hope. I did not think that the White Paper and cross-party talks that I led before the election achieved as much as they might, but perhaps I was wrong, because they might have prompted the Government to establish the Dilnot commission, on which we congratulate them. We also congratulate Andrew Dilnot and his commission on the intelligent way they addressed their brief and delivered a solution that politicians on all sides can work with. It provides a basis for progress, and we should take it.
Since then, we have also had the Health Select Committee’s excellent report on social care, which made a persuasive case for integration. At present, the social care debate is happening in isolation from the debate about NHS reform, which is unhelpful. We are looking at a Bill called the Health and Social Care Bill, but there is not much about social care in it. Indeed, it is slightly odd that a Bill of this name is going through Parliament, yet a social care White Paper is not due until May, as my hon. Friend the Member for Worsley and Eccles South said. It is essential that we start viewing reform of social care and the NHS as two sides of the same challenge—how to provide integrated, people-centred and preventive care in the century of the ageing society.
The Committee’s recommendation of a single commissioner for older people was an important one, and I was pleased to hear the hon. Member for Truro and Falmouth endorse it. I do, too, not least because it was precisely what I would have done had I returned to the Department of Health as Health Secretary had we secured a different result at the general election. However, I am worried that this vision, which we share, is made more difficult by the Health and Social Care Bill and the new landscape that is developing.
Those are the issues that the Government need to address in the White Paper. We are grateful for the opportunity that the Minister and the Secretary of State have extended to us to take part in cross-party talks and to influence that debate, as well as the crucial issue of how to fund the Dilnot proposals. Speaking for the Opposition, I can assure the House that we will play a constructive and responsible role in those talks. However, I would also like to take this opportunity to place three caveats on the table. First, we need to make it clear to people that although the Dilnot package is an important step forward, it is only that. It is not the whole answer to the challenges that the country faces. Its introduction would make the system fairer than it is today and would deal with the catastrophic costs of care that the most vulnerable people face. However, people would still be liable for high charges, with the vulnerable paying the most.
Secondly, there has to be a recognition from all parties in the House that progress will come only with difficult decisions and nettles being grasped. We need to have a mature discussion with the public about those difficult options, rather than using them for point-scoring purposes. What stands in the way of progress is not the complexity of the issues—they are not over-complex—but the political will to advance a difficult argument. That is what has prevented us from making more progress than we should have. To push things along and give our talks some impetus, it would help if the Government committed to introduce legislation in this Parliament to implement whatever has been agreed. That would bring a useful focus to the cross-party talks. Thirdly, we believe that there is a genuine danger that the debate might focus only on funding the Dilnot recommendations, and not on the existing pressures in the system. That must be avoided at all costs, as my hon. Friend the Member for Worsley and Eccles South said. As one care charity told me yesterday,
“We can’t have jam tomorrow if we have no bread today”.
I, too, was concerned by the comments that the Minister made before the Select Committee on Health, specifically when he said:
“We don’t accept the position that there is a gap. We have closed that gap in the spending review. On the issue of unmet need, I am yet to find any agreement among academics on a definition of unmet need.”
Many councils would struggle to reconcile that statement with the reality of what is happening on the ground. Council budgets are being cut by more than a third over the course of this Parliament, and as we know, adult social care makes up the largest part of those budgets, at around 40%.
The Prime Minister is fond of quoting me on health funding at Prime Minister’s questions, but he only ever uses the bits that suit his purpose. If I may, I would like to give the House the full version of that quotation today, because what I was warning of was the danger of taking an unbalanced approach to public spending. Before the election, the Conservatives were saying that they would give the health service real-terms increases, over and above inflation—which have not, in fact, materialised—within a much reduced overall public spending envelope. My worry was that taking such an unbalanced approach could damage other public services, including those that are intrinsically linked to the health service. What I actually said was:
“It is irresponsible to increase NHS spending in real terms within the overall financial envelope that he, as chancellor, is setting. The effect is that he is damaging, in a serious way, the ability of other public services to cope: he will visit real damage on other services that are intimately linked to the NHS,”
such as social care. I believe that this is what we are seeing right now.
Paul Burstow
The right hon. Gentleman made those remarks ahead of the spending review in 2010. The spending review also gave the Government the opportunity to make announcements about social care spending, and it is when we committed £7.2 billion extra for social care support. We have to challenge local authorities to use those resources wisely. Indeed, I hope that he will join me in challenging local authorities to commit to spend the resources that the Government have allocated for social care on social care.
Andy Burnham
Yes, I will. There is no difference between us on that, but there is a difference between us on the funding position that the Minister has set out. The King’s Fund and others have identified that there is a £1 billion funding gap in adult social care in England, not just because of the money but because of the demographic pressures, which we cannot get away from.
The Government’s commitment was to give more money to the health service, but we have produced figures showing a real-terms cut in outturn last year, and we also notice that transfers—indeed, recent transfers—have had to be made to the social care system, which implies that the Government have left it short, and that there is an emergency propping-up of the system, revealing the flaw in their position.
Kelvin Hopkins (Luton North) (Lab)
I apologise for being away from the debate for a short time, Mr Deputy Speaker. I was speaking in Westminster Hall on another subject. Being in two places at once, even for a Member of Parliament, is rather difficult.
I have long had an interest in this subject. I congratulate the hon. Member for Truro and Falmouth (Sarah Newton) on securing this important debate and my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley) on her excellent speech. I also give full credit to the two Front-Bench spokesmen because I believe that they genuinely care about this matter and are not just speaking warm words. I appreciate that.
I will focus on residential care, but I believe that domiciliary care is also in a poor state. I know of many cases in my constituency of people not being looked after well under the new privatised, personalised approach to care. The contrast between that type of care and what people get from an NHS district nurse who goes around to tend to people is extreme. I have spent a day with one of my local district nurses—they are not called that any more, but Members know who I am talking about—and seen how a true professional, a public employee motivated by the public service ethos, treats their patients at home. That is how all sorts of care ought to be provided, rather than by private companies or private individuals who often have heavy work loads, are impatient and do not provide the care and sympathy that they should when they visit people in their homes.
The royal commission on long-term care for the elderly, which recommended that care ought to be free at the point of need on the same basis as the national health service, was absolutely right. The Government of the time rejected its recommendation, and went so far as to ensure that a couple of members of the commission voted against it so that it was a majority view, not a unanimous one. I personally think that was a terrible thing to do. I have raised it before in the Chamber and probably will again, because I think it was so wrong. Nevertheless, the royal commission recommended free long-term care for all, and I absolutely agreed.
I tabled an early-day motion in the 1997 to 2001 Parliament calling for the Government to adopt the royal commission’s recommendations. More than 120 Members signed it, most of them Labour Members, but other parties were represented as well. No notice was taken of it. The current Minister was one of the signatories. I tabled another early-day motion in the 2001-05 Parliament saying the same thing, and it got similar support. I hope I am not embarrassing him, but he tabled a similar motion when he was in opposition, which I supported. We were on the same side at that time, and I like to think that he is doing his best to push that agenda forward within the constraints of the coalition.
My position is absolutely clear: I believe that there should be free long-term care for all, provided by a professional care service of directly employed public service workers. That is how people would be served best, and it would be properly publicly accountable.
Paul Burstow
The hon. Gentleman is absolutely right that I signed early-day motions supportive of the royal commission, but I need to correct the record ever so slightly. He is giving the impression that the royal commission recommended that all aspects of long-term care should be free. I am sure he will want to acknowledge that accommodation and hotel costs were not intended to be covered by its proposal.
Kelvin Hopkins
I thank the Minister for his correction, and I think the situation is possibly similar in the health service.
I come to the problem of affordability. I remember that in the early days after 1997, the Government were trying to keep down public spending, and there was a crisis in the NHS because of under-spending. That crisis was inherited from the previous Government, but for the first two or three years after 1997 nothing happened. We got well behind in what we needed to do to fund the NHS.
During that Parliament, the standard rate of income tax was reduced by 1p, and nobody even noticed. I believe that at that time, 1p on income tax was the equivalent of about £3 billion, and that income was just lost. It could have been spent on long-term care or the health service, but the decision was taken to reduce tax. Later on, in the last Parliament, the then Chancellor decided to reduce the standard rate of tax by 2p. I am not suggesting that the standard rate of income tax is necessarily the way to pay for care, but it is not right to say that things are unaffordable when big tax cuts are being made. I believe that 1p on the rate would now raise about £4 billion or 2p about £8 billion—plenty to pay for free long-term care for all who need it.
Dr Sarah Wollaston (Totnes) (Con)
I have good news: people in their 40s and 50s are at the pinnacle of evolution, according to Dr Bainbridge writing in the New Scientist. I do not think my children would agree with that assessment, but they would agree that they feel rather outnumbered. This is a cause for celebration, however, and we should note it in this House: it is a good thing that we are all living longer—after all, the alternative is very unattractive indeed. A man who reaches the age of 65 can now expect on average to live a further 18 years, and a woman at 65 can expect to live even longer—to 85 and a half. We should welcome that on international women’s day. This is good news all round, therefore, but these extra years must be lived well. We should add to people’s years of life while also helping them live with independence and dignity.
I have the privilege of serving on the Health Committee, and I have also had the privilege of working for 24 years on the front line in the NHS. I have therefore met many carers, and also many people who, sadly, are suffering from dementia. Many Members have commented on that topic however, so I will not discuss it further now.
I want to focus on the Select Committee’s recommendations following our inquiry into social care. I acknowledge that, by 2014, an extra £2 billion a year will be spent on social care, and I welcome that investment. There is still an issue that needs to be addressed, however, and it transcends party politics.
As the King’s Fund and the Dilnot commission have made clear, demand is outstripping supply—by 9% over the past four years—and the Local Government Association and the Association of Directors of Adult Social Services have stated that this underfunding is a long-term problem. According to the King’s Fund, the funding gap could be as high as £1.2 billion by 2014. Also, about 890,000 older people in social care may have a need that is not being met. As the Select Committee heard, some councils are tightening their eligibility criteria, so that people who perhaps would have been classed as having “substantial” needs are now being classed as having “moderate” needs. Other councils are setting a different benchmark, so they are funding only “substantial” needs, rather than both, as they might have done in the past. Obviously, the problem goes beyond the total spend. Government Members are taking a realistic attitude to our national debt, knowing that there are no blank cheques. However, we need to continue to increase our social care funding slightly, so that we can achieve what we want to achieve for our older people: dignity and independence.
It will not matter how much we spend unless we change how we spend it. One thing the Dilnot commission examined well was how we divide our spending. We know that we spend £145 billion a year on older people in England, about half of which goes on benefits, such as pensions, housing-related benefits and pension credits. Some £50 billion is spent on the NHS but only £8 billion goes towards social care. That balance is not right. If we were designing the system from scratch, we would not set the funding in that way. That structural problem has been recognised for decades, but the White Paper and the changes in the Health and Social Care Bill give us an opportunity to address it. I therefore ask the Minister to rebalance things by examining the Select Committee’s key recommendation, which was to deliver integrated health and social care, with a single commissioner or a commissioning body, and to drive this joint working by also looking at pooling budgets.
Some wonderful examples of that approach are available, as we found when the Select Committee visited Blackburn with Darwen PCT and Torbay Care Trust. I am fortunate that the Torbay Care Trust covers much of my constituency, because it achieves real results: low average lengths of stay; rapid access to equipment, thus avoiding hospital admissions; and getting people out of hospital much quicker. The key to all that is recognising that keeping people independent in their own homes, rather than admitting them to expensive hospitals, saves money. As has been said, for every £1 we spend on integration, we save £2.65 for the health service—as is so often the case, the best care turns out to be the cheapest care.
I was disappointed to hear the Minister describe the care trust model as an experiment that never really got “out of the lab”. I urge him to get back into the laboratory with care trusts, because this is good practice. They bring a positive culture on joint working, pooled budgets and putting patients first. In Torbay, they have considered an imaginary patient, “Mrs Smith”, who has complex care needs and at every stage in the system they have designed everything around her, putting her needs first. That sometimes means sweeping away the silo working that we so often see. In many parts of the country, six different phone calls have to be made when dealing with a patient with complex care needs, and there are endless delays and frustrations, and repeated assessments, but Torbay has a care co-ordinator with a single number. We need to adopt that kind of working.
Paul Burstow
The hon. Lady is making an important set of contributions to this debate. That comment I made during the Health Committee’s evidence session was very much born out of frustration—it is frustration that my hon. Friend the Member for Southport (John Pugh) has echoed. How we spread best practice and get it adopted is one of the key challenges in delivering more integrated health and social care, and it is one of the things we are going to address in the White Paper. The Select Committee’s contribution to that process has been very helpful.
Dr Wollaston
I thank the Minister for that encouraging response. I am glad to hear him say that rolling out good practice is key to this. I ask him to consider the Select Committee’s recommendation that the way that we can best drive that is by having a single outcomes framework. We are currently going to have outcomes frameworks for housing, for social care and for elderly people in health. Bringing those together would drive proper integration. Having a single commissioner for all these services would bring people together. If we do not have that, we risk carrying on as we are. When budgets are stretched, as we all accept they are, there is more of a tendency for organisations to say, “This money is for social care”; where spending the money would perhaps improve only health outcomes, there is less of an incentive to spend it. We should consider pooling the budgets, and having a single commissioner and a single outcomes framework. I am not saying that we should be too rigid in imposing how that is done, but we should set out what we expect. In addition, we should recognise how important housing is in this area. We should not leave it out of the equation when we consider how we help older people to continue to live independently.