(11 years, 5 months ago)
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Baroness Pitkeathley
That this House takes note of the impact of changes in local authority budgets on the provision of social care and its integration with other health, housing and care services.
Baroness Pitkeathley
Well, my Lords, here we are again. It is almost exactly a year since I last introduced a debate on social care, and once again I feel like Captain Renault in my favourite film, “Casablanca”, rounding up the usual suspects. Noble Lords speaking today are once again those with form on this issue, although I am pleased to say that we have some new recruits to our numbers as well.
Last year’s debate focused on the report of the Dilnot commission, and it is a matter of great regret to me—and to many others, I am sure—that, in spite of general agreement around the House at that time that doing nothing was not an option, still no decision has been taken about these important proposals. Andrew Dilnot and his colleagues continue to press the issue with hope and enthusiasm, and we hear lots of rumours that we may have an announcement in the Autumn Budget Statement, next spring, next Budget or in the next spending review—but still no actual commitment.
In his response to the debate last year, the Minister said that we have an opportunity to get this right and we must not miss it. No one could possibly disagree with that but I must begin this debate by recording my intense disappointment that, one year on, we are no further ahead with implementing a long-term solution to the problems of social care.
However, we are focusing today on the immediate problems faced by local authorities and the impact of those on the rest of the system. When we discuss integration, as we often have during the past year, we usually focus on the particular interface between health and social care services. The topic of this debate is deliberately wider, though, acknowledging that care needs do not come in discrete packages but are stretched across the whole of an elderly or disabled person’s life, including their housing, their families and their income.
We must acknowledge that we are not in exactly the same place that we were last year. The Health and Social Care Bill that we were debating then is now an Act, and many promises were made about how it would make integration between health and social care easier. It perhaps is too early to say whether this is becoming a universal reality but none of the reports coming out of local authorities and the NHS fill one with hope. In a recent survey by the NHS Confederation, for example, 66% of NHS leaders said that shortfalls in local authority spending had impacted on their services last year. Delayed transfers of care cost the NHS about £200 million a year, and the human distress that such delays cause to patients and families is incalculable.
I know that the Minister will remind us that in last year’s CSR the Government transferred an extra £2 billion to social care by 2015, £1 billion of that coming from the NHS. Local authorities were grateful for that, of course, although it has been called a sticking-plaster solution. Even if it were to be allocated on a permanent basis, £2 billion is not nearly adequate to meet the needs of the social care system. While the transfer of funds from the NHS to social care has been crucial, not all areas have been able to use the money in the way intended—for example, on hospital discharge, reablement and intermediate care. These have made a difference in some areas but too often they paper over cracks in a system that is groaning and only storing up more problems for the future.
In summary—I will say this briefly since I know that the usual suspects are only too familiar with it—the system is not fit for purpose and we spend inadequate amounts on care and support both publicly and privately. Social care funding has totally failed to keep pace with demographic change. Since 2004, while spending in the NHS has risen by £25 billion, spending on social care has risen by just £43 million.
I am always aware of saying how inadequate our care provision is, lest it be seen as criticism of the many dedicated people who work in the system providing care and sometimes pushing the boundaries to focus on prevention and innovative ways of meeting need. We cannot avoid recognising that the way in which local authorities have dealt with the fact that need has far outstretched funding has been to increase charges and rapidly to raise the threshold at which you can qualify for care. You get care only if your needs are seen as substantial or critical.
In too many areas, services are provided only to those whose care needs are the most severe. The LGA has stated that it expects a funding gap for local authority services of £16.5 billion a year by 2019, or a 29% shortfall, between revenue and spending pressures. It further estimates that in the not-too-distant future, social care and waste spending together will absorb such a huge percentage of their funding that other services will have to take an 80% cut.
Without action on funding and integration, even very basic care—those basic 15 minutes a day, which is all that many elderly and disabled people can expect—will not be available in future. Only this week, the weather sees us having to factor into local authority budgets the huge extra costs that many of them will have as a result of the floods. Not only is this level of care completely inadequate but the fact that it is provided only to those with severe or critical needs makes a nonsense of the prevention that all sides say is the key to ensuring that care needs do not escalate to crisis point.
Moreover, this takes no account at all of the many people who currently meet their own care needs in full. Not only may they have to use local authority services in future but no attempt to preserve the quality of the services can be made for those people. Mencap provides clear evidence that local authorities are struggling with reduced funding from central government and increased demand for services. Over the past three years, one in three local authorities has closed day services and 57% of people with a learning disability no longer receive any day-service provision. Carers UK reports that carers are being affected by the closure of council-run services and by the cuts to grants to the voluntary sector, which provides vital services locally. One carer said that getting respite care service nowadays is like getting blood out of a stone.
When people’s care needs are not met by social care systems, what happens? They turn, of course, to the NHS. This results in increased demand for unplanned and emergency services and delays in hospital discharge. In addition, 88% of GPs surveyed recently by Carers UK report that their patients are being put at risk due to a lack of social care support.
These extra pressures come at a time when the NHS is already under severe financial pressure. The CSR protected NHS funding to some degree but did not take account of rising demand and rapidly increasing healthcare costs. We all know that the NHS is expected to make £20 billion of savings and efficiencies by 2014-15, and the recent report from the CQC paints a sad picture of how cost-cutting is being put ahead of patient welfare, with 16% of hospitals surveyed not meeting the CQC standards for having enough staff on duty to care properly for patients, and warns that this may lead to a culture in which unacceptable standards of care become the norm. Yesterday’s report from the King’s Fund paints a similar picture for the NHS of bed closures, lost services and low morale.
No one could possibly disagree that the NHS and all care services must be run as efficiently as possible. One of the most important ways in which to make efficiencies in either health or social care is through integrating services, an issue that we have debated many times in your Lordships’ House. The money transferred to local authorities from the NHS has helped to stimulate integration and certainly to develop interest in it, but evidence given by the King’s Fund to the Health Select Committee notes that a lack of urgency in delivering integrated care remains and, indeed, that the huge upheaval that we have seen in the NHS since last year has hampered progress and resulted in lost momentum. In this context, it was a positive step to see a paragraph in the recently published mandate emphasise the role of the Commissioning Board in driving and co-ordinating engagement with local councils. For the sake of the increasing numbers of people in urgent need of co-ordinated services, we must hope that the mandate delivers.
The other significant development since last year is, of course, the draft Care and Support Bill. I am honoured to be a member, along with my noble friend Lord Warner, of the pre-legislative scrutiny committee considering this. We shall spend many happy hours with colleagues from this House and another place hearing evidence, testing proposals and debating provisions. There is not time to go into the detail of that Bill here, save to say that there are many welcome proposals in it, and the Government are to be congratulated on an excellent attempt to achieve co-ordination of the many disparate strands of care legislation and to give greater recognition and more rights to users and carers.
In terms of the issue that we are debating today, it is hard to feel anything but anxiety about the extra duties placed on local authorities and on how on earth they are to be funded. Do not mistake me—I could not be more delighted that support for carers will be strengthened or that there will be an obligation on local authorities to provide information and advice to promote diversity and quality, or with the references to assessments and care and support plans, as well as a very much to be praised reference to national eligibility criteria. But even those far-reaching reforms could be viewed as a sticking-plaster solution if we do not tackle the fundamental problem of how social care is funded. The inconsistency between fully funded NHS care and means-tested social care not only confuses users and carers but inevitably hampers the delivery of a comprehensive care package.
Noble Lords may have noticed thus far my subtle references to a need for more money in the system. In conclusion, I want to focus on money. I know that the Government’s response to calls for more money in the system is always, understandably, “There is no more money”. As Andrew Dilnot frequently says, though, it is a question not of “can’t afford it” but of “won’t afford it”. Our GDP shows that we are five times better off than we were in 1948. Time and again, we find that social care properly delivered, of good reliable quality and with an emphasis on preventive care is a better way of caring for older and disabled people than healthcare, especially in a hospital bed, could ever be. If we pool the risk—after all, only one in five of us will ever need high levels of social care—and give it the priority that it deserves, we can afford it. It is a matter of priorities. We can easily find several billion pounds by stopping tax avoidance if we really put our minds to it.
We need to start thinking long-term about the real costs of failures in social care and think more broadly about what those failures will mean to the economy as a whole. I shall give an example. Diminishing social care from councils has hit business productivity. As fewer older and disabled people are able to access social care services, growing numbers of family members are being forced to give up work to care for their loved ones. An estimated 1 million people have given up paid work or reduced their working hours to care for their loved ones. The LSE tells us that the public expenditure cost of families giving up work is £1.3 billion a year in additional expenditure on carers’ benefits and lost tax revenues. If lost earnings are taken into account, the figure rises to £5.3 billion. These are the sort of long-term effects of the current shortages in funding that we should be considering.
I know, as do all noble Lords, that the Minister cannot make a commitment here today to put more much needed money into the system. However, I know him to be a man of commitment and vision, as well as a very busy one today—I also know that the whole House will be delighted with the award that he received last night—and I ask that he commits to taking the message from your Lordships’ House back to his department and to the coalition Government and tries to persuade colleagues to see that investing properly in social care is just that—an investment, not a drain. It saves costs down the line, assuages one of the worst worries of citizens and will earn the thanks of the nation, both those in need of care at present and all of us who may need it in future.
As for the argument that says that times are hard and this is not the time to enter into major extra commitments, I remind your Lordships that the Beveridge report of 70 years ago was published and accepted in the middle of a world war, yet our forebears had no problem with the vision and commitment to take on those far-reaching changes even though the country was, in the words of one noble Lord in this House this week, absolutely skint. We are not skint. We live in a time of relative peace and prosperity. Should we not be prepared to follow in the footsteps of those courageous forebears? I beg to move.
Baroness Gardner of Parkes
My Lords, I am one of those old hands to whom the noble Baroness, Lady Pitkeathley, referred in her speech. No one knows more on this subject than she does and I pay tribute to the great work that she has always done. However, there is nothing new in this problem. It has grown hugely but there is nothing new about it. I was chairman of social services on a London council in the 1970s under the then Wilson Government. We were terribly short of money and had to choose between providing social care or saving the buildings in which we were doing it. We did not have the money for both. These extremely difficult choices have always had to be made.
Like the noble Baroness, Lady Pitkeathley, I am very disappointed that, one year on, we still have not had a real response to the Dilnot report. However, as she said, everything is stretched. The linkage between housing, health and care has always been terribly important. There is nothing new in that. I would be sorry to see unacceptable standards become the norm, as the noble Baroness fears, but we have reached the point where there is simply no money. Local authorities have done everything they can to reduce their expenditure. They have put a lot of the care out to agencies because that saves hugely on management costs and staff costs and they believe that that is more effective. I am not so sure of that. I met a woman who was going to take on a caring job and found that she had to see eight different clients a day at eight different venues, each one supposedly for an hour. However, in that hour she had to do everything for that client. As has been said, 15 minutes is more the norm—someone runs in, makes a cup of tea, gives the client a bath or dresses them and then is gone. If they are doing breakfast for people, those people are getting their breakfast at all times of the day because the same person is running from house to house.
The woman who applied to the local authority agency found that she would have been paid nothing for her travelling time between jobs, which could be half an hour or more. She would have had to locate each address herself and then go to it. The whole thing was not on. This is a very genuine and loving Latin American woman. I came across her through an immigration issue. She has been here for many years. She works for 48 hours non-stop, day and night, for an elderly lady. She lives with her, looks after her, gets up in the middle of the night and does everything. She does this on a self-employed basis. I have raised this matter before in the House. If you are self-employed, there is no talk of a working wage or even a minimum wage. There is no wage protection for carers who are self-employed. The family of the lady with dementia pays her £100 for two days and two nights—48 hours. That is £2-something an hour. How can we expect people to work for that sort of money?
We rely on people working. In the past you could rely on family because people lived near to one another. In my GLC days you could exchange your social housing and move nearer those who could care for you. None of that—or very little—is available now. Most people are lucky to have a roof over their heads at all. It has reached the point where local authorities have combined forces so that several boroughs can work together to reduce costs and spread the load. These things are not easy now. People are reaching the limit of their resilience. They have made efforts again and again. We keep trying and we make a little progress, and then we find that the demands are growing all the time. The huge growth in the number of elderly people who survive is perhaps something that no one could have foreseen. Perhaps it is a reflection of how successful our health service and way of life are. The basic issue is money.
I went—I think it was yesterday but I lose track of time—to a meeting on the future of nursing. Everyone talked about the need for more time for each nurse to do her job. We read press reports on this. Nothing could have been reported more than the issue we are debating. I have picked out three headlines. The first is very emotive and states:
“Hungry, sick, neglected: the care home scandal”.
The next one states:
“Urgent action needed to tackle care failings that lead to horrific abuse”.
These things are absolutely vital. Care inspections are very important, but will be effective only if they are unannounced and unexpected. If you have told people that you are coming, you will not get the true picture at all. Today, I read in the paper:
“Cruelty had been ‘normalised’ in parts of the NHS, the Health Secretary declared yesterday”.
It may be that that emotive word had been picked out, but what is happening in most cases is not deliberate cruelty. In many cases people are giving a marvellous service. However, the cases that all the press sensation is about are ones where staff are failing.
I was in hospital two or three years ago. I was put in a ward full of elderly people. All night the woman in the bed next to me said, “Help, help, help”—non-stop, for the whole night. Of course the nurse responding to that had become case hardened, because she had heard the woman saying “help” not just the night I was there but probably every day and night of the week. People are amazingly patient and good, but it is an impossible task. Everyone knows that it comes down to the need for more money—but where are we going to find it? The medical set-up is also in a state of chaos while staff adjust to all the changes. It is extremely difficult.
We want to see social care of good, reliable quality. We want to see specialist hospital facilities used only where there is a real benefit from them. We do not want people to be occupying hospital beds that could be used by acute care cases when another type of accommodation might be better. It is alarming for people. They know that they do not have the money to pay for things themselves. But the changes in family patterns—the geographical thing—are very worrying.
Expectation is another big problem. We have all raised expectations to a point where we expect everything to be perfect all the time, but no one has the money for that. This is an extremely complicated issue that we have to be very aware of, and today’s debate must help to increase awareness and show all the various aspects of it. There is no simple solution. I wish there was. It is going to take a lot of time and effort and we will still be relying to a very large extent on volunteers, which the noble Baroness, Lady Pitkeathley, knows so much about.
Baroness Barker
My Lords, I, too, am one of the usual suspects. I thank the noble Baroness, Lady Pitkeathley, for bringing us back to this subject.
I will start by pointing out the contrast between today and a year ago. A year ago, we were inundated with messages about what people thought about the Health and Social Care Act and their fears for the NHS. Now, when we are talking about social care, which probably has a bigger impact on more people, we have received almost nothing. I know that over recent weeks a number of noble Lords have attended a lot of very good briefings and meetings with some of the more noted social care policy bodies—but apart from that, nothing. That is very telling. The future well-being of many of our citizens relies on the extent to which the NHS engages with, understands and promotes social care, so that fewer people end up going to hospital and those who do quickly return to the place where most healthcare will happen in future—their own homes. That is the debate that we should be having with people in the NHS, and we are not.
It is understandable that people talk in apocalyptic terms about social care. The Barnet graph of doom says it all. I have to say that the LGA laid it on by doing exactly what I would have done in those circumstances, which is to pick the very worst case.
The key issues in social care arise because of the successes of the NHS. The NHS was designed for and spectacularly successful at organising acute care for treatable conditions. As a result, the majority of people now live with long-term care conditions, but we still have a health service based on that old model. We need to work out ways in which the NHS and local authorities together can buy packages of health and social care that enable people to go along a health and care pathway. At the moment most people’s experience of health or social care is that a part of it may work fantastically well but it is not related to any other parts of the pathway of their lives. That experience and the economic models that underlie it are the key things that we have to turn our attention to.
I want to say a little bit about personalisation, a subject that I talk about quite a lot, as the noble Earl, Lord Howe, will know. It is the chosen method of the previous Government and this Government for addressing some of the many deficiencies in social care. I think that the noble Baroness, Lady Campbell of Surbiton, will be delighted when I say that the big problem with personalisation is that it has been taken by many people in its most basic and crude form to mean a direct payment and a list of providers. It is about much more than that. It is about more than disaggregating existing services and giving people money to purchase them. It is about finding new ways to enable people to have the power to shape the services they need. The Housing Learning and Improvement Network is currently engaged in working on some very interesting different forms of collectivisation of personal payments, enabling people, for example, to combine in buying a core housing service and then buying different personal services to turn what was previously residential care into assisted living. That is the sort of work which local authorities and, in future, the NHS need to support so that we can ensure that more older people remain in assisted living for longer, rather than ending up in hospital and acute care.
We have a plethora of examples of how community care can be improved and work very well in preventing people needing higher levels of care. All the usual suspects will recognise Dorset POPP, North East Lincolnshire Care Trust Plus and Southwark Circle—all of them packed with evidence about how older people can thrive in supported settings. However, to the best of my knowledge none of them has a model of economic sustainability. My key question for the Minister is whether, in this coming year—with the potential of health and well-being boards and the potential which arises from some of the changes in the NHS radically to alter the way in which services are commissioned, designed and provided—the Government will continue to work on developing economic models which can show us whether those small localised examples can be either scaled up or replicated in different parts of the country.
We are in danger of missing the point that the creation of health and well-being boards gives us the potential to do what is brought out in the subject of this debate—to create communities in places where older people want to be. They want to be at home; they do not want to be in hospital. It is for the Government to provide these new bodies with research, which so far has been lacking, into the efficacy of social care compared with acute treatment to enable the joint pathways of care that I talked about earlier not only to be real in terms of the services that they give older people but to be viable models in which the NHS feels it can safely invest, as opposed to investing, as it has done, in acute care.
In my remaining final minute, I want to say that so far we have achieved something quite remarkable—a consensus on Andrew Dilnot’s report. I hope that that consensus continues because, whatever one may think of its deficiencies, it is the only game in town. It is important that a form of Dilnot comes about soon and that it should be a compulsory and not a voluntary scheme. If that does not happen, we will never get the economic basis on which to build the new future of health and social care to which we aspire.
Baroness Campbell of Surbiton
My Lords, I, too, am very grateful to the noble Baroness, Lady Pitkeathley, for securing this debate. We have worked together for many, many years, and I am afraid that I am another usual suspect.
The integration of social care is a complex nut to crack. I am sure that Ministers with responsibility for health, both acute and primary, local government, housing, and work and pensions will also wish to pay attention to what is said here today. Together, they are responsible for the solution.
There is widespread agreement that care and support services are underfunded. The distinguished economist Andrew Dilnot, expertly advised by the noble Lord, Lord Warner, said as much in his report on how to fund the future of social care. There is not enough money in the system and we all know it. It is not just that the growth in demand for support has not been matched by a growth in resources; it is also clear that the needs and circumstances, and the aspirations, of disabled people, old and young, are increasingly complex. I am far from alone in your Lordships’ House in speaking from personal experience on these matters.
Budget restrictions are causing local authorities to make terrible decisions. Would any of your Lordships wish to tell a severely disabled lady that she cannot have help to go to the toilet at night and that she must wear incontinence pads even though she is not incontinent? Would you wish your names to be on a letter telling a frail, elderly couple that charges for their home care are to be increased by 30% when they cannot even pay their heating bill? These things are happening now and every day.
Yet, around the country some local authorities and their NHS partners are tackling these pressures with more constructiveness, co-operation and creativity than others. The Social Care Institute for Excellence, of which I had the privilege to be the founding chair, is looking at such examples through the eyes of service users. I applaud this approach. Service users are genuine experts by experience. For some local authorities the funding challenges have been a catalyst for new ways of working. They have encouraged the statutory authorities to work in partnership with people and their families; to listen to what they want to achieve and how they want to live their lives; and to work out the best way of supporting them to stay independent. Some councils are using a whole range of resources to come up with really innovative solutions tailored to individual circumstances. They have rediscovered the value of putting people—not services or resources—at the centre of decision-making. This is music to my ears. It reassures me that many in charge of care and support will not simply take the easy and destructive option of cutting services in a sheep-like fashion.
I was deeply troubled when I heard of a local authority, Worcestershire, announcing a blanket policy of cuts, including capping non-residential care costs to a level equivalent to the residential care rate. I knew that it would not be long before yet another authority followed suit, and I was right. At least three other local authorities are now proposing the same policy. There is nothing creative or collaborative about this approach. Such a policy has the potential to overturn three decades of building an independent living culture for those with the highest support needs. Surely we do not want to go back to the 1970s when disabled people and those with long-term medical conditions were invisible in society—patients or residents but not people, expected to live out their days in a hospital or nursing home, or trapped at home in the back bedroom. Denial of independent living is a breach of the UN Convention on the Rights of Persons with Disabilities.
I would like to remind your Lordships of the late Baroness Lane-Fox. She was a remarkable disabled Peer with a much larger electric wheelchair than mine. She championed the cause of patients living in iron lungs at Guy’s Hospital during the 1970s and early 1980s. She brokered an initiative between government, healthcare, social care and housing to get them living in the community. These victims of polio were under the care of Dr Geoffrey Spencer, a visionary physician who placed nothing in the “too difficult” tray. I do not know whether any of your Lordships have ever seen an iron lung. It is like a seven-foot cylindrical missile on wheels—a challenge for an integrated team in the 21st century, let alone one in 1981 when Felicity Lane-Fox joined the Conservative Benches and captured the imagination and support of this House and the other place, and got money where there was no money to pay for it. In those days, as I said earlier, there was no budget line. We were really, really strapped for cash. There were no complex-needs commissioning boards and no integrated housing or social service practice guidance, just a shared belief that these patients should enjoy the same human rights as the rest of society and should be prioritised. Government money for their care in hospital was creatively redirected and renamed as “health research”. Occupational therapists and clinicians worked with local authorities as one team. Together, they liberated these reluctant bed-blockers, who became known as “responauts”—a remarkable achievement.
Now fast-forward 30 years to 2011. The JCHR conducted an inquiry into disabled people’s right to independent living. We heard from witnesses about situations not so different from those of the hospital-bound responauts. It struck me how easy it has been over the past few years of austerity to slip back to a time when young and old people with significant support needs were second-class citizens, denied their human and civil rights. It is a travesty that lessons learnt from an emerging human rights approach to the funding and delivery of care and support in this country have been so easily cast aside in the name of austerity.
At the launch of the JCHR report, I found myself making pleas not dissimilar to those made by Baroness Lane-Fox 30 years ago—this time for a young Asian man with Duchenne muscular dystrophy, stuck in the same respiratory unit as the 1979 responauts. He was there for four months longer than was necessary, surrounded by critically ill patients, reminding him daily of his recent trauma. The reason was not financial. The cost to the state was more than £900 per day, as opposed to a maximum of £400 in the community. No, the reason was that the local authority social care services had no budget compared to their health services partner. The result was the usual “who pays?” war, preventing a joined-up approach. This caused the inability of both to put the young man and his family at the centre of planning. His well established independent living arrangements were torn apart by the long unnecessary stay in hospital. He lost opportunities to work and further his career, and his overall well-being suffered inextricably. He paid a high personal cost and much-needed public money was wasted.
The JCHR made many recommendations in its Article 19 inquiry report last year—recommendations that will help the Government to regain their international reputation for delivering a human rights approach to care and support in this country. They challenge us all to understand, and action, the true meaning of mutually supportive systems, spending and consuming.
In conclusion—I know I am running out of time—I would be grateful if the Minister would tell your Lordships about the current status of the Government’s plans to address the conclusions and recommendations in the JCHR report. To date, it simply has not been good enough
Among the concerns of witnesses at that inquiry was, of course, the closure of the independent living fund. Will the Minister explain how the Government will ensure that money currently safeguarded through the mechanism of the Independent Living Fund will continue to be used only for modern independent living purposes? Will he again reconsider ring-fencing that money?
Please, do not let this be another debate where we share human rights stories. The UN Convention on the Rights of Persons with Disabilities embodies 21st-century ideals of what public support services should be striving towards. Rather than allow the backward slide to accelerate, let us begin by taking Dilnot off the shelf and working together to fix social care.
The Lord Bishop of Liverpool
My Lords, I begin by declaring that I am not one of the usual suspects in this debate and I hope that the noble Baroness, Lady Pitkeathley, and others will forgive me, as a novice, speaking. I defer, of course, to her experience and expertise and that of other noble Baronesses who have spoken, especially the noble Baroness, Lady Campbell. On behalf of the communities in Liverpool, I thank the noble Baroness for this debate and for the opportunity to consider the impact of the reduced local authority budgets on the welfare of the people of Merseyside, and to localise the debate in that way, if possible.
I do not deny the need to be financially prudent or the need to live within our means. I also understand how difficult it is for the Government to be pressed persistently to fund all the demands on the public purse. The question I want to press in the debate is not whether there should be cuts to the budget but, rather, how assured the Government are that the financial settlement across the nation is fair. In his response to the debate, I would like to hear the Minister say that he is prepared to review the local authority settlement in terms of the provision for social care.
The city of Liverpool is expected to reduce its spending by 52% over the next four years. This cut is more draconian than elsewhere and leaves us asking why the north-west seems to be targeted more severely than, say, places such as London, Bournemouth or Brighton. For people to be able to accept such drastic measures there has to be a sense of fairness across the country. I hesitate to paint the picture of need in Liverpool for fear of giving the wrong impression of the city and of the region. The truth is that Liverpool is a thriving European city, with a vibrant cultural life, three universities and an enterprising business community. The elected mayor is pragmatic politically, seeking every opportunity to gain investment in the city.
However, alongside this cultural and economic renaissance, there are areas of consolidated poverty that demand intervention. We have the highest percentage of people with a history of substance abuse and some of the highest rates of unemployment, cancer and teenage pregnancy. That is why there is genuine fear in the city over the impact of 25% cuts in adult social care over the next four years and 25% cuts in children’s services.
The council knows that throwing money at these problems is not the solution, which is why it is already working in partnerships to maximise the value of the money already invested, and economies are certainly being made through better co-ordination and management. However, save as it tries, there remains an axe hanging over the head of the support services—the home visits and support for the elderly and the mentally ill. If these go under the axe, it will only put more pressure on the front-line services, as we have already heard. To support someone in their own home costs Liverpool City Council up to £250 per week. If you cut these services and the patient ends up in a nursing home, the cost goes from £250 to £550 per week. I would be glad if the Minister could tell us how the Government view this problem and whether they are prepared to be more creative and flexible, channelling between the different silos of policy and funding to avoid the social disaster that might follow. It is demoralising for the city council to analyse the statistics across the country and discover that, far from there being a level playing field, there are staggeringly steep differences in funding across the nation, which makes the pain of applying these cuts even more severe.
I have refrained from anecdotes, although I could give noble Lords many of them. In fact, the cuts and the anecdotes are much greater and more numerous than people are already testifying to, because once these 52% cuts have really kicked in there will be dramatic stories of people who are not cared for in their own homes and further afield. Will the Minister please review the settlement and give us an assurance that these cuts are fair across the country?
Baroness Wheatcroft
My Lords, I should like to add my thanks to the noble Baroness, Lady Pitkeathley, for securing this important debate and for her eloquent speech which showed how well she knows this important sector and the issues it faces. She also made an eloquent plea, as have others, for more money. But money is not the only answer to this problem, and that is just as well because, as we know, we are living in a time of austerity and the money to do everything we would like to do simply is not there. We have to look for more creative and collaborative solutions, as the noble Baroness, Lady Campbell, has just said. We have to look for more integration and the greater use of computer technology. We have to be inventive.
There are productivity gains to be had. A recent report from the King’s Fund pointed to the fact that there is a great search for cuts as an end in itself rather than a search for the productivity gains that could deliver cuts in spending. A recent report from the Policy Exchange, of which I am delighted to be a trustee, sets out the following sentiment:
“If we could provide integrated care bringing together primary, community, acute and social care we could provide better care for the frail elderly and save a great deal of money”.
That statement was made by David Prior, the chairman of the Norfolk and Norwich University Hospital NHS Foundation Trust—and he was talking only about integration within the NHS itself. Here we are talking about the need for integration across the NHS, social services and housing, but none of that can be done until the NHS itself manages to bring down some of the extraordinary barriers it has put up between the various parts of its own organisation. The NHS could and should be a much more integrated and efficient organisation. Experiments are being carried out in parts of the country, but nowhere near enough is being done on that front. Even the Local Government Association accepts the need for reform and that money alone will not be enough to solve the problems we now face in this area.
The state cannot do it all. Although we have already heard some appalling stories of people who are really suffering, I would maintain that that is not just because of the cuts; they are suffering because of some very severe breakdowns in our society. Those who have seen the Times today will have noted the headline on the front page about the number of people in our country who will spend Christmas alone this year—some 250,000. The Times quotes a survey which has found that one in 10 of those aged over 75 confesses to being intensely lonely all of the time. Loneliness is not just a misery in itself; it is a cause of ill health. It drives people to see their doctors. It is something that we all need to address together. Family breakdown has caused severe agony in this country. We have to look for creative solutions to help those who are growing old not to feel lonely and end up seeking medical help. They need to be integrated into communities and not to live in single-person households, as so many do, unless that is what they really want. We should be able to offer more constructive, healthy and enjoyable alternatives. While they are still fit and well, we need to get people to move into communities where they will have the sort of wonderful life that we in this House enjoy. It actually encourages life expectancy far beyond the norm. People need to be in groups. If they were living in groups, the state could provide at much less expense the sort of 24-hour care that will eventually be required.
We have heard about people who have had to give up their jobs to care for elderly members of their families, but they are rarities now. What we need is to make sure that the community as a whole takes on the responsibility of looking after its elderly. There are other constructive ways in which we can do this. Some schemes arrange for younger people with nowhere to live to be paired with elderly people who live in houses with too much space. The relationship benefits both sides. The young person agrees to do a certain amount of work helping around the house and doing the shopping, although just being there is often more than enough. That sort of help can preserve an elderly person’s sanity and keep them fit for many years.
We will hear again today about the need for more money and more spending, but I think that we could spend what we have more effectively, more efficiently and more creatively.
Baroness Donaghy
My Lords, I am extremely grateful to my noble friend Lady Pitkeathley for her perseverance in this important area. Those of us who sat through the debates on the Local Government Finance Bill can be in no doubt about the parlous state of local government funding, and the Question asked in the House yesterday about cuts in arts funding in Newcastle brought it home even more how councils are having to set priorities which are assessed on the least harm rather than the most good. I start from the standpoint of being a supporter of local government, but that is not to say that there are no failings in the system, if you can call the state of social care in this country a system. I will concentrate my remarks on care for the elderly and, in particular, those who need nursing care as opposed to residential care.
A growing number of frail elderly people are living alone when it is no longer safe for them to do so. The care they receive, if they receive it, is often totally inadequate for their needs. This is not new, as the noble Baroness, Lady Barker, pointed out, it is just getting worse. Let us look at the demographics. Last year, 720,000 people reached the age of 65, the largest number ever to do so. They are the cod liver oil generation and they are better nourished than any previous generation. Some continue in paid employment, and a considerable proportion of their number will still be around in 2031 when they reach the age of 85. That is good news, but by then many more will require support in their homes or in residential or nursing care. Moreover, many among those 720,000 people are already caring for elderly relations, as I did a few years ago. They are finding out for the first time in their lives the extent of the financial and administrative hurdles they have to overcome on behalf of their loved one or ones.
Today’s 85 year-olds are not a sufficient political lobby to frighten any Chancellor of the Exchequer into taking action on social care, but the generation that retired last year is a different matter. Their experience as carers and their concern for their own futures will affect the political agenda. By way of a word of advice to my noble friend Lady Pitkeathley, if she moves the same Motion for debate this time next year, she ought to ask the noble Lord, Lord Sassoon or his successor to reply instead of the noble Earl, Lord Howe, because this is a Treasury issue.
We all believe that care is in desperate need of reform, that it is urgent and that cross-party consent is probably the only way we are going to achieve it. Having said that, I first participated in a debate on the urgent need to integrate health and local government services for the elderly in 1973—so the word “urgent” is losing its meaning. It is shocking to learn that social care for older people in England makes up about 1% of total public expenditure in the UK. We know that much of NHS expenditure is also concentrated in this area, to some extent subsidising the failure of social care, the lack of adequate housing and the diminution of the role of extended families. Although the Government have announced new social care funding, rising from £1.18 billion in 2011-12 to £2 billion per year by 2014-15, which of course is welcome, that is in the context of overall cuts and cancelled funding from central government of £3.5 billion.
This area has always been underfunded. Age UK has said that,
“care is not fit for purpose”.
Each year, the level of unmet need has increased as people are excluded from accessing services or have their care packages reduced. In 2009-10, the total hours of support purchased by local authorities for older people fell from 2 million hours to 1.85 million hours. People who are unable to undertake essential personal care tasks find themselves ineligible for support depending on where they live. It is estimated that 800,000 older people with care-related needs receive no support of any kind from public or private sector agencies. This figure is likely to rise to 1 million people by 2020. Those who are poor and have no family support face a grim future.
As the noble Baroness, Lady Wheatcroft, said, although funding is of course very important, we must look to different ways of spending it. We should find out why our elderly are more isolated than elderly people in some other countries in Europe, where specially built communities exist. Perhaps older people in this country cling on to their own— sometimes hopelessly inappropriate—accommodation because it is preferable to going into a home or living with their children. Of course there are purpose-built homes with community facilities now, but we must find ways of ensuring that, once someone has bought a property in such a purpose-built facility, the annual service and maintenance charges do not overtake their budget and reach nightmarish levels. At a time when housing budgets are facing dire shortfalls, it may seem fanciful to demand new forms of housing or to persuade the elderly to move from the suburbs into the city, as they do in Copenhagen, but when times are desperate we need to be at our most imaginative.
Another area that I think deserves independent examination is the administration of the estates of deceased nursing home residents, many of whom have no living family member. I realise it is not something that the CQC can deal with, but I feel that a lot of money is being made by some solicitors, and probably banks, with little oversight. This is an area where local authorities could become entrepreneurial—the salaries of the staff who are employed would be covered several times over and the elderly residents’ interests would be better protected.
We should ask ourselves whether nursing homes, as presently constituted, are the right model for the future. There is no doubt that cuts in local authority funding force authorities to cut the fees they pay to private nursing homes, which forces many to close. After all, local authorities fund about half the places, but shareholder value may well be the decisive factor. Is the comfort and well-being of the patients in nursing homes given more priority than their potential for bed-wetting? I ask these questions because of my own experience. The CQC report is, if anything, an understatement of the real problem. I wish my noble friends Lady Pitkeathley and Lord Warner, and other colleagues, all the best in their endeavours to keep Dilnot alive.
Baroness Tyler of Enfield
My Lords, I add my congratulations to the noble Baroness, Lady Pitkeathley, on being such an excellent and enduring champion in this area. I view the issue of how adult social care is provided to vulnerable elderly people and to those with disabilities as the pre-eminent social issue facing this country.
Integration has been a buzzword around health and care services for a long time. Overcoming the entrenched divisions between health, social care, housing and wider services is indeed a major challenge, particularly with the great financial pressures that we are currently under, which is very much the focus of this debate. It is important that we are realistic about some of the barriers faced, which include cultural barriers as well as those to do with separate funding and planning systems and separate workforce training—I could go on. We probably all agree that making a reality of integrated care is now an absolute imperative.
I talked about the need for realism. Despite what has been described as its optimistic modelling, the LGA’s funding outlook report confronts us with some pretty brutal figures, such as a £16.5 billion shortfall in funding by 2020. Of course these kinds of savings cannot come from efficiency alone. In my view, it will require a fundamental and system-wide reform. I am also clear that more money is needed. The Barnet graph of doom has been very effective in placing a spotlight on the very real dilemmas faced by local authorities; but equally, it must not lead to a complete counsel of despair. Through well co-ordinated services that look to prevention as well as crisis response, it should be possible to make some contribution to the efficiencies needed and certainly to achieve greater cost-effectiveness, for example by reducing emergency admissions or readmissions and by speeding up discharge from hospital to the community. Integrated care can no longer be reserved as somewhere for rhetoric but has to become a reality. How do we actually do that? The most important thing is getting the right financial incentives in the system, both nationally and locally.
The additional money that was announced in the last spending review for social care was welcome. I am well aware that £1 billion of that was redeployed from the NHS. However, the evidence that we have seen so far says that too often that money has to be used to offset budget cuts and to meet changing demographic needs rather than to promote integration. Ultimately, real progress should focus on aligning the whole of the £121 billion currently spent on health and social care around the needs of individuals, particularly by pooling some of the local budgets, and having shared budgets and a much more strategic assessment of the funding needs in the round.
I have talked about joining up statutory services, which I think is key, but I also want to draw the attention of the House today to the value and potential of our voluntary sector in tackling some of the important problems of isolation and loneliness, which have already been referred to by other noble Lords. If you ask older people which local services make the biggest difference to their lives, they point to lunch clubs, keep-fit classes and day centres. It is often through organised group activities that many older people keep active, make friends and stay engaged with the world around them. We know that problems of isolation and loneliness are not just emotional—they have a very real impact on people’s physical and mental health. Research shows that loneliness can increase the risk of heart disease, blood clots and dementia, and that it encourages people to exercise less, drink more and avoid going out. It can also mean that people are more likely to undergo early admission into residential or nursing care. The introduction of a new loneliness measure as part of the adult social care initiative is therefore a very welcome move. But how is this going to be achieved in practice? I would be very grateful if the Minister could explain the thinking in this area.
For many who take part, volunteer-led local services are rare, even unique, opportunities for social interaction in a friendly and supportive environment. By creating networks of people who are looking out for one another, local services can generate vital sources of informal care, with benefits which resonate across the health and social care services. Instead of an older person’s health deteriorating without anyone noticing before a crisis happens, these services can prompt earlier intervention and help prevent problems escalating.
Sadly, these schemes and activities often do not get the support that they need. Alongside the tightened local authority budgets about which we have heard quite a lot today, the emphasis on personalisation is inadvertently taking its toll on some such voluntary sector services. As we have heard today—not least from my noble friend Lady Barker—personalisation is a perfectly good principle and has many benefits, but it has also had some unintended results. Fragmented amounts of money are difficult to tack together and shared approaches can become much harder. So, yes, of course, we must start with the individual, but what that sometimes reveals is the importance of collective and inclusive approaches which benefit both the people involved and the public purse.
These services do not need to cost much. Largely dependent on local volunteers, such initiatives have got by up till now mainly on small grants from their local authorities. Age UK, which does so much vital work in this area, recently told me of a discussion with one director of social services whose first instinct had been to withdraw funding from her local daycare services provided by the voluntary sector to help make the books balance, but she then realised, when she looked at it more carefully, just what a cost-effective and crucial access point they offered. Not only did the service enable her to stay in touch with how the older people in her area were doing but it provided a platform for delivering key services.
As I said at the beginning of my speech, as funding is reined in, so the focus shifts to acute needs. Daycare services, under pressure to take on older people with illnesses such as dementia, become less suitable places for older people looking for a lower level care. Of course, it is no criticism of local authorities that, when resources are scarce and they are being reduced to their bare essentials, acute needs become the main focus.
I conclude by returning to the big picture. I chose to make the focus of my remarks today the often undervalued and underfunded contribution of the voluntary sector—it is dear to my heart—but the big picture is critical. As so many other noble Lords have said, there are two key issues for the Government to address: first, the current funding gap for social care and, secondly, the need to implement a long-term, sustainable funding settlement for social care. On the former, without further action on funding, even the basic and too often inadequate social care currently provided will no longer be available from local authority-funded care. On the longer-term issue, there is a wide consensus, which I strongly share, that the Dilnot proposals are the most credible and practical solution. Difficult as it is in the current financial climate, the Government must make a firm commitment in the next spending review to implement Dilnot. The time for talk and deliberation is over; it is now time for action.
Lord Warner
My Lords, I congratulate my noble friend on securing this debate and opening it in her customarily clear, knowledgeable and wise way. I shall not repeat her analysis. I want to talk about the funding crisis. It is pretty clear from the contributions so far that there is a funding crisis in social care in a wider context. I shall touch on Dilnot—here, I declare my interest as a member of the Dilnot commission—but we cannot solve the problems of stabilising social care funding by Dilnot alone.
We are seeing local government in many areas having to concentrate virtually all its discretionary spending on adult social care and child protection, a situation to which the right reverend Prelate drew our attention. This will mean that big cities in particular lose those civic services around arts, leisure and other things which make for a civilised society as their authorities concentrate on social care and child protection. Yet these sacrifices may be insufficient to preserve good-quality, publicly funded social care services. Eligibility criteria will be tightened even further. Quality of care will deteriorate in a labour-intensive sector where the people providing the services have less money to ensure the quality and training of staff. These things are happening now on a considerable scale and the situation will only get worse. Local authorities will continue to chop their payments for publicly funded care.
We will see, and it has already started, private payers taking more of the services because the providers of those services, which are largely no longer public bodies, will have to concentrate their investment and activities on people who pay the true cost of care. Increasingly, that is not those who are in receipt of publicly funded social care.
Nothing stops the remorseless arithmetic of demography. The ageing and longevity of the population base of adult social care inexorably increase demand for care. With more than a third of the adult population having long-term conditions, and often with multiple morbidities, the demands on health and social care services will rise year by year for at least the next two decades. Yet we still pretend that the core business of the NHS is acute hospital treatment, when it is now community-based care involving care pathways that embrace health and social care and often housing and financial support. Yet our funding is in separate silos, with strong incentives to cost-shunt and to protect hospital budgets.
We have to begin treating the Department of Health budget as a single budget to be spent in the most cost-effective way for people’s care needs. We need to reimagine the whole system as a care system with a medical treatment adjunct rather than as a hospital treatment system with a care adjunct. We need money flows and payment systems that reinforce that new approach, rather than one that incentivises and reinforces episodes of care in acute hospitals and diverts money from overstretched community-based care. This means radically changing political and public attitudes to hospitals so that we can reduce the excessive number of 24/7 acute hospitals trying to provide a full range of medical specialties and concentrate specialist services on fewer sites. Not only would that be more cost-effective but it would be safer in many areas, such as maternity, for the public who receive those services. Money is now locked up and being spent in inappropriate ways in acute hospitals. That money should be extracted and used to boost community health and social care services.
We cannot expect local commissioners to produce these changes without national leadership. I am all in favour of localism, but to expect local commissioners to engineer these big-scale changes is frankly fantasy politics. I would like to see set up an independent, medical-specialty review of 24/7 acute services, led by specialist doctors and possibly under the aegis of the Academy of Medical Royal Colleges. I would ask them to see how these specialist services could be reconfigured on fewer sites, with the objective of safer specialist services that released—let us say—£l0 billion over five years to create a new time-limited care development fund. The fund’s mission would be the joint development by local authorities, clinical commissioning groups and health and well-being boards of more community-based care services. It is not a fantasy idea. In the US, Medicare is setting up a $10 billion fund to develop these kinds of community-based services.
Even with such changes, we still need major reform of the funding of social care to make it sustainable in the long term. This is because people have to save more for their old age and use more of their own assets to pay for their care, especially by equity release from housing assets. To do this we have to find a way of implementing some version of the Dilnot recommendations instead of sheltering behind the current fiscal difficulties to not do so.
As my noble friend said, there are ways of funding the relatively modest cost of starting on Dilnot. If we set the Dilnot cap at £50,000 or £60,000 and implemented the commission’s other recommendations, it would cost barely £1 billion a year or less to make that start. We could do this for three years by using underspends on NHS capital rather than repatriating them to the Treasury, and then if necessary find other funding sources including subsidies from the care development fund that I am proposing. There is a lot of money knocking around in government that could actually get Dilnot going in a reasonable way.
We cannot ask the social care world to adapt and find new ways of working without demanding much more from its wealthy relative, the NHS. Without more radical funding reform involving more use of NHS resources for social care, the good intentions of the draft Care and Support Bill will simply remain a wish list with no Santa Claus to deliver it. I hope the Minister—and my own Front Bench both here and in another place—will see these as constructive suggestions for further consideration.
Lord Sutherland of Houndwood
My Lords, I too, thank the noble Baroness, Lady Pitkeathley, for organising what seems to be an annual reunion of those of us who are the usual suspects. I would like to think that after the Minister’s speech the noble Baroness will organise an annual celebration, but perhaps I will hold my breath on that.
My remarks are intended to help establish two main points. First, the lack of central policy in England on the relationship between social care and healthcare is creating huge uncertainties for both providers and clients. Secondly, much of the difficulty already recounted in the debate is to be found in the practicalities of providing unified care services for many of those who need them. These difficulties of both policy and implementation will not be resolved until there is clear leadership at both national and local levels. Alongside this, structures must be created to enable the positive implementation of new policies. I pay tribute to the analysis that the noble Lord, Lord Warner, just gave on this.
What of the uncertainties that I mentioned? The legacy of a decade and more of a failure of leadership to face demographic realities is that it has brought huge uncertainty and consequent misery. The realities have been known for a long time. The demographic changes in society are as plain as plain could be. Whether we think of the developed or the developing world, even China now has begun to take note of the fact that the one child per family policy is building future demographic nightmares. To compare that with something else, the facts of climate change are all too evident this week as much as any. Those facts now have a leadership response from the Government and things are beginning to happen. Perhaps some would like them to happen more quickly but they are beginning.
The realities of demographic change are equally plain if not less contestable. Why does no similar cold shower of reality bring minds and political will to the table of demographic change? I can think of many reasons for that. One is that we always have on our desks the “too hard” basket. It is easy—and has been too easy—to put this set of issues into that basket. I confess that my own “too hard” basket at home contains a series of domestic tasks that I think are too hard but my wife clearly does not. However, if I were a government Minister, I would have a rather different use for that basket. That is what tends to happen.
The second possible reason is that it will cost too much. The issue has been raised of how much is too much when the reality of demographic change, rather than evading it, calls for a change in leadership direction. Reality, not habit and precedent, should dictate priorities in spending. If reality means spending less on this or that to face demographic change, then so be it. That is not a request for an additional or new priority to be added, but rather to reassert and re-examine what our priorities are. Are they still top of the list in view of demographic change?
A third reason given for doing nothing is, “We shall deal with this after the next election”. We have heard that more than once. What we have after the next election is usually a request for a review, report or even a commission. God forbid that that is where we will be in 2015, but we begin to worry that that will be the reality. The burst of enthusiasm that leaders have before elections for this issue tails off into long discussion and prevarication. The Dilnot report is the latest example of this—and, some are beginning to fear, the latest victim.
What are the uncertainties of which I speak? There are uncertainties, for example, for those attempting to make provision for themselves and their family. There are questions that they all ask: “Where do I go?”, “Whom do I ask?”, “How much will it cost?”, “Can I afford it?” and, “Can I insure against future need?”. Those are real questions masking real uncertainties. There is uncertainty for those in the insurance industry, who could surely help us here. They ask: “Are the risks pooled in any way?”, “Is there a cap on liability?” and, “How much will the market bear as a charge for insurance products in this area?”. We tend not to pay too much attention to private providers and the banks which finance them, but they have uncertainty, too: “Should I invest in building new care homes?”, “Should I invest in extending, refurbishing and improving my current stock of care homes?”, “Will local authorities commission places from me?” and, “Will they be able to afford to do so?”. Bankers might reasonably ask: “Should my bank offer loans to any of the above?”. Unless there is investment, there will not be adequate provision for the future. The banks would reasonably ask what the rate of return will be.
Then, of course, there are the uncertainties for those already in the care system: “Will I have to sell my house?”, “What happens if the money runs out?”, “Is my care package portable if I move to be nearer relatives?” and, “Are benefits assessed and commissioned to common standards or is there still a postcode lottery?”. I acknowledge the points made by the right reverend Prelate the Bishop of Liverpool on that. There will be differences and those will become accentuated. Successive Governments have failed to deal with these core uncertainties over at least 15 years. Ironically, the only certainty is the remorseless march of demographic change and yet we do not recognise it for what it is. The system is burst and we must fix it, and fixing it means radical thought and change.
In conclusion, I refer the Government to some recent research sources which point to future action. The King’s Fund has already been mentioned more than once. It commissioned a series of studies recently, including an excellent and balanced study by Raphael Wittenberg and his colleagues from the LSE. These complement work in this area in pointing to the central pathway down which we must travel—a unified system of providing and funding care, initially and most importantly by removing disincentives to combining assessment, commissioning and the provision of care packages. As the noble Lord, Lord Warner, pointed out, the disincentives are there now and we have to get away from that. We all know something of the problem of delayed discharges and unplanned hospital admissions—indeed, of unplanned readmissions. The separation of the budgets for health and social care and restrictions within healthcare budgets between one area and another add to the difficulty rather than contract it.
Lastly, in the University of Edinburgh and the Royal Infirmary, Edinburgh, there is important new research about what happens to those discharged from intensive care units. The researchers reckon that approximately 60% will be readmitted. Many of those readmissions are unplanned. The reason for that—this is an area to which not enough attention has been given—is a lack of coherent and adequate community provision. A re-examination of priorities would show real leadership.
Baroness Wilkins
My Lords, I, too, warmly congratulate my noble friend Lady Pitkeathley on obtaining this debate. Most especially, I applaud her for highlighting the significant role which housing plays in this debate. The impact which the lack of housing—poor, inaccessible and unsafe homes—have on our health and social care is too often ignored. It is rarely even mentioned, but cuts in the housing budget impact significantly on increasing expenditure on health and social care. I thank Sue Adams of Care and Repair England for her advice and help.
The crisis in housing means that, at last, it is moving up the political agenda. The Government have set out plans for a £220 care and support specialised housing fund to encourage providers to develop new accommodation options for older and disabled people. That is very welcome, but it comes in response to a severe housing shortage and a scandalous lack of new homes being built. In the past year, new home starts fell by 9%. Building new homes takes time. In the mean time, the Government’s benefit and housing policies are greatly exacerbating the problem, creating what many people have termed a perfect storm. The benefit cap, the bedroom tax and the removal of permanent tenancies and succession rights will all serve to increase the ill health of those affected and impact particularly severely on disabled and older people, multiplying the pressures on the health and social care services.
In 2006, a PSSRU discussion paper pointed out that, if we do nothing to change the current housing situation, occupied places in care homes and hospitals would need to rise by 151% by 2051. Some estimate long-term care expenditure will rise by around 325% in real terms by 2041. With such a depressing prospect, let us not waste this crisis but seize the opportunity to put effective reforms in place.
The Papworth Trust published a timely report this month based on a survey of 640 disabled and older people. It clearly demonstrates the cost to our health and social care budgets of not addressing the problems with housing. The trust’s research found that almost one in four people could not get around their home safely and two in five said that the design of their home meant that they needed help to do everyday things, such as cooking—all increasing their dependence on other people and potential costs to the health and social care budgets. The great majority of those people did not require rehousing, with the cost and upheaval that that entails, but the provision of relatively simple adaptations, such as grab rails, more accessible shelves and cupboards or level-access showers.
There is ample evidence that spending on those relatively simple adaptations to people’s homes can produce major savings to the health and social care budgets. A study published this year by the London School of Economics suggests that the annual spend of about £270 million on disabled facilities grants is worth up to £560 million in health and social care savings and quality-of-life gains. In other words, for every pound spent on DFGs, two pounds is saved on health and social care costs. A fractured hip can cost the state an estimated £28,000, so £30 on a grab rail is quite good value for money. Falls by older people cost more than £1 billion a year in the UK. The Welsh Government have estimated that a programme to help older people to remain living independently in their own homes has saved the NHS and social care budgets more than £101 million since it was set up 10 years ago.
Local authorities administer the home adaptation services, so cuts to local authority budgets are impacting on an already inadequate, overstretched and underfunded service. The service consists of two main elements: disabled facilities grants, which provided finance; and home improvement agencies, providing help and advice. For many years, there have been calls to strengthen the system and address its many problems.
A survey of English local authorities published in August this year by the Labour Party through freedom of information requests found that 17% fewer grant applications were approved in the past two years. That means that an estimated 10,700 fewer people received funding for home adaptations in 2011-12 than in 2009-10. Over the past two years, there has been a 31% increase in the number of delayed discharges from hospitals due to lack of appropriate home adaptations. That is costing the NHS £985,000 a month.
Despite a welcome extra £20 million provided by the Government for DFGs in January 2011, the money is not ring-fenced, with the result that some local authorities have used the extra funding to reduce their contribution rather than to fund extra work. The trust’s report of October this year found that, of the 326 local authorities which receive DFG funding from the Government, 62 have stopped providing Home Improvement Agency services altogether. That figure has doubled since June 2010.
The Papworth report recommends a radical overhaul of the DFG system. It sees it as wrong that responsibility for home adaptation lies solely with district councils, and proposes that local government and health money is pooled together in a DFG pot to be administered by the new health and well-being boards and clinical commissioning groups.
Finally, anyone who heard yesterday the devastating account of the research done into the situation of spinal-cord injured people in care homes, recently published by ASPIRE, could not fail to acknowledge the crucial role which housing plays in reducing the health and social care budgets. Following successful rehabilitation in a spinal injuries centre, the scandalous lack of accessible housing results in 20% of those patients being discharged by their local authorities into an elderly care home, with an average stay of two years. Twenty-five per cent of those people had tried to kill themselves. ASPIRE has made repeated requests to meet the housing Minister, with no success to date. I ask the noble Earl to do all he can to facilitate that meeting.
In conclusion, there is no denying that we are in a crisis, but let us not waste the opportunity that this crisis offers to make sure that we put in place the essential reforms needed, just as Beveridge did in the Second World War.
Lord Shipley
My Lords, I thank the noble Baroness, Lady Pitkeathley, for initiating this debate and declare my interest as a vice-president of the Local Government Association. My contribution will amount to a plea for urgent clarity in the future funding of adult social care. Time is short, given the enormous pressures on local authority budgets, where the cuts in central government grant amount to 28% overall in the four years up to 2014-15 but which in their implementation have impacted most heavily on the poorer parts of the country, where demand for publicly funded social care can be very high.
It has been generally agreed for some time that social care reform is essential. From the perspective of elderly people, local government, central government, the NHS, the voluntary sector and care providers, clear policy decisions are necessary to enable planning to take place and responsibilities to be agreed that will stand the test of time. Without that clarity, councils risk running out of money. That is a very serious matter, so I hope that the reports published yesterday that work is concluding on the recommendations of the Dilnot report prove to be true.
However, this is not just about Dilnot. There is a financial vacuum which needs to be overcome, of course, but it is not just about affordability. Government policy needs to be agreed as a crucial building block for allocating financial responsibilities. Policy-making affects individuals needing support; councils trying to cope with rising demand and reducing budgets; central government trying to cope with having less money to distribute; voluntary groups trying to plan and deliver services; the NHS trying to control its costs; and care home providers trying to maintain both capacity and standards of care.
From the perspective of local government, by 2019-20 there will be a funding gap of £16.5 billion—or 29%—between the revenue available and the spending pressures forecast. Assuming that social care is funded as now and that other essential statutory requirements are met by councils, there will be cuts of two-thirds in cash terms to all local government services other than social care. If concessionary fares are also fully funded and capital financing charges are met, 90% of current spending on other services will disappear. I believe this to be simply undeliverable for those other services include leisure, libraries and transport, all of which play a major role in the lives of elderly people and their health and well-being.
From the perspective of central government, net public spending on social care and continuing healthcare for older people will rise from £9 billion in 2010 to £13 billion in the early 2020s if current demand and spending assumptions apply—a rise of a little under 50%. There is actually a current funding gap, which has in practice been papered over through temporary financial solutions. The imperative of a long-term solution commanding all-party support has become overwhelming. Dilnot has been estimated to cost £2 billion. Current suggestions are that the cost will prove to be higher and require a higher cap. All this tells us that there is a very serious financial problem. I hope that the Minister will be able to say a little more about how the Government plan to address this funding problem and, in particular, what might be done in the very short term given that the focus of cuts is at the moment being applied to the poorer parts of the country.
We should remember that older people are a massive asset to their communities. They may become recipients of care but they are for many years essential providers of help and support to neighbours, families and friends, saving substantial sums of public money through their voluntary action. Implementing Dilnot would give many of them, and their families, peace of mind and confidence in their financial planning. It would also give the Government greater certainty about how to manage a 60% forecast growth in the number of over-75s within the next 20 years.
Perhaps I may draw your Lordships’ attention to the perspective of care home providers. Providers are claiming that there is now a funding gap of approaching £1 billion between the cost of providing quality care and the amounts paid to them by councils. Indeed, it is claimed that the average residential care home fee paid by councils does not meet the essential standards of the Care Quality Commission. If this is true, there needs to be an urgent review of why and what can be done because one of the consequences of inaction is a risk of more hospitalisations. We should note that fewer older people are now getting care, with a reduction from 1.2 million to 1.06 million in the past three years, which in itself may increase the numbers entering hospital directly. Yet we know that investment in prevention and in the voluntary sector saves money for the NHS. We also know that delayed transfers from hospitals are estimated to cost the NHS £200 million a year, which pooled budgeting might reduce.
While the Caring for our Future White Paper is in principle welcome, unless answers to Dilnot and related funding problems are given speedily there is a danger that councils will cut spending on social care, reducing levels of support to “critical only” and reducing fee payments in real terms to providers. Some older people who are not able to afford extra costs might then have to be looked after by the NHS. The long-term costs to the NHS of this could be substantial, which is why we need so urgently an agreed funding system for care.
In conclusion, we spend £121 billion on health and social care. I feel certain that the King’s Fund is right when it says that budgets should be pooled locally, with a single strategic assessment of the funding needs of the NHS and social care. It is vital that health and well-being boards should work well because they will drive the integration of adult care and health, which should in turn generate some efficiency savings to be redirected into service provision. It is vital that spending on prevention gets protected because in the end that is better for the individual but cheaper, too, for the public purse. Above all, it is vital that we get clarity in implementing Dilnot as the first step in building a system of adult social care that is sustainable into the future.
Much of this is about the medium to longer term but there is a massive problem now in some parts of the country. Over the past two years, I understand that the NHS has sent back to the Treasury some £3 billion. If that is the case, might the Government return that to health and well-being boards to enable them to find local solutions to their specific funding problems and for those parts of the country suffering the biggest cuts to get further support to reduce their impact?
Lord MacKenzie of Culkein
My Lords, I join in the thanks to my noble friend Lady Pitkeathley for securing this important debate and for her most eloquent speech. This debate is about the ambition to integrate health and social care. I am not, I think, one of the usual suspects because nurses of my generation were not very good on social care. One of the joys of being in this House is that one is always on a learning curve.
The integration of health and social care is a laudable objective and whether it succeeds, as we all hope it will, will depend on a number of important matters. Are NHS trusts, local authorities, clinical commissioning groups and health and well-being boards going to work well together, or will a new commissioning and marketisation framework, together with the existing barriers, lead to fragmentation and diversification in care services and perhaps disrupt any consensus? Will we get the innovation that we need? That must be the way forward. Or could it be that without proper regulatory guidance and funding, any new social service will end up like the present model—best described as patchy, incomplete and with a lot of staff who are poorly trained and paid, and unregulated. Will there be multiprofessional input into clinical commissioning groups? Will nurses be properly involved in hospital discharge policy and the development of community care?
The elephant in the room is: will there be sufficient money? It is fine to talk about efficiencies but so many so-called efficiencies are, in reality, not showing any demonstrable improvement in care. All too often they are a euphemism for cuts, rather than savings being reinvested into services. There are dark clouds on the horizon. The worst scenario, if I can repeat a phrase used a few minutes ago, is a perfect storm of demographic pressures combined with cuts in central grant support, council tax freezes and NHS organisational change, which could lead to a worsening of social care and further reductions in services, leaving the Government’s aspirations and policy in tatters. A lot of the money from the NHS that is designed to encourage joint working is, in reality, being used to avoid further cuts in services. That is a real concern.
I am also concerned about what might be said to be an auction race to the bottom, with providers appearing to win contracts by bidding at lowest cost rather than on quality. For example, when the Serco conglomerate took over the excellent Suffolk Community Healthcare, it was predicted by UNISON that there would be job losses. That was, I understand, denied. Now Serco, following its usual pattern, has proposed cutting more than one in six posts. That is how one can underbid an already good provider by some £10 million. The combination of financial restriction and the delivery of quality care is, to say the least, extremely difficult.
In domiciliary care, there is much reported worry, and much has been said about it today. I fail to see how we can have dignity, client choice and safeguarding with the present “time and task” system, which is so often the pattern. A recent UNISON survey showed a situation for many care staff which rather reminds me of the low-cost airline model of employment, with staff under pressure and paying for their uniform and training, quick turnarounds and wages varying every week. As the noble Baroness, Lady Gardner of Parkes, said, many of these care staff are not being paid for time travelling between visits and have zero-hours contracts. There is one difference: easyJet would not tolerate for one moment its customers being treated in the way that vulnerable elderly people or people with disabilities are being cared for in short, 15-minute visits. It is not possible in so many domiciliary care settings for there to be proper adherence to safeguarding principles and practice, and much too often the possibility of the client exercising choice is not a realistic proposition.
The situation in many care homes is little better. Nurses I speak to report that there are intolerable staffing pressures with often poorly trained staff. When things go wrong, the staff are made scapegoats when the resources are not being provided and managers and home owners are not held accountable.
The pattern is repeated for nurses working in the community. A recent Royal College of Nursing survey showed that 6% of respondents said they could deliver the quality of care that they wished to, and 75% of community nurses indicated that pressure on the nursing team had increased, leading to considerable concern about their capacity to protect adults and children at risk. Much of this problem emanates from cuts in social care budgets.
Who picks up the pieces? We have already heard today, and UNISON and the RCN remind us, as does the King’s Fund, that it is the National Health Service. Pressures on social care budgets lead to increased emergency admissions and pressures on A&E departments and continue the revolving door, with which we are so familiar, delivering inappropriate care in the wrong setting. That is not good for the National Health Service or for patients who are so often denied, for example, the prospect of good palliative care at the end of life at home or in a hospice.
The health charity sector is also suffering at a time when the need for its contribution has perhaps never been greater. There is no doubt that the Government will be looking to it to pick up more of the pieces as funding from local authorities and NHS commissioning is cut. Smaller charities, in particular, are affected, with the probability that staffing will be reduced or, as in the case of that great charity, Turning Point, that staff will be dismissed to be re-employed on poorer terms and conditions. That is an unenviable choice for dedicated staff and for the charities that do so much to fill gaps in our health and social services.
Social care is a complex subject. There are many areas one could speak on, for example, housing and so on. Others have spoken eloquently on them, so I shall conclude by mentioning the Local Government Association’s “Show Us You Care” campaign. I will not repeat all the details or even the bullet points. The Government know full well what that campaign is about. It is about the current funding problems, the future of social care, fairness and the ability in the future to maintain roads, libraries, swimming pools and so on.
This leads me neatly to the Dilnot commission, which has been much mentioned this afternoon. My noble friend Lord Warner said that it may not solve all the problems, but I think it will go some considerable way and would be a good start. I hope that the Minister can tell us when we will hear about the Government’s proposals following on from that excellent piece of work. There were reports in yesterday’s press that we might hear something in the near future, and it would be wonderful if the Minister could confirm that that is the case.
I again thank my noble friend Lady Pitkeathley, and I look forward to what the Minister will tell us when he winds up.
Lord Lipsey
My Lords, it is said that there are many Members of your Lordships’ House who habitually recite Trollope in their sleep, but I do not think many of them will have read his novel The Fixed Period, and I do not suggest that they do because it is pretty dreadful. It is set on the island of Brittanula where the law says that on reaching the very advanced age of 67—two years less than the age of the average Member of your Lordships’ House—people should be admitted to the college, as it is called, to spend a final year reflecting on their life. Then they are placed in a warm bath amid the smell of incense and their veins are opened so their life flows away. It turns out that this solution to the problems that we are considering today has certain disadvantages—for example, healthy inhabitants in their 66th year frequently try to flee the island—but, and this is the serious point, if we continue as we are in this country, the disadvantages of Brittanula may seem as nothing compared with the disadvantages of continuing life into an old age which, for poor people in particular, is characterised by neglect and degradation on an incomparable scale.
The signs of stress are already there. Fewer councils provide home care services for those with less than substantial needs. There are tales of care homes on the verge of bankruptcy because they cannot afford to provide decent services on the inadequate rates local authorities pay and of 15-minute home visits, which is barely time to change a diaper, let alone to have a chat.
The Government have sought to take some steps to mitigate the worst effects of fiscal stringency, although whether the extra money notionally made available is actually flowing through to services on the ground is another matter. Care services have been cut by less than other services, as the excellent IFS briefing circulated for this debate shows. There has been a cut of 4% in social care, but planning and development has been cut by 43%. However, this is cold comfort, for the plain fact is that we should not be contemplating spending less on care services—that is, if we want to avoid the Trollope solution—but more because the number of older people is growing rapidly. The number of those aged 65 or more will go up by 27% between 2010 and 2022, according to the OPCS. We should be spending more because the number of old people in impaired health at the end of life is increasing. There will be a 32% rise in those with disabilities in that period, according to the PSSRU at the LSE. The old hope that as we lived longer, we would have shorter or the same periods of ill health at the end of our life is unfortunately not necessarily being realised, and more people seem to be lingering on in more difficult states. We should be spending more because the cost of providing care will escalate. You cannot readily increase productivity in care in the way you can in some other walks of life. Just think about it; how do you change a nappy quicker? We should be spending more, increasingly, I am afraid, as the Government’s anti-immigration policies bite, making it harder to attract decent staff.
We are not allowed visual aids in this Chamber, or I should now hold up the notorious Barnet graph of doom, which was referred to by the noble Baroness, Lady Barker. It shows what the council expects to spend on services and, on another line, what it expects to be allowed to spend in total. By 2030, spending on social services alone, the bulk of that on old people, exceeds the total budget. Either no bins will be emptied in Barnet and there will be no libraries or parks—no town hall, even—or there will be further big cuts for old people.
It is important that the more that needs to be spent does not have to be just public money; we know there are restrictions on that. There is private money available, most particularly, the very large sums that increasing numbers of people have locked up in a valuable asset; namely, their house. It is surely right that they contribute from that to the cost of their care and do not just give it to their children, much though they may wish to do so, and as desirable as it often is. Their care should come first. Of course, half the people in care homes at the moment do not have to pay because their wealth and income are too low. There will need to be public money for them.
Where does Dilnot fit into this? We are in danger of confusing Dilnot with the shortage of funds. Dilnot is not aimed at the shortage of funds problem. It is aimed at quite a different problem: the care lottery which means that some people, the better-off people, will not need to spend anything on care because they will live to a hearty age and then die, whereas others will need to find literally hundreds of thousands of pounds to fund their care. That is deeply unfair.
The Dilnot solution has attracted consensus support. I am part of that consensus, but with one proviso. Public spending is limited. The more we spend to implement Dilnot, the less we will have to put in place better care services. We are given a choice, and we have to be careful that it is weighted in favour of decent care services, not in favour of more help for people to pay for them. I favour Dilnot, but on as cheap a basis as possible, with a £75,000 cap the minimum that should be contemplated, as was floated in the White Paper.
Finally, and wearily, I turn to the integration of health and social care. Wearily for this reason: I, we, all of us have been talking about this for years and years. It features in every single report that comes out on the subject, and to say that progress is “patchy” is to take an extremely optimistic view. I am afraid that I do not expect that to change soon. Everybody pays lip service to integrated care, but the brute fact is that, on one side, you have local authority budgets with one set of incentives, including the incentive to pass as much cost as possible to health authorities; and, on the other side, you have health authorities with another set of incentives, including the incentive to pass as much cost as possible to local authorities. While that persists, we will not get very far. Without integrated budgets, you will not get integrated services. It is as simple as that in principle, if extremely hard to put right in practice.
Baroness Scott of Needham Market
My Lords, I thank the noble Baroness, Lady Pitkeathley, for securing today’s debate. Like the right reverend Prelate, I am not one of the usual suspects; I rather share his nervousness about stepping into this. However, as the chair of the England Volunteering Development Council, I want to speak today to talk a little about the role of volunteers and the voluntary sector as they relate to social care.
Of course, people are living longer across all age groups, with much more complex needs, and there is a rightful expectation that they will be cared for. The noble Baroness, Lady Campbell, was quite right to set this in a human rights context. The strain of trying to provide social care and the scale and cost of this provision have been well highlighted in the briefings from the LGA and the NHS. It still begs a response from the Government. While I accept that Dilnot is not the answer to everything, it still represents the best that I have seen in many years. Therefore, I am also looking forward to hearing what the Government might say. I was very taken by the comments of my noble friend Lord Sutherland about the worry and stress on individuals who are concerned about what may face them as they get older.
In medical terms, this is not a crisis but a chronic condition. The situation has been getting worse for many years, as my noble friend Lady Gardner points out; it did not start in May 2010, nor will it end at the end of this Parliament. We therefore have to look at more long-term sustainable solutions, of which I would argue the voluntary sector is a part. That is particularly the case with the growing concern about the quality of care and the isolation and vulnerability of people, either in private care settings, as we heard in the Southern Cross case, in their own homes or even in hospitals, as we saw in the recent reports from the Patients Association and the CQC.
Set against this, there is an important role for volunteers to play in the care of vulnerable people as befrienders and advocates, and in complementing much of the work of the statutory services. I was pleased that my noble friend Lord Shipley made the point that older people are also of huge benefit to society. We must not always couch the “aging population” debate in negative terms.
The genuine integration of social care cannot happen unless there is a real community dimension to it, and that means using volunteers. For example, we need to have a proper look at how care homes can be opened up to the community, with more volunteers going in to offer personalised support, friendship and advocacy, and helping to generate a better quality-of-life experience. No regulator can be on hand all the time, nor can they see everything. Indeed, in my experience, regulators operating within statutory frameworks, subject to legal challenge and so on, often focus on systems and fail to be centred on individuals. As a complement to the work of regulators, volunteers can be around to see that individuals’ interests are foremost.
Volunteers can add enough support to enable someone to stay at home instead of in hospital. It is a much more humane as well as cost-effective approach, a point made well by my noble friend Lady Barker. Indeed, having someone around a little more of the time who can spot problems in earlier stages can reduce the need for later acute visits and hospitalisation. There are some very good case studies in the briefing from the WRVS.
I noted with interest last week the PM’s announcement on dementia, which came the week after an announcement that prisoners on release would be provided with one-to-one support. Both of these initiatives will rely on volunteers to deliver them. I make two points to the Government on this. First, the enthusiasm for volunteering that we saw during the Olympics had a lot to do with involvement in an iconic, one-off event. It is a different proposition to go from that one-off commitment to a weekly commitment to one individual who can have very difficult needs. Secondly, volunteering is not free. The Government have to put money in to recruit volunteers, to sort out the ones who are suitable and to train and organise them. The great lesson that we should learn from the Olympic volunteering programme is that it worked because the money went it to make sure that it worked.
Moving from individual volunteers to voluntary organisations, a piece of work needs to be done, on which I am sure that Volunteering England would be happy to work with the Government, on the placement of volunteers in care homes. I recognise that placing volunteers in a commercial operation is a controversial proposition. We probably need to do some work to develop protocols for that, as I know that Volunteering England already has with the rather tricky question of job substitution.
It is just over 20 years since I went into local government. At the start we always just talked about inputs; it was about how much we were spending. Then we started thinking about the outputs, and then finally we started talking about outcomes. Voluntary organisations by their nature are focused on outcomes; it is what they do. The conundrum now is that, with tight budgets, the focus on outcomes runs the risk of becoming lost. For example, a local charity or social enterprise that uses ex-offenders to deliver a lunch club to older people has multiple benefits, but they are quite hard to monetise. Outcome-based procurement requires commissioners to be much less prescriptive about how something is delivered and just to empower providers to deliver it. Commissioners often look down their noses at these soft outcomes—“Give us hard facts”, they say—but there is nothing soft or woolly about measuring the internal changes that service users experience.
There is a problem with commissioning. Public authorities are not good at seeing the added value that comes, for example, from giving contracts to organisations that use small local suppliers or those that employ long-term unemployed or people with mental health problems. Among local authorities and health authorities, procurement is the sort of area where cutbacks have resulted in fewer staff. They tend to take the rather easy route of offering single, larger contracts that are much less likely to deliver added value. Small to medium voluntary sector organisations and social enterprises do not always have the capacity to join in a lengthy bidding process. Even larger ones like CABs and volunteer centres are having their core funding cut. If you do not have core funding, you do not have an organisation to make robust bids. The social value Bill has been designed to get at some of this, but help is still needed to learn how to value certain things and to assist smaller organisations in the procurement jungle.
We should not still be having this debate; we have been talking about it for years. Therefore, will the Minister say something about how the new commissioning arrangements will work in this regard, and how he sees the voluntary sector interfacing with the health and well-being boards? I genuinely believe that the voluntary, community and social enterprise sectors have a fundamental role to play in securing and facilitating this community involvement and genuine integration of health and social care. However, it needs the Government to think carefully about their policies in a whole range of areas.
Baroness Greengross
My Lords, the reason why we are facing this huge crisis in health and social care is the amazing advance that has been made, mostly in medical care, in controlling a lot of acute conditions that used to kill people. Those people are now able to continue to live and we must celebrate that. However, because we have not changed the systems adequately to cope with that advance, we are in crisis. We should not think of it all negatively, but we should be quicker to change and adapt our systems to cope with what has happened.
Integrating the two funding streams of health and social care seems a huge problem. However, if we take advantage of the localism agenda and the fact that funding from Government is coming down to the clinical commissioning groups and the health and well-being boards at a local level, and if that money can be ring-fenced and secured at that level, the CCGs or the boards can mix the funding and solve that crisis by using it in the best way available to meet the needs of this population. It cannot be difficult to achieve that. Maybe the Minister will tell me whether he thinks that that is nonsense or whether it might be possible; I cannot see why it is not.
We need to get other changes into the system very quickly, including the culture change from a clinically driven focus on acute care to a patient-driven focus on long-term conditions. That is all part of the same change. Because it needs to be managed differently, it is a question of managing it at the different levels—national, regional and local. We must bring more to the forefront of these caring changes. The allied domains of care—housing and welfare benefits, the DLA and attendance allowance—are all part of the changes that have to be incorporated into getting this right.
We must also remember that we are not dealing just with elderly people. As the noble Baroness, Lady Campbell, among others, has reminded us, we are dealing with people with disabilities who now, thankfully, live to a greater age. Their care goes across their life, so we need a pan-age mechanism for treating people on an equal basis. At the moment, that does not happen. Younger people who need long-term care get a breadth of care plans that is not available to older people. Therefore, discrimination is often apparent in the system that we have now.
We have to expand the evidence base for early intervention and really understand the benefits of that. The ILC, with which I work, has done a lot to look at saving money through people going into extra-care housing. It has clearly demonstrated that this saves a huge amount of money because people do not go into much more expensive care in a care home or even in hospital until a much later age. I believe that that is a system change that we can achieve. I hope that the Minister will confirm he feels that this is possible.
We know that by speeding up home adaptations and equipment, we can also help people to stay at home for longer. The city of Hull did something that is purely common sense. It realised that no one would ask for a ramp or a plastic lavatory seat unless they needed it because neither is very decorative in one’s home. It decided that, rather than wait for someone to assess the need and then exchange information, which takes several months, before allocating a ramp or a loo seat to anyone, it would just give them to anyone who asked. Hull has saved a huge amount of money and immediately speeded up the process by doing that. Things can be done.
The goals that the Government have indicated that they want to achieve are achievable if sometimes we just use common sense. We are all determined to speed up the process of what we need to do to make life tolerable for a whole lot of people who at the moment are subject to quite a lot of neglect. There have been many illustrations of that in the speeches made by noble Lords today.
The recent Nuffield Trust report on integrated care for patients and populations gave the Government measures that I hope they will adopt—in fact, I think that they already have. I hope that we will get clear, measurable goals to improve the experience of people; that we will be able to enhance these goals by guaranteeing a certain standard of care for patients with complex needs; and that we, and the Government, will recognise that we are talking about people for whom time is very precious. They do not have that much longer to live, so we have to have timetables that are kept to and we have to understand the complex needs of the population that we are seeking to serve. I hope that the Minister, who I know feels very strongly about these issues, in representing the Government can assure us that he will take into consideration those and the many other points that have been raised today.
Lord Turnberg
My Lords, I, too, thank my noble friend Lady Pitkeathley for introducing this timely debate. She made a remarkably robust case and we have had some excellent, well informed speeches today. I imagine that it is very hard for the Minister not to have got the message, even though I suspect he does not need it. I, too, am struck by the faint ring of familiarity about this debate.
I want to focus on just two aspects: standards of care for the elderly and the mentally ill, and the integration of hospital and community services. Last week, we had two important reports. One was on the prosecution of those responsible for maltreating an elephant and the other from the Care Quality Commission about the poor standards of care for the elderly and mentally ill—and here, this elephant in the room, although rather more devastating, disappeared from the news rather too quickly.
The CQC painted a picture in which, faced with a rising demand from increasing numbers of elderly patients suffering from an often complex mixture of diseases, many nursing homes and some NHS hospitals were failing to meet basic standards of care. Failing to treat patients with the dignity that they need, failing to feed them properly and failing to care for their basic needs was just too common for comfort. Very importantly, it also found that management and staff vacancy rates were very high. As a result, poorly trained staff were rushed and asked to take on tasks for which they were ill equipped. Patients with complex multiple diseases need well trained staff, and these are in short supply.
All this may sound familiar and similar to repeated reports going back at least 15 years. We have had Age Concern’s report in 1997, the Healthcare Commission in 2004, its successor in 2007, and now in 2012, with so far not much change. If we do not do something now, it will just get worse. So is there anything we can do, apart from putting more money in? Of course, we need more money. Incidentally, the noble Lord, Lord Shipley, spoke about the valuable contribution that the elderly make to society. I do not think that we should forget that the elderly—that is, those over 65—who are supposed to be retired contribute to the national Exchequer through taxed income, and that needs examining. Apart from putting more money in, though, we could look again at the need for the proper training and registration of healthcare assistants. It was a grave error that we were unable to persuade the Government to include in the recent Health and Social Care Act a requirement for healthcare assistants to be trained and registered. I hope that the Minister will look again at the proposal to wait three years before we can revisit that decision.
I turn to the need to co-ordinate care between hospital and community, which has been the subject of some discussion this afternoon, and the need for the seamless care that we are supposed to provide. The problem has been well rehearsed, with elderly patients sitting in acute hospital beds when they would be better off at home or in accommodation more suited to their needs. There are many causes, including, of course, the lack of resources in the community that we have heard about, but often it is the result of failures in communication between the hospital and social services—and it is particularly bad at weekends and holidays. No one seems to take responsibility for this liaison, which is so essential, yet we know what to do, and indeed it is being done in many places. We do not have to go to Canada, where they have set up a very effective multidisciplinary team devoted to integrating care; we have excellent examples in Torbay, which is always being cited, where they have a single, merged care trust. Hereford and Devon have different but innovative schemes for integration. It is not only in leafy, affluent parts of the country where they are making a change; great work is going on in Bradford, Wolverhampton and South Birmingham.
So we know what to do, and one wonders why it is not being done everywhere. Partly it is a lack of lack of local leadership, and perhaps a touch of NIH syndrome—“not invented here”—that sets up resistance to change. Equally, though, we have not seen enough pressure and incentives from the centre. We need to use more carrots and sticks, as well as local leadership. Perhaps the emphasis in the new NHS mandate on care of the elderly and mentally ill will give us the push that we desperately need, and yesterday’s speech by the Secretary of State shows that it has moved up the agenda. I reiterate that we need action on many fronts: to encourage integration between hospital and social services; to ensure the better training and recruitment of healthcare assistants; and, as the noble Baroness, Lady Pitkeathley, pleaded, to have more resources for community services.
Baroness Wheeler
My Lords, I, too, thank my noble friend Lady Pitkeathley for securing this debate and for once again giving us the opportunity to place a spotlight on the growing crisis in social care provision and funding as well as on the importance of developing joined-up services between the NHS and local authorities and within and across the range of services that local councils provide. As usual, my noble friend provides us with a clear strategic overview of the situation and of the impact of cuts to NHS and local authority budgets, as well as firmly rooting the debate in the day-to-day realities faced by thousands of people and their carers who are struggling to cope without the support that they need, often for help with basic everyday tasks, such as getting up, washing and eating.
We last debated social care when the Government’s long-awaited White Paper was published in July, setting out key law and system changes in the Care and Support Bill, and the process for pre-legislative scrutiny, on which we are about to embark, but, of course, sadly ducking the issue that needs to be addressed for any new system to be implemented and for it to work; namely, social care funding and Dilnot.
Dilnot was then widely seen to have effectively been kicked into the long grass by the Government’s in principle only decision. Since then we have had a “will they, won’t they” stop/start coalition dance on the funding issue. Over the summer, our hopes were raised by media reports about U-turns, rethinks, and Prime Ministerial determination to implement Dilnot. If you fast forward to this parliamentary Session, however, there is continued confusion, with the reappearance of the unattributed leaks from government sources about the issue not being a priority, and the Health Secretary himself telling the Tory Party conference that the costs were unaffordable, while, ironically, only a few weeks later, stating his ambition to make England,
“the best place in Europe to grow old”.
He was referring to recent welcome initiatives on dementia care, but with an estimated 1 million people likely to be suffering from dementia by 2021, and 600,000 family carers currently caring for people with dementia, surely the only long-term solution for ensuring that we can address their future care and support needs is to reach agreement on social care funding. Otherwise, the current system, or the new system post the Care and Support Bill, just will not be able to cope.
Most recently, we have yesterday’s Daily Telegraph report that the coalition Government are close to agreeing a cap on elderly care, which could form a centrepiece of the coalition’s mid-term re-launch next year. Like other noble Lords, I look forward to the Minister updating us on what is going on. Does he accept that the need for a long-term funding settlement for social care has never been more urgent?
The debate today focuses on the role of local authorities in the provision of social care, housing and other care services, and it is good for us to be considering council funding and responsibilities in this wider care context. Council responsibilities run across social care, adult and children’s, mental health and learning disabilities, disability support, education, housing, welfare, leisure and transport—the services that people needing social care use or interact with. Last week’s debate on services for people with neurological and other long-term health conditions, for example, underlined the complex care pathways across NHS, council and voluntary sector care provision that need to be better integrated, including health and social care with housing and welfare.
Huge responsibility is placed on local councils to provide or jointly fund these vital services, but we have heard from noble Lords how the scale of reductions across council budgets and in social care highlighted by previous speakers are having a major impact. ADASS and LGA estimate that £1.89 billion have been taken off adult social care budgets in the past two years and that there will be a likely overall funding gap of more than £16 billion a year in overall council spending through to 2020.
There is welcome evidence that the funding transferred from the NHS budget to support social care has helped to stimulate joint working, but the reality is that the bulk of this money is being used to offset cuts to services, although to their credit, surveys show that half of the councils in England are seeking to protect adult social care from the most drastic cuts they are having to make. However, Labour’s and other surveys show that this is predominantly being achieved by holding down residential care placements and agency home care hours costs, and we know that this is simply not sustainable. One large independent sector provider has said that the multi-million pound funding shortfall between the true cost of providing quality care that meets CQC standards and the fees paid by local authorities to care home providers has increased by 16% in just 12 months.
References have been made to this year’s survey by Labour, which showed an 11% fall in the past two years of the number of vulnerable, old and disabled people having home care services fully paid for by the local authority. Eight out of 10 councils provide free care only for people with substantial or critical need. It also found that the average charge for an hour of home care had risen over the same period by 10%.
Noble Lords have underlined the impact that local authority budget cuts have on hospitals as social care funding is squeezed. One often underestimated impact is on accident and emergency services, as more people come through because primary care is becoming less accessible and social care is reduced. The system often seems as if it is in danger of falling over.
The Minister has been asked many questions and I look forward to his response. I want to touch on a couple of those questions. On personalisation, with the personal budget deadline of April 2013 fast approaching, we need to assess any potential negative impacts on existing services such as the provision of daycare centres. I welcome the comments of the noble Baroness, Lady Barker, on the need for more economic modelling on new services, and the references of my noble friend Lord Warner to ensuring that money flows to support these new initiatives.
On children’s services, the right reverend Prelate the Bishop of Liverpool referred to a potential 20% of cuts in children’s services there, and the likely impact on the NHS. On residential care, I was struck by the key quality of care test suggested by my noble friend Lady Donaghy: namely, are residents’ comfort and well-being viewed as of less import than the potential for bed-wetting? The noble Baroness, Lady Campbell, summed up integration as a complex nut to crack. I think that we all recognise this. She rightly praised local authorities that have introduced innovation into care support, even while having to make what she called terrible decisions about care provision.
I would like, in the time left, to pick up on the crucial issue of mental health. Labour has pledged to do all it can to support achieving real parity of esteem between mental and physical health, as Ed Miliband made clear in a keynote speech last month to the Royal College of Psychiatrists. He described mental health as,
“the biggest unaddressed health challenge of our age”,
and said that it affects,
“one in six people across Britain”.
Local government is a key player in mental health, in shaping and commissioning services in social and residential care and in local community services such as advocacy, mental health outreach, befriending, drop-in groups and daycare provision, working with the NHS, community and voluntary sector providers.
As the chair of Blackfriars Settlement, a small local multi-service provider in the London Borough of Southwark, I can cite direct experience of how important the local authority role and support is, and how challenging and difficult it is for the voluntary sector to get funding to replace the reductions in funding. The settlement is one of a consortium of council funded voluntary organisations helping to deliver the borough’s mental health strategy. We have traditionally specialised in work with people with severe and enduring mental health problems, many of whom have been in the system for a long time. We are having to work hard to adapt our services to meet the new challenges on the ground. Our previous delivery model has been updated and adapted to provide a service menu for clients with personal budgets, and we are working hard to develop partnerships with local community groups on a number of projects. We have set up, with Big Lottery funding, a small social enterprise called Art to Print which provides employment and training in art and design production for local people with mental health problems, many of whom have never worked before. However, it is tough going and if we do not succeed in keeping these vital services going, our clients will just not have anywhere else to go.
The Centre for Mental Health underlines that social care input into mental health services is vital for recovery, but the information to measure and assess progress is hard to come by from local authorities because of the absence of systematic reporting on mental health spending and service provision at local level. The charity Rethink’s report, Lost in Localism, this year pointed out the difficulties of assessing the proportion of local authority social care spending on mental health, which is currently achievable only through freedom of information requests. Will the Minister outline any plans the Government have to improve data on local authority mental health spending and services which will help measure progress on how parity of esteem can become a reality?
There are significant reductions in parenting programmes’ budgets to support families at high risk, particularly parents who themselves have poor mental health. The British Association of Social Workers has estimated that around 40% of local authorities have removed, or are considering removing, mental health social workers from NHS-led mental health community and crisis teams. Action for Advocacy’s recent survey found that organisations providing advocacy services for vulnerable groups have had their funding cut by an average 36%, mainly by councils.
I was going to refer to a number of other things, but I see that time is running out. Therefore, I shall put two final questions to the Minister. Although the barriers to providing integrated services are well known, mental health has to date been one area where there have been long-standing partnership arrangements between the NHS and local authorities, including secondments and Section 75 agreements delegating functions to NHS trusts. Given this existing good platform, what are the Government doing to promote the continuation of this?
On parity of esteem, the NHS mandate commits the NHS Commissioning Board to deliver the Government’s commitment of at least 15% of adults with relevant mental health disorders having timely access to services with a recovery rate of 50%. What are the timescales, costs and funding sources for this? The Minister assured us that the mandate had been fully costed and could be carried out within these costs. Is 15% good enough?
Like the majority of noble Lords who have spoken in today’s debate, I hope that the Minister’s responses will show us that the Government understand the scale and urgency of the social care crisis and are prepared to take effective action in this Parliament to address it.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)
My Lords, I begin by thanking the noble Baroness, Lady Pitkeathley, for calling this debate and for having introduced it so well. As the contributions today have amply illustrated, this is a subject of vital importance.
Care and support will affect most people in England at some point in their lives. More than 80% of people in their 60s now will need care in their old age. The fact that people are now living longer thanks to medical advances is something that we should all celebrate. The Government see care and support as essential to helping people live lives that are full and independent. Our vision is, first, for timely care that is preventive rather than simply catching people at a point of crisis. Secondly, to pick up a theme so well articulated by my noble friends Lady Wheatcroft and Lady Barker, and the noble Baroness, Lady Campbell, we believe that care is best when centred on the person and their family. This means that it is joined up with the other services that they use—health, housing and in the community. We also recognise that good, integrated care is important for the sustainability of the NHS.
Due to the economic situation, this spending review has been challenging for local government. However, we have been clear that social care must be protected. We moved swiftly to allocate an additional £7.2 billion over the spending review period to protect adult care. Since then we have allocated an additional half a billion pounds. We remain firmly of the view that the funding we have provided is enough to allow authorities to maintain access to services and to provide good-quality care. Independent research from the King’s Fund corroborates this. This does depend on authorities providing care and support in a cost-effective way, which is a principle we insist on for all public spending. The funding we provide assumes that authorities improve cost-effectiveness by 3% each year in this spending review period. This is an ambitious programme of efficiency savings, but one that partners in the care sector, including the LGA and ADASS, agreed was achievable.
The opportunity is there to make savings and improve outcomes for users at the same time: through investing in reablement—to pick up the word “investment” used by the noble Baroness, Lady Pitkeathley—so that people regain their independence following a crisis; through developing integrated crisis services to deliver health and social support quickly; through rolling out telecare, which is proven to move support from clinics and institutions into the home; and minimising back-office administration to focus resources on users. The Government have provided sufficient funding but authorities are responsible for how it is used. This is an important principle. Whitehall cannot dictate what is best for communities; nor do councils want it to. However, this means that we cannot guarantee that all authorities will prioritise social care or deliver it in the same way.
Social care has been protected more than other services. Many areas have increased their spending but, unfortunately, this is not the case everywhere. It is true that expenditure has fallen when seen at a national level. However, this is not the story of cuts that some critics have made out, and there is only limited evidence of impact on services or on users. My noble friend Lady Tyler will be interested to know that ADASS has found that three-quarters of the reductions are from increased cost-effectiveness. That is, councils are making savings by doing things better. They are achieving an average of 5% efficiency, which is 2% higher than we expected. There are exciting successes and my noble friend Lady Tyler referred to some. For example, Dorset has invested £1.6 million to help people regain independence at home after a crisis. It expects to save £3 million a year from providing preventive, integrated care. That is exactly the type of initiative that we want to see.
Councils have broadly maintained eligibility for services. A few have raised eligibility levels from “moderate”, but only to join the overwhelming majority of councils that already set eligibility at “substantial”. No council has raised eligibility higher than this. We have seen a reduction in the number of people receiving state-funded residential and domiciliary care, but this reflects a return on preventive policies such as those mentioned by the noble Baronesses, Lady Wilkins and Lady Greengross, that are helping people stay independent and in their own home.
The noble Baroness, Lady Pitkeathley, referred to integration of services. This theme was taken up by the noble Baroness, Lady Campbell, the noble Lord, Lord Turnberg, and others. When money is tight for local government, as it is for the NHS and the public sector, the most important way that health and social care services can meet this challenge is through better co-operation and more integrated working. I stress this to the right reverend Prelate the Bishop of Liverpool. It is why the SR settlement includes annual transfers from the NHS to be spent within social care. This year the NHS has provided £622 million in funding for social care.
Local authorities must agree with their PCT how the money will be used. From 2013-14, the conversation will take place through health and well-being boards and will involve the CCG, public health and social care. This is a real opportunity for integrated care. The evidence to date is that, precisely as we had hoped, local areas are investing the NHS contribution in reablement services, and are working in partnership with hospitals. There are some excellent examples of this. Some were cited by the noble Lord, Lord Turnberg. I was in Calderdale last week. Calderdale CCG has taken a joint approach with the local authority and other partners to introduce an integrated intermediate-tier service, informed by a consultation with patients, carers and the public. The single point of access was launched about a year ago. Services are delivered by Calderdale Council’s gateway to care. Patients and carers now need to make only one call to get access to a range of support and reablement services.
It is no coincidence that we have placed such emphasis on integration in the mandate to the NHS Commissioning Board and in the NHS outcomes framework. The department is doing a great deal of work in this area with the board, Monitor and the Local Government Association. We will publish a framework next year.
My noble friend Lady Barker asked what the Government would do by way of an economic evaluation of integrated care. We constantly evaluate new initiatives to get the best possible evidence to inform our policies. In addition, we are engaging with academics and partners from across the sector. For example, a number of local authorities are currently piloting a community budgets approach to integration. We are working with, and offering support to, local authorities to evaluate their pilots, and we will continue to look at emerging evidence.
Looking ahead, we are increasing NHS funding for care services over the next two years. By 2014-15 the NHS will provide £900 million in support for local care services. This increase in joint working will benefit health and care, and patients and the public. We have also invested in housing. I completely agreed with the noble Baronesses, Lady Donaghy and Lady Wilkins, that where the elderly choose to live is of real importance to their independence and well-being. In October, the Government announced an extra £300 million of capital funding to encourage providers to develop new accommodation for older people and disabled adults.
The noble Baroness, Lady Greengross, was absolutely right, as she so often is, that this will support people to stay independent for longer by allowing them to receive care in their own home and by reducing the need for them to go into care homes and hospitals. We have announced a national eligibility threshold that from 2015 will ensure consistent access to care and will end the postcode lottery. The measures in the care and support White Paper and accompanying draft Bill will ensure that prevention, personalisation and integration will become the standard. I will refer to those again in a second.
The right reverend Prelate the Bishop of Liverpool urged the Government to review the local authority funding settlement. We will of course review funding in the next spending review period. When we look at the current situation, it is not in fact accurate to say—as was implied by one or two noble Lords—that cuts to central government grants have hit poorer councils hardest. This year’s formula grant reductions are generally smaller for the most deprived areas and larger for the less deprived ones. The data that we have seen do not show that the most deprived areas have seen the greatest reductions in social care spend. The 10 councils with the greatest increases in spending on social care include Knowsley and Rochdale, which are two of the most deprived local authority areas in the country.
The noble Baroness, Lady Pitkeathley, referred to increases in charges. Of course, she knows that charging decisions for community-based services are the responsibility of local authorities, in line with guidance produced by the department. We have no evidence of widespread increases in what authorities charge for services. However, as a general point, I recognise that this has been an extremely challenging settlement for local government. A number of councils are cutting services or tightening eligibility, as I mentioned. Those councils will have to justify their decisions to the communities that they serve. While any change is regrettable, only six local authorities have tightened eligibility criteria this year, compared to 15 last year. Of these, none has tightened beyond the broad average position of “substantial”.
A recent report by Demos and Scope, Coping with the Cuts, suggested that there was no direct correlation between the budget reductions faced by adult social care services and the impact on local people. This demonstrates that if local authorities make appropriate efficiency savings and develop innovative solutions, they can maintain and improve people’s outcomes and access to the services that they need.
A number of noble Lords, including the noble Lord, Lord Warner, in his extremely thoughtful and constructive speech, the noble Baronesses, Lady Wheeler and Lady Pitkeathley, the noble Lord, Lord Sutherland, and my noble friends Lord Shipley and Lady Tyler, referred to the need to address funding reform and to the Dilnot report. We have stated that we agree with the principles of the Dilnot recommendations. However, I hope that I may be forgiven for repeating that funding reform is complex. In the current economic climate, it is right for us to wait until the spending review, when we can consider funding reform alongside other spending priorities. The noble Lord, Lord Lipsey, was right to make that point.
This will give us time to engage with stakeholders on these difficult issues, which we are already doing, to ensure that we have the right information before making a decision, not least on points of detail that affect the cost and practicalities of implementing a cap. This matter is definitely not on the back burner. Solving social care funding remains one of the key priorities of our time. In response to a number of noble Lords, I will say that since the Dilnot report was published the Government have been very clear about the value that they place on political consensus, and about their commitment to cross-party dialogue in pursuit of that objective. Our offer to the Opposition remains on the table. It is of course up to them to decide when and how to work with us on this.
A number of noble Lords, including the noble Lords, Lord MacKenzie and Lord Sutherland, and my noble friends Lady Barker and Lord Shipley referred to the problem of delayed transfers out of hospital. I will say as a general point that no one should have to stay in hospital longer than is necessary. The NHS must work collaboratively and innovatively with local authorities to help improve discharge, reduce delays and improve outcomes for patients. Older people often need particular support after a spell in hospital. That is why we have made available the £300 million in the current year to develop local reablement services and help people settle back into their homes and recover their strength and independence.
My noble friend Lord Shipley rightly mentioned pooled budgets. As I mentioned, in 2012-13 PCTs will also receive a total of £622 million to invest in social care services. That is in addition to funding for reablement services. In the year up to September 2012 the number of patients with delayed transfers was 5% lower than in the previous year. Delays because of social care issues fell by 12% over the same period.
My noble friend Lady Gardner and the noble Lord, Lord MacKenzie, spoke very powerfully about the tendency for care visits to last for about 15 minutes. While local authorities are responsible for the commissioning of services, not the Government, both the Government and ADASS are fully in agreement that 15-minute visits for personal care are absolutely unacceptable. We will bring an end to commissioning practices that undermine people’s dignity and choice, including commissioning care by the minute. We will work with commissioners, care providers, people who use services, carers and the Think Local, Act Personal partnership to end these practices.
My noble friend Lady Gardner also, rightly, pointed out the need for good regulation by the CQC to ensure quality. The CQC can and will take action where it finds residential services that are not meeting essential standards, and this action ranges from requiring improvement plans to restrictions on, or even the closure of, care and nursing homes in extreme cases.
The noble Lord, Lord Turnberg, spoke powerfully about the quality of care, as did the noble Baroness, Lady Campbell, about the importance of dignity and respect. The care and support White Paper sets out our plans. A national minimum eligibility threshold will make access to care more consistent. People will have clear, practical information and advice on the care system and new ways to report poor care. People will have easy access to information to help them narrow down their search for quality care providers. The new quality profiles will bring much needed transparency to the quality of care people can expect from a care provider. More care workers will be trained, including an ambition to double the number of care apprenticeships by 2017—a subject we debated earlier today. Dignity and respect will be at the heart of a new code of conduct and national minimum training standards.
The noble Baroness, Lady Campbell, spoke about the JCHR and human rights. She raised some extremely important issues and I listened with care to what she said. I hope that she will allow me to write to her to update her as to where we are on that subject.
The noble Baroness, Lady Greengross, spoke about the need to encourage preventive services in particular and I quite agree with all that she said on that subject. As part of the shift to a more preventive approach to care and support, the draft care and support Bill includes a duty on local authorities to commission and provide preventive services. Preventing needs from arising, or reducing them where they exist, is a critical part of local authorities’ responsibilities for care and support.
My noble friend Lady Wheatcroft referred to the centrally important phenomenon of social isolation and loneliness among the elderly. I agree that communities should ensure that people are not alone or isolated. Social isolation is a measure that will be covered in the social care outcomes framework. I will write to her with more information about that.
The noble Baroness, Lady Wilkins, spoke about housing and her wish to meet the Minister for Housing, and about the disabled facilities grant. The draft care and support Bill will set out new duties to be placed on local authorities to ensure that adult social care and housing departments work together. This will support adaptations and ensure that services are joined up better with people’s care and support. I hear her concerns about the disabled facilities grant and grants for housing. I will discuss them with my housing colleagues and respond to her in writing.
My noble friend Lady Scott and the noble Baroness, Lady Wheeler, highlighted the importance of voluntary organisations and volunteers in helping to care for our ageing population, including in the field of mental health. Of course, the Government agree that volunteers and charities play a crucial role, which we must support. I will respond with a note containing more detail on this, including how voluntary organisations may contract with health and well-being boards.
My noble friend Lady Barker and the noble Baroness, Lady Wheeler, spoke about personalisation; in particular, personal budgets, which are only part of the personalisation agenda. Again, the draft care and support Bill places personal budgets in law as the default option for adults and carers alike. People will be provided with a clear allocation of resources so that they can control as much of their care and support as they wish. This will ensure that all people in need of care and support benefit from the choice and control that personal budgets can bring, not least those suffering from mental health conditions.
We have supported social care in this spending review and have made additional funding available. We have provided funding in forms that support integrated and preventive care, extra resources from the NHS and extra resources for housing. There is variation in how well councils are coping with tighter funding. However, many councils are rising to the challenge; they are prioritising care, increasing efficiency and maintaining outcomes for their users. It is clear that this is where councils should be focusing and where we expect services to be by 2015.
Baroness Pitkeathley
My Lords, it is a comfort to me that the number of usual suspects swelled gratifyingly for this debate—a sign, perhaps, that we are getting nearer to understanding that this is the pre-eminent social issue of our times, in terms of both the current gap and the need for long-term solutions.
We have had a wide-ranging debate and a powerful set of speeches. There is agreement that there is a crisis—or rather a series of crises, in the short, medium and long term—and suggestions for how to tackle those. We have had ideas and examples focusing on innovation, integration, efficiency, and we have even had ideas about how we can get more money into the system. We also have agreement about the urgency of the need and about the importance of that old chestnut for many of us, integrated care.
The Minister has given us his usual thoughtful response, for which I thank him, and we all know his sincere commitment to finding a solution to the problem of social care, although I find it hard to recognise the picture of local services he paints from the ones presented to me. I shall take pleasure in checking this out with the group of 200 carers whom I am addressing tomorrow at a carers’ rights day. I shall ask them for their opinion of the situation.
I return to my original thought—which others have echoed, including the Minister—that social care should be seen as an investment, as a way of saving money, especially for the NHS. But this needs much more sharing of money and much less silo thinking, and more focus on the consequences of not doing it rather than on the cost of doing it. For example, if we just take Dilnot—and I am grateful for the calls from many Peers for Dilnot to be implemented—we know that the cost of implementation is about £2 billion. It is not the whole solution, as many noble Lords have said, but no one has yet found a better place to start. To set that £2 billion in context, family carers are contributing care worth at least £119 billion a year. If only 10% of them give up because they are too exhausted, stressed and poor to continue, that will cost £12 billion—six times the cost of Dilnot. Can we not afford to make the investment that local authorities, the NHS and, above all, the users and carers deserve?
The issue of social care needs radical thought and change, and leadership at national level. As has been said, the inexorable arithmetic of the demographics means that we cannot ignore it and put it into the “too difficult” box, however tempting that may be. Without tackling the resource issue, things will only get worse. Will we be here again next year, reporting on how the situation has deteriorated further? I sincerely hope not. I thank all noble Lords who have spoken, and beg to move.