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.