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Mr David Ward (Bradford East) (LD)
I was pleased when I heard that you were chairing this debate, Ms Clark, as I know that you have strong views on this issue. Most of us ought to have strong views on it.
In everyday conversation, we tend to use the word “ability” to indicate that we believe that someone has a special talent. We mean that someone has the ability to play the piano or tennis or to speak in public rather well. That is an inaccurate way to use the word, but it can sometimes lead to the false view that a disabled person is seeking special attention. We have heard that for ourselves: “They’re always after something.” Such disparaging remarks are often made. The reality is that that is simply not true. What disabled people seek constantly is not special attention at all—as a good liberal, I would say this, wouldn’t I?—but the basic human right to a normal life.
Of course, that does not mean that people with disabilities cannot ascend the heights and cannot have unbelievable special abilities—we know that all too well, and history is full of countless examples—but the starting place must be the basic human right to access all life’s opportunities, such as work, leisure and family, things that non-disabled people far too often take for granted. As a good left-of-centre liberal, I believe that the state has an important role to play in supporting people, not necessarily through direct state provision but by helping them attain their rights.
I thank the Backbench Business Committee for granting me time for this debate, and I thank the hon. Member for South Derbyshire (Heather Wheeler) for her support, as this debate is co-sponsored. I also congratulate her on the work that she has done on the issue—I am sure that she will refer to it—as the chair of the all-party parliamentary group on local government.
I thank Scope for the great support that I have received so far on this campaign and for the partnership work that we are carrying out in Bradford, where we are preparing at this very moment for the launch of the “Bradford Cares” campaign, part of the wider national Scope campaign “Britain Cares”. The launch will take place next Monday in Bradford, and I am delighted to say that the former Care Minister, the right hon. Member for Sutton and Cheam (Paul Burstow) will be speaking.
To add more power and force to our arguments when bidding to the Backbench Business Committee for this debate, we were rightly asked to justify the time devoted. We were given eligibility criteria, including topicality and importance. As for topicality, we know that social care is the largest remaining area of reform for the coalition Government in this Parliament, and the Care Bill is on its way through the legislative process. The crucial issue of eligibility, to which I will return, is extremely topical, not least for people in Bradford, where the council is one of the few remaining local authorities to use the moderate level of need when assessing support. However, the council is consulting as we speak with a view to moving to assessments of substantial need. That consultation will last until 4 August.
As for importance, we must acknowledge that much of the debate about meeting and funding care needs has focused on the elderly. We understand the reason perfectly, but we must also remember that one third of care users are working-age disabled adults. That one third equates to more than 500,000 people between the ages of 18 and 64. It is a big issue for us as a nation, and the numbers are projected to increase substantially. In addition, working-age adults have considerably different aspirations from the social care system. They are not more important, but they are different and must be clearly understood when developing social policy.
A report called “The other care crisis: Making social care funding work for disabled adults in England” was published in January this year by Scope, the National Autistic Society, Mencap, Leonard Cheshire Disability and Sense. The report highlights the fact that, since 2008, there has been a constant move from moderate to substantial needs as the basis for assessment in local authorities. Since 2008, the number of people using care, at a time when we know need is increasing, has fallen by at least 90,000, or one in six of all people using care. We also know that there is a shortfall of £1.2 billion in the funding required to support social care for working-age disabled adults.
The report states that if social care reforms go ahead as planned, a further 100,000 people or more risk losing vital care and support. I know the Minister, and I know that if that is true, it will not be acceptable him. I am willing to admit that all the organisations that I mentioned and I must be wrong in our fears, but the trouble is that I cannot see how, which is why I wanted to have this debate.
On the first page of the briefing prepared for this debate by the Library, there is an article by Baroness Grey-Thompson, who apparently can see that we are all wrong. She states:
“The Chancellor announced a £3.8 billion investment”—
I know that the Minister will refer to it—
“including £2 billion of new money, in social care—the support disabled and older people get from their council to get up, get washed and dressed and live independently.”
My understanding is that setting the national eligibility threshold at the substantial level of need would mean that that was simply untrue. People would not get that support. The needs that Baroness Grey-Thompson refers to would not be met.
I know that the Minister will say that local authorities can provide support at what levels they choose. They could provide it, as many did for many years, at the moderate level of need, but the trend is moving in the opposite direction and at a rapid rate of knots, hence the figures that I gave earlier, which are getting smaller and smaller, on the number of people receiving support.
We all understand the need to avoid the existing confusion with the so-called postcode lottery—the differing levels of support in different parts of the country—but I must ask a question. What is the value of having the certainty, wherever I live in the country, of being guaranteed a level of support that fails to provide me with my basic human right to live an independent life? That is not a freedom: to be told that I cannot have the life that I deserve. It is not an improvement to provide the certainty of not knowing what care I will get, which we have at present, with the certainty of getting almost no support at all. I know the Minister and that that is not his intention, so I am in the Chamber today not to bury Caesar—not to criticise my hon. Friend—but to understand better how the planned reforms will work. I cannot work them out; we cannot work them out; and we desperately need to know.
I read the discussion document on the draft national minimum eligibility threshold for adult care and support and I do not get it. To me, there seem to be four crucial elements to the provision of care and support, and there may be more. First, without sufficient funding, there will be a problem, no matter how effectively and efficiently we deploy the available resources. Funding will always be vital. The other three parts are integration, eligibility and the actual care services provided.
We are told that £3.8 billion—£2 billion of new money—is there to help with that crucial integration, but good integration will improve the efficiency and quality of care and support at any level of funding. If we were given 1p, through good integration we could spend that penny better than by being disorganised and chaotic. Eligibility, however, will determine the level at which a person can access the wonderfully improved care and support that we will achieve through integration. Eligibility is the gateway, and the integration can take place at any level of care. We could remove all the postcode lottery uncertainty by setting the eligibility level at critical and yet integrate wonderfully, but how would the improved integration help the hundreds of thousands of people whose needs fall below the threshold level? I do not get it.
The Minister of State, Department of Health (Norman Lamb)
If my hon. Friend were to go somewhere such as Torbay, where completely integrated teams of health and care workers have been created, he would see that those teams can together make rational judgments about the people who need care and support, by identifying the individuals most likely to end up in hospital and allocating a worker from an integrated team to support them. I absolutely recognise that the eligibility criteria play a role, but the joint team can assess the needs in the area and do whatever is necessary to maintain people’s health and to prevent the deterioration of health and people ending up in hospital. Integration seems to be essential to what he seeks to achieve.
Mr Ward
It is not an either/or, or a route from one to the other. We can integrate at any level of support, and greater integration would certainly improve the system with greater economies and, we hope, greater equality of provision. If the Government had planned to introduce a whole new system and remove all criteria—looking simply at people and their needs—I could possibly see, with a wonderfully well funded and integrated system, how that might work. What is planned, however, is not that but an eligibility threshold against which people will be assessed. At that point, even with the washing, the getting dressed and all the other things that Baroness Grey-Thompson was talking about, the decision might be made that the person is simply not at the required level—the threshold—to be given support.
In the foreword to the discussion document, the Minister stated:
“We are establishing a system that will place a greater focus on prevention, which will mean that the care and support needs of people will be considered earlier than is currently the case.”
That is good, and it must refer to the early identification of potential future needs through improved integration. From my own background—in particular, in the area of children with special needs—I am well aware that early identification, so that support can be given, even from mainstream provision, can stop those needs developing to a level at which additional funding and support are required.
I understand all that, but a working-age adult can, for example, have a stroke—something that we saw at the Stroke Association event yesterday—and move, within a day, from being perfectly healthy to having needs that might even be classed as critical. On the direction, however, this is not about progression for many working-age disabled people, because they may move from critical or substantial down to moderate, but about how someone who has had a stroke perhaps may never move back to a point at which support is not required and live a truly independent live. The danger is that such people might go down, in terms of the needs as assessed, and fall out of the system. Where will they then end up? Later, at greater cost, they will go back into the system. That is the concern.
The discussion document refers to the creation of a working group to take matters forward. My problem is that it also states that developing and evaluating the research carried out by the working group may take three to four years. Too many disabled people, however, may quite literally not have that long.
Heather Wheeler (South Derbyshire) (Con)
It is a pleasure to serve under your chairmanship, Ms Clark.
I warmly welcome this Back-Bench debate, which allows us the opportunity to discuss the findings of the joint all-party group’s important report on social care reform for working-age disabled people. I congratulate my colleague, the hon. Member for Bradford East (Mr Ward), on securing the debate, and it is a pleasure to follow him.
I take a moment to thank the right hon. Member for Stirling (Mrs McGuire), the Baroness Campbell of Surbiton and the all-party disability group for joining me and the all-party local government group in writing our report, “Promoting Independence, Preventing Crisis”. I also thank Scope for all its superb help in facilitating the inquiry.
Social care reform is a cross-party concern and provides a clear example, notwithstanding what has recently been splashed across the media, of how all-party groups do good work in Parliament. I applaud the Government’s commitment to investment in social care, which they set out in the 2013-15 spending review—£3.8 billion is not a small sum. As our joint inquiry underlined, the social care system has faced decades of underfunding, and the Government’s understanding of the need to address the problem effectively should be recognised.
It was extremely important to me to be involved in the all-party group’s inquiry. For the first time, we managed to bring together the voices of working-age disabled people with those of local authorities. That represented a valuable and timely opportunity to continue to build on the Government’s positive vision for social change, and to develop the positive disability strategy, “Fulfilling potential: making it happen”.
We want to bring the focus of social care on to working-age disabled people. I praise the Government’s ambition to deliver a care system that is capable of meeting the needs of both the older population and working-age disabled people. The plans to improve integration and closer working between health and social care bodies have been a positive development. However, in the Chancellor’s speech on the spending review no reference was made specifically to the one third of care users who are working-age disabled people. I hope that the Minister will confirm the Government’s commitment that the purpose of moving the money from the NHS to local government was to meet not only older people’s needs but those of disabled people of working age. We must ensure that this group remains in the spotlight when reforming the care system.
I want to reiterate the importance of addressing the national eligibility criteria that my hon. Friend the Member for Bradford East raised. Despite the intention that the current fair access to care services criteria should be a broadly national framework, councils have considerable leeway in setting the threshold for eligibility. That has resulted in significant variation throughout the country. Moreover, councils have been tightening their own local eligibility criteria in response to budget pressures. That is completely understandable, but the implications are that people are living with the fear that they will lose their support. The new eligibility framework and national threshold proposed in the Care Bill will therefore go a long way towards alleviating the lottery of care, and will be vital in ensuring more clarity and consistency in the provision of care for disabled people in England.
The Government published the draft regulations for the national eligibility threshold on 28 June and confirmed in the accompanying document their intention to set the threshold at a level equivalent to “substantial” in the current FACS system. People tell us that that means that, for more than 100,000 working-age disabled people, the bar has been set too high to receive the care and support they need to live independent lives. I hope that the Minister will respond to that.
Norman Lamb
I reiterate that the proposed eligibility level set out in the document to which my hon. Friend referred would maintain for the vast majority of people what already exists within their local authority area and, as my hon. Friend the Member for Bradford East (Mr Ward) said, do absolutely nothing to prevent other authorities that choose to be more generous from maintaining that level at “moderate”, as currently exists in Bradford and about 15 other places around the country. Nothing will take away from anyone what they already have as an entitlement.
Heather Wheeler
I thank the Minister for his intervention.
I turn to what social care means to our constituents when real help is given. It means that someone can get up, and be washed, dressed and fed each morning. Those are basic, everyday actions that many of us take for granted. When that level of support is offered comprehensively, the person may hold down not only genuine social interaction but employment. Real social care may also prevent social isolation. For example, a member of the National Ankylosing Spondylitis Society has said:
“I feel overly tired most days. Outside of work my participation in activities has been reducing. I don’t spend as much time as I used to socialising with friends and family. I used to be very active and go out in the evenings but now I have early nights instead.”
It is brilliant that, with help, that person feels able to remain in the work force, but we must ensure that the care offered is not at the cost of other factors, such as mental health or well-being.
Well-being is an unambiguous concern of the Government and is clearly addressed through the well-being principle in clause 1 of the Care Bill. That reflects the fact that it is, first and foremost, a human issue. The principle is the thread that runs through the whole of the Bill and ensures that the care system not only delivers basic support but promotes disabled people’s independence, allowing them to realise their potential by participating more fully in their communities. That is a bold vision for the future and will truly revolutionise the care system.
It has been stated that for some people social care means
“being able to have the same aspirations as others. I hold down a job, live independently and I am able to live life in the way that I choose. I believe this is a fundamental right, but it has also given me an immense sense of freedom and satisfaction as I am able to contribute to society.”
Those great quotes come from our inquiry.
Well-being and independence also means providing support when an individual moves from one local authority area to another. The Care Bill should ensure that the receiving authority has a duty to ensure that any social care provision for an individual will ensure the same outcomes as those of their previous local authority. I stress to the Minister the importance of that portability factor to our constituents. They live in a mobile world.
A preventative social care system not only has benefits for the quality of care and the lives of disabled people but represents a financially sustainable approach for the future. In addressing the concern about the eligibility threshold, local authorities will be in a position to deliver appropriate care at an earlier stage, reducing escalation of the crisis. As the British Red Cross told the all-party group’s inquiry:
“There must be a dramatic rethink to the way social care is organised in the future, with a focus on preventing crises before they occur and keeping people independent for as long as possible.”
Without a truly preventative system, councils will have no choice other than to intervene at crisis points when the personal and financial costs are already too great. The former president of the Association of Directors of Adult Social Services, Sarah Pickup, told the inquiry:
“Prevention is one of the very few things where you can get both a better outcome and a reduced cost.”
The Government have recognised that local authorities are delivering innovative solutions in social care provision, and have rightly chosen health and wellbeing boards as the mechanism through which social care can be delivered effectively. The boards have been implemented fully since April 2013. The Health and Social Care Act 2012 mandates a minimum membership consisting of one local elected representative, a representative of the local healthwatch organisation, a representative of each local clinical commissioning group, the local authority director of adult social services, the local authority director of children’s services and, crucially, the director of public health for the local authority. That will ensure a wide range of views and experience on the boards and will help with the implementation of preventative social care.
If the Government fully resource local authorities to implement preventative social care, the financial returns to local authorities, national Government and the NHS will be significant. Deloitte’s economic modelling in Scope’s report, “Ending the other care crisis”, has shown that a £1.2 billion investment in establishing a lower national eligibility threshold would lead to a £700 million saving for the Government and a £570 million saving for local authorities and the NHS. That is care and compassion at a better net price for the nation.
In addition, that money must be available to be used for care services within communities that are not exclusively health focused such as housing and employment. Such support would aid many disabled people in actively contributing to society as independent, participating, tax-paying citizens. As Sue Brown, head of policy at Sense, told our inquiry, the employment market currently risks losing out on the contributions that disabled people can make. That is the crux of the debate; we want to get disabled people living the lives that they want to lead, and being as independent and as self-sufficient as possible. Not only do they benefit from that, but the economy benefits too.
The National Autistic Society told me that new economic modelling by Deloitte published earlier this month shows that for every £1 invested in support for people with autism—and other disabilities—who have moderate needs, returns of £1.30 are generated. As the Government have rightly recognised, social care is not merely about allowing people to survive; rather, it is about enabling them to live full and independent lives. The Bill explicitly places a duty on local authorities to provide care that promotes the well-being of individuals. Let us now establish that the regulations fulfil the Government’s ambition and ensure that more than 100,000 disabled people with significant needs can live full, varied lives, with the basic dignity that we all take for granted.
To reiterate—and to be absolutely clear—I feel that the care provisions that we put in place need to be standardised between local authorities in order to promote portability. Those affected by the provisions are the most vulnerable in society. We do not want to make moving house an ordeal for people, with tensions and stresses about the level of care that they can expect to receive in the new area. Before the excellent changes to this groundbreaking, joined-up government measure can be implemented, we would like to ensure that a proper impact assessment is undertaken. We would like any administration costs, or other associated costs, to be known to local authorities before implementation. We want to ensure that costs do not force the most vulnerable in society to be left behind, because of new bureaucratic layers imposed on local government.
In conclusion, the Care Bill is a significant, welcome step in the right direction that acknowledges that reforms need to be made. Provided that they are properly resourced and supported, local authorities, working with the NHS, now have the opportunity to demonstrate their considerable experience of delivering social care in a financially sustainable manner. Funding preventative social care in the manner that the report recommends represents a win-win situation for the Government. I look forward to the Minister confirming the new way of working, by recognising that budgets between the NHS and local government, as announced in the recent spending review, will be used, not only for the elderly, but for working-age disabled people. Thank you, Ms Clark.
Mrs Anne McGuire (Stirling) (Lab)
It is a genuine pleasure to serve under your chairmanship this afternoon, Ms Clark. I also want to congratulate the hon. Member for Bradford East (Mr Ward) and the hon. Member for South Derbyshire (Heather Wheeler) on promoting this afternoon’s debate. Protocol would not allow me to join them in sponsoring the debate, but I am delighted to be able to participate by making a short contribution.
For the record, I also want to identify colleagues from both Houses of Parliament who took part in what was a groundbreaking inquiry in terms of our Parliament. It was cross-party and cross-House, so I want to recognise the contributions of my right hon. Friend the Member for Coatbridge, Chryston and Bellshill (Mr Clarke), Baroness Eaton of Cottingley, the hon. Member for Meon Valley (George Hollingbery), Baron Low of Dalston, the hon. Member for Truro and Falmouth (Sarah Newton), Baron Tope of Sutton, the hon. Member for Broxbourne (Mr Walker), and the hon. Member for Bradford East, who gave up their time to participate. I also want to thank the all-party parliamentary local government group, under the admirable chairmanship of the hon. Member for South Derbyshire, for joining with the all-party parliamentary disability group in promoting the inquiry.
It is also worth nothing that a distinguished group of people presented evidence to us, both as individuals—people who came from a variety of backgrounds—and as organisations, including the Joseph Rowntree Foundation, Sense, the Royal National Institute of Blind People, the NHS Confederation, Inclusion London, Mencap, Mind, the National Autistic Society, and the president of the Association of Directors of Social Work. I hope that the Minister and my hon. Friend the Member for Leicester West (Liz Kendall), the Opposition spokesperson, will recognise that the evidence brought together a significant spectrum of expertise from organisations, but more importantly, that it brought to the inquiry the particular experiences of disabled people themselves. It was not only about talking to the organisations that are out there, either representing or delivering services for disabled people; it was also about listening to disabled people. To echo the comments made by the hon. Member for South Derbyshire, I would like to thank Scope most sincerely, not only for servicing the inquiry, but for going beyond the bounds of what was expected to ensure that it happened—and happened professionally—and that our publication is both professional and challenging. I want to place that on record.
Disability can happen to anyone at any time. We could have an undiagnosed condition, a car accident, or we could develop a progressive illness. Last week, I attended a reception in the House of Lords for the management of bowel problems. I met a young man who became disabled in his early 20s when a rugby scrum collapsed on him. He never thought, in his wildest dreams, that he would be disabled in his 20s. He loved and played rugby, and one day, an accident happened. I hope that that would be the context in which we can discuss some of the issues that both my colleagues have identified today, because my benchmark for social care is what we would want to happen if it were us. If we start from that premise, we can build a picture of what we think should be the exemplar in terms of social care.
I want to identify why the inquiry took place, and why now. There is a momentum with the Care Bill, with both political parties—perhaps, in this company, I should say three political parties—coming together to recognise the importance of social care. As the hon. Members for Bradford East and for South Derbyshire highlighted, a third of those who rely on social care are, in fact, working-age adults. Sometimes, there is a great frustration among the disability community that working-age adults are not mentioned. We talk about care of older people—indeed, sometimes we use care of “the elderly”, which I think is somewhat disparaging, as we are talking about “older people”. That is only my particular pedantry, I suppose. However, working-age adults sometimes get forgotten, and I certainly welcome the focus that we are giving those younger people today.
As both my colleagues have identified, care cannot only be about basic survival. There is more to life than getting up, eating and drinking, getting into your pyjamas and then going to bed. Frankly, although the Minister mentioned Torbay, that, sadly, is exactly what social care means for many people around the country. For disabled people who want to live fulfilling lives, care is a facilitator for independent living, fairness and respect. It is an enabler to a social and family life and, thankfully, for an increasing number of disabled people, to participating in their own way in the wider life of their community through employment.
Frankly, social care for working-age adults cannot only be about fitting them into a pre-ordained system, nor can it be about a template that is pulled down, and then someone’s name is slotted into it. It is about ensuring that the individual disabled person has real independence, choice and control. Sometimes we talk glibly about independence, choice and control, without thinking about exactly what they mean; they can be different things for different people. There is no point in having someone come in to help a person dress at 11 o’ clock, when they need to get to their work at 10 o’clock. What is the point of that? That does not allow them to live a fulfilling life, and there is little dignity and respect in getting that person into their pyjamas at 6 o’clock when they might want to go out to the cinema, to visit their friends, or, indeed, to have their friends round to visit. Let us just imagine what that must be like. Their family, friends or neighbours are there, and the person is sitting there in their jimjams. That is not what we should mean by social care, but sadly it is what is happening in many parts of the country.
In addition, as the hon. Member for South Derbyshire highlighted, social care should not just be another arm of the emergency services. It should not be a response to a crisis. That is where some of the difficulties in terms of preventive measures come in, but I want to make two or three points to echo some of the recommendations in the report.
First, I think that the current Government, like previous Governments, believe in principle in the right to independent living. We believe, I hope, as a Parliament, in breaking down barriers for disabled people and breaking down some of the Government silos that create those barriers. Disabled people do not live their lives according to the Department for Transport, the Department of Health, the Department for Work and Pensions—we can add on whichever number of Departments we want. That is not how people live their lives and it certainly is not how disabled people live their lives, so it is important that we do not just talk about independent living, but look at how it can be delivered.
Both my colleagues identified the important issue of the portability of care, and I cannot emphasise enough how important that is to disabled adults of working age. I ask the Minister to think about this issue. Let us consider the case of a disabled person in the borough of Lambeth who has to move to Westminster but finds that they cannot take their care package—their support—with them. That is echoed across the country. If it is difficult within one city, just think how much more difficult it is if someone happens to live in Carlisle and wants to go and live in Bradford. Let us just think of the challenges that that poses for an individual disabled adult.
However, it is not just individual disabled adults who are affected. Let us consider the case of people who are the parents of a disabled child. The mum or dad gets a new job and moves from Bradford down to Birmingham. The disabled child has some sort of support mechanism. This starts in childhood and can develop into adulthood. I appreciate that we are talking specifically about working-age adults, but I think that we must recognise that the picture is even bigger than the focus that we have today. In many cases, this is an issue from the cradle to the grave.
Norman Lamb
I agree with the case that the right hon. Lady is making, but I want to ask her this. Presumably she is pleased that the Care Bill introduces the capacity to move from one part of the country to another without the care package collapsing and that it stays in place until the person has been reassessed in their new area. It may be that someone’s needs change if they are closer to a loved one, their home is different or whatever, but the care package stays in place until the reassessment happens.
Liz Kendall (Leicester West) (Lab)
It is a pleasure to serve under your chairmanship, Ms Clark. I thank the Backbench Business Committee for giving us time to debate this very important issue, and I congratulate the hon. Members for Bradford East (Mr Ward) and for South Derbyshire (Heather Wheeler) for sponsoring the debate. It is a great pleasure—this is the first time that it has happened to me—to follow my right hon. Friend the Member for Stirling (Mrs McGuire), who made a very powerful speech.
This subject is hugely important. One in five adults in Britain has a disability of some kind, and that figure is rising due to medical advances and better survival rates. As my right hon. Friend says, it could happen to any of us, so this is not a side topic but an essential issue. Britain will not be a fair country if disabled people are denied the opportunities that many of us take for granted, and we will not be a successful country if we miss out on the talents and contribution of disabled people, not only in economic terms, but in our communities and wider cultural and social life.
Good social care is essential to enable disabled people to be full citizens and live full and fulfilling lives. As hon. Members have said, that is about not only the basics of life—help getting up and getting washed, dressed and fed. It is about what I call the very stuff of life—ensuring that disabled people can spend time with their family and friends; learn and get new skills; find a job; contribute to their local community; take part in sport, art, culture and music; and have fun. In other words, it enables disabled people to have the same aspirations as every other citizen. That is why today’s debate, the joint report from the all-party groups on local government and on disability and “The other care crisis” report are important.
This is not about a particular public service, but about what kind of society and country Britain should be in the 21st century. Despite all the economic challenges, we are one of the richest countries in the world. What kind of country and society do we want, to ensure that we have genuine fairness and opportunity for people of all kinds? The debate is therefore about not only social care, but wider life, which is why it is so important.
As hon. Members have said, there is a growing crisis in social care for working-age adults with disabilities, and services have now reached breaking point. That is eloquently spelled out in the joint report of the all-party groups and “The other care crisis”, the report by Scope, Mencap, Leonard Cheshire Disability, Sense and the National Autistic Society. It rightly says that social care does not only affect older people: one in three people who use social care are working-age people with disabilities. It also says that local authority budgets for adult social care have been under pressure for many years, but have now reached breaking point, as councils have lost a staggering 28% of their budgets so far under this Government, with even greater reductions announced in the latest spending review. As a result, councils are reducing the number of disabled people eligible for free care and support.
The report says that 40% of disabled people are failing to have their basic needs met. They are unable get the help that they need to eat, wash, dress or get out of the house, and their mental health suffers. There are some terrible, upsetting and distressing quotes from people with disabilities. Disabled people’s families also suffer huge stress and strains.
Norman Lamb
I agree with the points the shadow Minister makes, but she mentions cuts to local government budgets and I hope that we can all be realistic and honest about the situation that we face. Is she saying that a future Labour Government would substantially increase funding for local government? Alternatively, does she recognise that, collectively, we must all think about different ways to make the money go further?
Liz Kendall
I believe that we must fundamentally rethink how our care and support system works. The Minister knows that my right hon. Friend the Member for Leigh (Andy Burnham) and I have called for a far bigger and bolder response, by fully integrating the NHS and social care. I shall come to the Government’s proposals for the £3.8 billion of pooled resources. With the greatest respect, I think that the Government should be bigger and bolder in their response, with full and true integration that goes beyond the NHS and social care. If we really join up local services and support and bring together support from the Department for Work and Pensions, there is huge potential to do much more to give better care, better outcomes and better value for money. I will say more on that in a moment.
In “The other care crisis”, organisations raised concerns about the number of people—105,000 in total—who will lose out if the Care Bill goes ahead as it stands, given where the eligibility criteria will be set. The report warns that the huge strides made over recent years in promoting independence and personalising care and support will go backwards, as councils and other providers revert to more traditional service models—salami slicing services separately—thus restricting peoples’ independence. That specific crisis in social care for adults with disabilities will lead to a far bigger crisis: a crisis in opportunities for disabled people to live the life they want, which other citizens have; a crisis for taxpayers, because failing to invest in up-front preventive social care services will lead to more expensive NHS and social security bills; and a crisis for our country as whole, as Britain misses out on the talents and contribution of disabled people and we all end up paying more as the price of failure.
What should happen instead? The Care Bill could and should be a profound opportunity to establish a framework for social care that could be truly transformational for disabled people. The Bill is the result of the Law Commission review of adult social care legislation, initiated by the previous Government.
Liz Kendall
I give much credit to the Minister, but the Bill is the continuation of a process that Labour established when we were in government—I want that on the record. [Interruption.] I fully and readily acknowledge that local council budgets have been under pressure for many years. He knows better than anyone that towards the end of Labour’s time in Government we tried to reach an agreement on a social care funding system, which I will come back to in a moment. [Interruption.]
Katy Clark (in the Chair)
Order. I ask the Minister to intervene formally if he wishes to say anything, for no other reason than it would assist the Hansard writer.
Liz Kendall
I never mind interventions in debates; I warmly welcome them.
I shall make five specific suggestions to the Minister about how the Care Bill could be developed. First, the definition of well-being in the Bill is important. I welcome how broad it is. It covers mental, physical, social and economic well-being; personal relationships; and a person’s ability to contribute to society. The definition also includes ensuring that individuals have control over their day-to-day living, but I question whether the definition is as strong as it could be. The joint report from the all-party groups asks why it could not specifically include promoting independence, to strengthen the definition further.
An issue raised by my right hon. Friend the Member for Stirling relates to my point about definitions. The duty to co-operate in the Bill says that local councils will need to work with a range of partners. I understand that Ministers usually do not want to specify lots of organisation types, but I am concerned that although local councils would, we hope, know that they had to co-operate with the NHS, there is a real issue about the DWP. There is not that link-up locally, and if people’s ability to get training and to participate in the work force is so important, will the Minister consider whether, either in the Bill or in guidance, there needs to be more detail about who local councils should co-operate with? I am concerned that that local relationship might not be there.
Secondly, the eligibility criteria are, as the hon. Member for Bradford East said, the most crucial aspect of the social care system because they determine who is and is not eligible for social care support. We absolutely welcome the commitment to clear national eligibility thresholds, but the Minister knows that disabled people, organisations that represent older people and many of the groups involved are hugely disappointed that the draft regulations have set the thresholds at substantial rather than moderate. I am fully aware of the cost pressures on the system, but has the Department done a true cost-benefit analysis, to consider the potential saving? The hon. Member for South Derbyshire made a point about how investing up front can save money further down the line. Has the Minister discussed with his Treasury colleagues whether, if a longer time frame were used for assessing the costs, we would end up saving money for taxpayers if the moderate level was set?
My third point relates to the so-called capped care costs model—aka Dilnot. The Minister knows that I am concerned that the so-called cap on care costs is not really a cap. I am concerned not only because it does not cover hotel accommodation, but because it covers only what someone’s local authority would pay rather than the amount they might actually pay in residential care and because no one will benefit from the cap until 2020.
Norman Lamb
Does the hon. Lady accept that if the cap were to cover all someone’s care costs, however much they chose to pay, wealthy people who chose to live in much more expensive care homes would be at a substantial advantage?
Liz Kendall
The Minister will know that my point is that I warn Ministers, including the Prime Minister and the Deputy Prime Minister, that going around the country strongly saying that it is a cap on care costs will create confusion—that is the best word I can use.
I do not want to focus on older people; I want to come to the point that the APPGs raised. The joint report states that the majority of working-age people with disabilities will not benefit from the so-called capped social care costs model, because they will not have had the chance to acquire assets. How many disabled people will benefit from the model? Why does the Minister believe that it is more important to put in excess of £1 billion into implementing the Dilnot model rather than into the current system, which is being increasingly squeezed?
My fourth point is about personalisation. I am a huge champion of personal budgets. I have seen them transform many of my constituents’ lives, not just because they promote genuine independence by giving people a say in how they live their lives rather than the system telling them how they should, but because they are essential to integration. The people themselves know best about how to join up their needs and support, because they do not see the two things as separate. However, I have heard the concern expressed in many different places across the country that personal budgets are getting a bad name. People feel that they are increasingly not based on their needs and that less money is being given than is needed, because of how the resource allocation system works.
Another important recommendation in the joint APPG report is about considering whether the resource allocation system should go on to a statutory footing, supported by new duties on councils to be transparent about decisions. I do not want personal budgets to get a bad name, with people feeling that they are a cover for cuts, rather than being based on what people need.
My final point is on the absolutely essential issue of prevention and integration. The Government announced in the spending review that there will be pooled budgets across health and social care totalling £3.8 billion, including £2 billion transferred from the NHS. The joint APPG report states that much of the previous transfer of money from the NHS to social care never reached the front line, and there is a concern that just continually transferring money in that way is not sustainable. How will the Minister ensure that the money gets to the front line? Will it be available, as I think the hon. Member for South Derbyshire said, for working-age adults with disabilities, rather than just for older people? Finally, will the Minister acknowledge that if this keeps happening year after year, it would be far better to have much fuller integration, such as the whole-person care approach proposed by Opposition Members?
The Minister of State, Department of Health (Norman Lamb)
I join others in saying that it is a pleasure to serve under your chairmanship, Ms Clark, and I apologise again for my rudeness earlier. I noted that the right hon. Member for Stirling (Mrs McGuire) said that it was a “genuine pleasure” to serve under you. I am not sure what it means when on other occasions she leaves out “genuine”; none the less, it was clearly a tribute to you, Ms Clark.
I congratulate my hon. Friend the Member for Bradford East (Mr Ward) on securing the debate. This is the second time this week that the two of us have discussed and debated care issues, and I know that he cares passionately—and genuinely—about the subject.
I want to make a number of points at the start. I very much welcomed the fact that the hon. Member for South Derbyshire (Heather Wheeler) highlighted the absolutely central importance of the principle of well-being in the Care Bill. The Bill has the potential to be transformational in how it challenges culture—how the system works and how it treats people. In part, it is about a big shift from a paternalistic system in which people get done to, to a personal one in which their needs and priorities come first.
The right hon. Member for Stirling made the point, absolutely correctly, that there is more to life than getting up, being washed, eating and going back to bed. I am not sure who focused on the important issue of social isolation, but the truth is that many people in this day and age live miserable lives. If someone lives on their own and has substantial care needs, and the extent of their life is getting out of bed, getting washed, sitting in a chair and going back to bed, with no one to see during the day, that is a miserable life.
One point I want to make today is that this is not just about care services. If we are talking about a good society and about giving people a good life, there must be collaboration between statutory services and communities, families and the streets on which we live. I have floated the idea of neighbourhood watch groups applying to provide care. We have a national movement that looks out for whether our houses are being burgled, so should we not be thinking—all of us stepping up to the plate—about whether there are people on our streets who have care needs, or who might just be very lonely and could do with a bit of companionship?
If we are to have a civilised society, the focus has to be not just on statutory services but on collaboration within the community. That is all the more important given the extraordinary strains which the public finances are under now and will be under in future. All political sides in the debate must face up to the extraordinary financial challenge and how best to meet it.
Reference was made to setting the eligibility criteria. My hon. Friend the Member for Bradford East argued cogently for the level to be set at moderate, and the shadow Minister, the hon. Member for Leicester West (Liz Kendall), asked whether there had been a cost-benefit analysis. The problem faced by any Government is that the up-front cost for both working-age and older people is £2.7 billion. I absolutely buy into the case for preventing ill health and the deterioration of health and into making another fundamental shift from repair to prevention—the whole system must reflect that—but Governments should be very careful about committing themselves to that level of up-front cost. That would be exactly the same if Labour were in power.
The shadow Minister and the hon. Member for South Derbyshire asked whether the £3.8 billion pooled sum applied to working-age disabled people as well as older people. Absolutely, yes. My passion for integrated care and for preventing ill health and deterioration in health applies to people of whatever age. We have a particular challenge with frail elderly people, but we also have an understated challenge with people of working age who have disabilities, because often the focus is not enough on them.
Mr Ward
In relation to the impact on people, “The other care crisis” report states that we must look at not only what may happen but what has already happened over the past two years up and down the country, and the impact there has already been and no doubt will continue to be on people. I understand that the legislation is due to go through in 2015, and there is talk of having a working group over three to four years. That seems an awfully long period before we will have an assessment of what has happened and what may occur as a result of the legislation.
Norman Lamb
I will come on to the work that we intend to do on a more sophisticated way of assessing eligibility and responding to assessments. I absolutely accept the current danger that the system in effect says, “Go away, become more ill or more disabled, and when there is a real crisis, we might help you.” I want us to be more sophisticated and to intervene in ways that will help to build capacity and resilience and to stop the deterioration of health. I genuinely believe that the Care Bill will give us the foundations for a much more rational approach.
Liz Kendall
May I take the Minister back to the £3.8 billion pooled budget? He said that it was absolutely available for care and support for working-age people with disabilities. Will he explain, when the money goes down to clinical commissioning groups and local councils, first, where it will go to, and secondly, how he will ensure that it actually goes to working-age people with disabilities? I know how the NHS works, and all the focus is on the frail elderly because they are in hospital. The NHS wants to get them out of hospital—that is its prime focus—so unless there is something specific in what the Minister sets up, the money will not go to working-age people with disabilities.
Norman Lamb
We will publish further details about how the system will work. To deal with the hon. Lady’s challenge to our approach, we could go for another massive re-organisation, which in a sense is what she is advocating—
Norman Lamb
Well, it is. To bring health care and social care together structurally would be a massive re-organisation, and there is no way of avoiding that. The smart way is to focus on the care that an individual receives. The issue is not just about bringing health and social care together and integrating those two systems but about the health service itself and the fact that, institutionally, we have separated mental health from physical health and primary care from secondary care, which is crazy. The whole thing is fragmented, but we should shape services around the needs of patients. The Government’s approach, based on the duties to integrate in the Health and Social Care Act, is the smart, fast way of achieving much more joined-up care for the patient, whether individuals are elderly or of working age. I want to make some progress with my speech.
The Government are committed to improving the lives of disabled people and to supporting them in their independent lives. In very difficult financial circumstances, we have done much to achieve that through the disability strategy, welfare reform—it is incredibly controversial, but any Government would have to pay attention to the extraordinary growth in welfare spending—and a whole raft of condition-specific initiatives.
One outstanding issue still needs to be addressed—social care reform. The importance of care and support for disabled adults cannot be understated: it is the enabler of independent living. We hear much about the ageing population as the driver for care reform, but a third of all health and care users are working-age disabled people, so it is vital that the social care reforms address their needs. The fact that my hon. Friend the Member for Bradford East and his colleagues have secured this debate is valuable because it ensures that we focus on the needs of working-age disabled people. I repeat that there is a risk of their being forgotten, which must not happen.
Earlier this year, I read with interest the “Promoting Independence, Preventing Crisis” report into making social care reform work for disabled adults. It was a joint inquiry by the all-party groups on local government and on disability. I congratulate them on an important piece of work, and I will attempt to address some of the points raised in a moment. I first want to talk about some of the things we have done.
We know that disabled people face a number of challenges. They are far less likely to be in employment than non-disabled people. In fact, shockingly, only 46% of disabled people are in employment compared with 76% of their non-disabled counterparts. Some 19% of individuals living in a family with a disabled member are in income poverty, although I am pleased to say that that has been falling over time. Progress is being made, but much more needs to be done.
The first thing to say about all the Government’s reforms is that we are committed to the UN convention on the rights of disabled people, which includes the right of disabled people to independent living. The Department of Health has been working closely with the Office for Disability Issues on the new cross-Government disability strategy, “Fulfilling Potential”, which was published last September. It is about making the UN convention a living reality for disabled people in Britain. It describes the rights that disabled people—just like anyone else—have in all areas of life, and the duty on Government to ensure that those rights are met.
The shadow Minister made a point about co-ordination with the DWP. There is scope for much more joined-up working at a local level to bring disparate public services together and to achieve far more bang for our buck than we presently manage.
Mrs McGuire
I do not wish to embarrass them, but I suggest that both the Minister and his officials look at the disability strategy report based on the “Fulfilling Potential” report that he mentioned. That update was published last week. I think the jury is out on what it says, but in the interests of joined-up government, he should have the most up-to-date picture.
Norman Lamb
I am grateful to the right hon. Lady for that intervention. What remarkable timing she shows. On 2 July, the follow-up document, “Fulfilling potential: making it happen” was published, which sets out the indicators that will show where we are making progress and where more work needs to be done.
In my Department, we have been working to ensure that we can hold the new health system to account for the quality of services and outcomes that they provide to disabled people. The NHS outcomes framework includes a number of measures that relate specifically to disability, including, critically from my point of view, mental health, which is an area that is sometimes forgotten. Talking about an outcomes framework sounds like horrible jargon, but it is actually about focusing on results for people—the impact on people of what we spend. If we can measure that and then measure the changes that happen over time, we can focus the whole system’s attention on the need to achieve outcomes for people rather than on process. Essentially, we will expect to see a reduction in premature death among people with a learning disability and people with serious mental illness. It is a scandal in this day and age that such people die so much younger than others. We will also expect to see an enhanced quality of life for people with mental illness and an improvement in their experience of health care.
This matter is not just about the NHS. We will also be holding to account the adult care and support system through the adult social care outcomes framework for ensuring that
“people are able to find employment when they want, maintain a family and social life and contribute to community life, and avoid loneliness or isolation”.
We will be measuring that through the proportion of adults with a learning disability who are in contact with secondary mental health services, who are in paid employment and who live in their own home or with their family.
We have responded robustly to the challenges posed by the really dreadful events at Winterbourne View hospital and to the way in which people with learning disabilities, autism and behaviours described as challenging are viewed and treated. All too often, society has treated them as second-class citizens. I take a simple view that people with learning disabilities have exactly the same rights as anyone else, and we have to ensure that the whole system respects that basic position. By April 2014, every area will have a joint plan to ensure high-quality care and support services for this group of people in line with best practice. By June next year, everyone inappropriately in hospital will have moved to community-based support.
We are reviewing the national autism strategy to assess how it is addressing the barriers that people with autism face, and how care and support services are responding to their needs. However, that is not something that the care and support system can do on its own. As a Government, we are also aiming to make the benefit system fairer, more responsive and more affordable to help reduce poverty, worklessness and welfare dependency, and to reduce levels of fraud and error. For many, that will include support to work, which is the best route out of poverty and is very often beneficial for those with long-term health conditions. It is worth reiterating that severely disabled people who need support will always get it, and we will provide unequivocal support for those who cannot work.
I mentioned care reform. Many people have told us that today’s care and support system often fails to live up to the expectations of those who rely on it. Although many have good experiences, the system can be confusing, massively disempowering, paternalistic and not flexible enough to fit around their lives.
Our White Paper, “Caring for our future”, which was published last year set out a vision for a reformed care and support system. Yes, it was based on the Law Commission report, but it was implemented, I am proud to say, by this coalition Government. We need a modern system that promotes people’s well-being by enabling them to prevent and postpone the need for care and support, and puts them in control of their lives to pursue opportunities, including education and employment, to realise their potential.
The Care Bill, which we introduced in Parliament in May, is a crucial step in delivering that vision. It represents the most comprehensive reform of social care legislation in more than 60 years, creating for the first time a single, modern statute for adult care and support. The existing law that underpins care and support is outdated and confusing. It is rooted in the post-war period and must be overhauled, as the Law Commission concluded after its three-year review. Our new statute will be clearer, fairer, and will empower people to take control over their care and support. It has been done in the most collaborative way, with pre-legislative scrutiny and widespread consultation with the sector and the wider community.
The current legal framework is narrow and paternalistic; it is built around the idea of providing state-defined services, rather than of meeting and responding to the needs and goals of individuals. The other day, my hon. Friend the Member for Bradford East talked very movingly about the brilliant community work on dementia care that is under way in Bradford. That is where we see this collaboration between ordinary people who are good citizens and who care for one another and the supportive role that the state always has to play to back that up. The Care Bill will help to shift the focus of care and support from paternalism to a much more personal approach. It will place personal budgets on a legislative footing for the first time. I agree with the shadow Minister about the importance of personal budgets being real; they must empower people and not mask a cut in support or provision.
We want to extend the greater roll-out of personal budgets to give people who are assessed as needing care and support more choice and control over how their care is provided. Where personalisation has taken root it works—people get better results and it is popular with users and carers. That is particularly true for working-age adults; take-up is relatively high compared with that among older people. This great reform came about through working-age disabled people demanding that they have more control over their lives, and local government responding to them.
The current law fails to reflect the importance of supporting people in caring roles. The Bill, for the first time, puts carers on the same legal footing as those for whom they care, with expanded rights to assessment and new rights to support.
The Care Bill also implements historic reforms to the way in which the care system is funded, by introducing a cap on the care costs that people incur. Of course, as I said in an intervention on the shadow Minister, people can choose to spend more than that if they wish, but if we were to do what I think she was implying it would mean giving enormous financial support to wealthier people, which cannot be justified in times of real financial constraints.
The current care and support system offers little financial protection for the cost of care. As the Commission on the Funding of Care and Support said, because care needs are unpredictable, individuals and families are unable to know what care costs they might face in the future. We recognise that some working-age adults may face having to pay for care earlier than most elderly people do, so we have therefore said in our funding reform proposals that people who need care before they reach retirement age will pay less. In addition, the changes we are proposing will mean that people who are assessed as having care needs before they turn 18 will have their cap set at zero. We will be consulting on those changes very shortly.
We have made it clear from the consultation and publication of the White Paper through to the publication of the Care Bill that the same principles apply to all who need care and support. That applies equally to an adult with a physical disability, someone with a learning disability, an adult with mental health issues or an elderly person needing care. I know that my hon. Friend the Member for Bradford East is particularly concerned about eligibility criteria. We have published draft regulations setting out national eligibility criteria for discussion. They are set at a level that will allow local authorities to maintain the same level of services for service users when they move from the current framework.
Let me end by saying that I would prefer to have a more sophisticated system. Work is under way on developing that. I invite Scope to participate in that and work with the Government to achieve a much more rational system in which we can intervene earlier, provide some support and help to build capacity and resilience so that people get help when they need it rather than when they reach a crisis.