(11 years ago)
Commons ChamberRead Hansard Text Read Debate Ministerial Extracts
21:59 - The House divided: - Ayes: 231 / Noes: 289 - Question accordingly negatived.
Mr Speaker
I should inform the House that I have selected the amendment in the name of the Leader of the Opposition.
The Secretary of State for Health (Mr Jeremy Hunt)
I beg to move, That the Bill be now read a Second time.
Our health and care system stands for compassionate care, or it stands for nothing. That was the vision when the NHS was founded 65 years ago: that anyone and everyone, regardless of background or income, should receive the best quality health care and be treated with dignity, compassion and respect. Because we have made much progress in delivering that vision, the NHS rightly remains the single biggest reason people are proud to be British. This Government want to keep it that way, which is why we are determined to root out poor care whenever and wherever it exists. Tragically, it does exist, both in the NHS and in private provision. In recent years, we have heard of patients being left in their own excrement at Mid Staffs, of patients left unchecked on trolleys for hours on end at Tameside, and of blood on the curtains and catheters on the floor at Basildon. All are issues that could and should have been dealt with by the last Government. Tragically, those problems were swept under the carpet, with devastating consequences for families across the country.
Today it gets worse, because the same people who failed to face up to those problems as Ministers will troop into the Lobby to try to vote down the very measures that will stop them ever happening again. People watching this debate will be asking one simple question: what more will it take for Labour to learn the terrible lessons of these tragedies? How many more people will need to suffer before the Labour party, the party that is rightly proud to have founded the NHS, comes to its senses and recognises that, on its watch, targets mattered more than patients and good news mattered more than good care?
Ian Lucas (Wrexham) (Lab)
The right hon. Gentleman casts those allegations around widely. Will he name the Ministers against whom he is making them?
Mr Hunt
I will absolutely go on to name the problems and the Ministers involved, if the hon. Gentleman will just be patient.
Hon. Members should not simply take my word for this. This is what Mid Staffs campaigner Ken Lownds, a former Labour party member, says about Labour’s decision today:
“It’s shocking and deeply depressing that Labour have learnt nothing from Mid Staffs. Their decision to oppose the Care Bill is a slap in the face for the campaigners and relatives who have fought for years for these measures that deliver a safer, more transparent and more compassionate NHS. Once again they have let patients and whistleblowers down by putting their political interests ahead of patient safety.”
Heidi Alexander (Lewisham East) (Lab)
The Secretary of State has come here to introduce the Second Reading of a very important Bill, yet it has taken him only two minutes to start casting aspersions on the previous Labour Government. When is he going to start acting like a Secretary of State?
Mr Hunt
I will make some progress, then I will give way.
Labour will today vote against measures that will help to implement 61 of the most important recommendations made by Robert Francis. Many of these will be policed by the new chief inspector of hospitals, appointed to be the nation’s whistleblower in chief, whose duties will be enshrined in today’s legislation, which Labour are voting against.
Andy Burnham
How can it be appropriate to introduce a debate on such fundamentally important issues as the way we care for older people with such narrow, petty, partisan, point scoring efforts? May I just say to the Secretary of State that he should not stand there and misrepresent the position of the Opposition? We will not oppose the Second Reading—we have tabled a reasoned amendment, because we do not believe his proposals for a cap are what they seem, but we will not oppose the Second Reading of this Bill. He should get his facts straight before he comes to that Dispatch Box.
Mr Hunt
The right hon. Gentleman needs to read his own amendment, because it says that he “declines to give” the Bill “a Second Reading”. If he is changing his position now, that is the fastest U-turn in history.
Let me go on to say why it is so important that the Labour party supports today’s Bill and does not, as the amendment says, decline to give the Bill a Second Reading.
Mr Hunt
I am going to make some progress. The new chief inspector of hospitals will act as Ofsted does with schools and, as with Ofsted, will inspect and rate hospitals using simple language that the public can understand: “Is my local hospital safe? Is it caring? Is it responsive? Is it clinically effective? Is it well led?” We will also make sure that the same scrutiny is directed at services outside hospitals, so the Bill makes provision for a chief inspector of social care and a chief inspector of general practice.
Ministers in the previous Government were repeatedly asked to strengthen the regulatory system and repeatedly ignored those requests. [Interruption.] The right hon. Gentleman says, from a sedentary position, that that is rubbish, but this is what Barbara Young, the chair of the Care Quality Commission at the time and now a Labour peer, told the Francis inquiry about the inspection system that the right hon. Gentleman introduced:
“The annual health check was so flawed in so many ways that I went and saw the Secretary of State. It was nonsense. And having argued that with the Secretary of State, I was told firmly that we weren’t permitted to change it. I was very unhappy about that.”
Well, today—
Andy Burnham
On a point of order, Mr Speaker. Is it in order for the Secretary of State to misrepresent the views of the previous Government and previous Ministers, and refuse to take interventions? He has just said that I refused to change and strengthen the regulation system of hospitals in England—that is factually incorrect. I brought forward a new system for the registration of all hospitals in England in autumn 2009, on the back of recommendations from the CQC. Again, he should get his facts straight at that Dispatch Box.
Mr Speaker
I am grateful to the right hon. Gentleman for his point of order, and I make two points in response. First, every Member and every Minister must be responsible for his or her comments in the Chamber—the accuracy and appropriateness thereof. I am afraid that, however angry people feel, on either side of the argument, these are matters of debate. Secondly, the situation would be greatly helped if the Secretary of State now, immediately, turned his mind to the presentation of the argument in support of the introduction of the Bill, which is, ordinarily, the matter upon which one anticipates a Secretary of State will focus his remarks. This is not an occasion for a historical legerdemain; it is an occasion for the presentation of the case for a Bill, to which I know that, without delay, the Secretary of State will turn his mind.
Mr Hunt
I am delighted to do so, Mr Speaker, and I know that you would think it was legitimate of me to hold the Labour party to account for its decision if it is voting against today’s Bill or declining to support it, as its amendment clearly states.
However, today is a day to rise above party political considerations, as Mr Speaker has just said, and recognise that putting these things right is overwhelmingly in the interests of patients. If the Labour party continues its stubborn refusal to support legislative underpinning for a new chief inspector of hospitals, which is in today’s Bill, how will it ever be able to look patients in the eye again? Perhaps the most shocking thing about Mid Staffs, which is one of the reasons we have so many provisions in the Bill, was not just the individual lapses in care but the fact that they went on for four long years without anything being done about them.
Barbara Keeley (Worsley and Eccles South) (Lab)
Will the Secretary of State give way?
Mr Hunt
I am going to make some progress.
When problems are uncovered, action must be swift. Robert Francis cited confusion over which part of the regulatory system is responsible for dealing with failing hospitals, so this Bill makes it clear where the buck stops. It is the CQC’s job to identify problems and instigate a new failure regime when it does so. Monitor and the Trust Development Authority will then be able to use powers to intervene in those hospitals, suspending foundation trusts’ freedoms where necessary to ensure that appropriate action is taken. If, after a limited period, a trust has failed significantly to improve, the Bill requires a decision to be taken on whether the trust needs to be put into special administration on quality grounds—and, yes, where necessary, a trust special administrator will be able to look beyond the boundaries of the trust and consider the wider health economy. As we know from Lewisham, that is not easy, but we will betray patients if we do not address failure wherever it happens.
Dame Joan Ruddock (Lewisham, Deptford) (Lab)
Why, when the Secretary of State and the Prime Minister have clearly set out the four tests that have to be met for any downgrading of hospital services, is he now introducing this clause? Those greater powers will totally undermine the clinical commissioning groups that his Government set up to meet local clinical and health needs, and not to balance the books for people outside their area.
Mr Hunt
I recognise that the right hon. Lady campaigns hard for her constituents. The four tests set out by the Prime Minister were never designed to require unanimous support from local CCGs for necessary changes. If we had to secure that, it would be virtually impossible to make any major reconfigurations. Where there is a failing hospital, it is important to resolve and address situations. There are exceptional occasions when that cannot be done in an individual trust’s area. The change in the law will not apply retrospectively to Lewisham, but it is right to ensure that, if we are to learn one lesson from what has happened in recent years, we deal much more quickly with failing hospitals, and that applies to South London Healthcare NHS Trust as well. Governments and the NHS must never again sit on coasting or failing hospitals for year after year without doing what it takes to sort them out. That is why this year, for the first time, we have put 13 hospitals into special measures. How utterly inexplicable but sadly predictable it is that the Labour party, which failed to sort out those problems, is today refusing to back the changes that mean those mistakes can never be repeated.
Another lesson from the Francis inquiry is that we need to create a culture of openness in health and social care so that, rather than being bullied and intimidated, doctors and nurses feel they can speak out about problems. The Care Bill will introduce a duty of candour as a requirement for registering with a CQC. That means that honesty and openness must come as standard for every organisation. We are also introducing a new criminal offence that will apply to care providers that supply or publish false or misleading information. Directors and other senior staff involved in committing the offence will be held to account. In addition to the Bill, the professional regulators have agreed to place a new strengthened professional duty of candour on all doctors and nurses. The Government are on the side of openness and transparency in our health care system.
Grahame M. Morris (Easington) (Lab)
I am sorry that the Secretary of State has not made any reference to part 1 of the Bill, which is about care and support. I hope he will come on to it, because it is so important. Perhaps he will also explain why Francis’s recommendations on a duty of care are being applied to organisations but not to individuals?
Mr Hunt
As the hon. Gentleman knows, we considered that matter carefully. We decided that the best way forward is to strengthen the professional duty of candour on individual doctors and nurses through their professional codes. After extensive consultation, which was supported by the medical profession, including the British Medical Association, we decided that that was a better way of ensuring that we had the right outcomes and did not create a legalistic culture that could lead to defensive medicine, which would not be in patients’ interests.
If supporting the Francis measures in the Bill is too awkward or embarrassing for Labour Members, can they not see the merits in the parts of the Bill that deal with out-of-hospital care? I am talking about not just vulnerable older people, but carers, for whom we need to do more. We need to do much more to remove the worry that people have about being forced to sell their own home to pay for their care.
Mr Hunt
I want to make some progress.
At Committee stage, we intend to table amendments to enable the creation of a £3.8 billion better care fund in 2015-16. That represents the first significant step any Government have ever taken to integrate the health and social care systems.
Mr Hunt
I will give way in a moment, but let me make some progress first.
I commend the right hon. Member for Leigh (Andy Burnham) for championing integration, although he chose not to do anything about it when he was in office. How, then, when a Government take steps to do that for the first time, can he possibly justify not supporting it?
Hazel Blears
At a time of austerity, when there is very little public money around, the need for innovation and creativity is much greater. On reflection, does the Secretary of State regret not being more ambitious in the Bill about the full integration of health and social care in order to maximise the impact for those who need care and support—unlike my right hon. Friend the shadow Secretary of State for Health, who has talked about whole person care and full integration?
Mr Hunt
With the greatest of respect to the right hon. Lady, who, I know, played a good role in the G8 dementia summit last week, the Bill is extraordinarily ambitious. Nearly £4 billion is going into a merger of the health and social care systems. The previous Government had 13 years to do something about this and they did nothing. We are delivering. I hope, if she believes in this, that she might at least support the Bill in the Lobby tonight and not decline to support it, as her party’s amendment suggests.
The fund will ensure joint commissioning and the seamless provision of services, preventing the nightmare of people being pushed from pillar to post with no one taking responsibility. It has led to the unprecedented step of the NHS and local authorities working together in all 152 local authority areas to plan joined-up services.
Mr Hunt
I am going to make some progress.
Thanks to our reversal of Labour’s 2004 GP contract, vulnerable people over 75 will have an accountable, named GP responsible for making sure they get the wraparound care they require.
The collapse of Southern Cross showed the risks to people’s care when providers fail, so through the Bill we are introducing provisions to help ensure that people do not go without care if their provider fails, even if they pay for their own care. The CQC will monitor the financial position of the most difficult-to-replace providers in England to help local authorities provide continuity of care in a way that minimises anxiety for people receiving care.
We also need to improve the training of health care assistants and social care support workers. For the first time, health care assistants will have a new care certificate to ensure they get training in compassionate care and the Bill allows us to appoint a body to set the standards for that training. That means that the public can be assured that no one will be assigned to give personal care to their loved ones without appropriate training or skills. My hon. Friend the Minister of State, who is responsible for care and support, will have more to say on those elements of the Bill when he closes the debate and I thank him for his outstanding work on raising standards in that area.
We also need to address the funding of care. At the moment, people fear being saddled with catastrophic costs and even having to sell their home at the worst possible time to pay for their care. The Care Bill significantly reforms the funding of care and support, introducing a duty on local authorities to offer a deferred payments scheme so that people will not be forced to sell their homes in their lifetime to pay for residential care.
We will also introduce a cap on people’s social care costs, raising the means test at which support from the state is made possible and delivering on the recommendation of the independent Dilnot commission.
Andrew George
I am very grateful to my right hon. Friend for giving way. He says that everyone will be protected, but of course the cap on care costs is not a cap on “daily living costs”, as the Bill puts it. Will he therefore confirm that the £70,000—or whatever figure the cost ends up at—will not be the end of the costs for many people going into residential care?
Mr Hunt
My hon. Friend is right. We followed the recommendations of Andrew Dilnot, who did not think that the cap should apply to hotel costs, and, indeed, the policy that the Opposition followed in their national care service White Paper. We think that it is reasonable to cap the care costs. There is a cost issue—we would like to be more generous, but by the end of the next Parliament this proposal will cost nearly £2 billion. People who would like a more generous system must be obliged to tell us where they will get the extra funding.
Mr Hunt
The right hon. Gentleman will have a chance to speak later.
We want to be one of the first countries in the world where it is as normal to save for one’s social care costs as it is for one’s pension, and this Bill’s provisions make that possible. The deferred payments scheme, with a threshold of £23,250, on which we openly consulted, excludes only the wealthiest 15% of people entering residential care. How extraordinary it is that Labour should play politics by feigning concern for the richest in society, when they failed to do anything for the poorest over 13 years when they had the chance to do so.
Mr Hunt
The Government’s response to the tragedy of Mid Staffs has been widely welcomed, which is why the Opposition’s stance today is so disappointing. Robert Francis welcomed our measures as a
“carefully considered and thorough response”
to his recommendations that will
“contribute greatly towards a new culture of caring and making our hospitals safer places for their patients.”
The BMA said that it supports
“the Government’s commitment to put patient care first and foremost”.
The Patients Association said that it believes that this
“is a move towards restoring the faith patients have in the NHS.”
This Government would prefer to proceed on vital matters such as this with cross-party support, but I must warn the Opposition that we will do what is right for patients, whether or not we have their support. If they are today refusing to learn those lessons by not supporting this Bill, the country will draw its own conclusions about their fitness to run the NHS. They will know that for Labour it is all about politics, and it is politics before patients every time. We, on the other hand, profoundly believe that if we focus on patients, our NHS can be the safest, highest quality, most compassionate and fairest health care system in the world, and we will stop at nothing to make that happen. I commend this Bill to the House.
Mr Speaker
Order. I should give notice to the House that there will almost certainly have to be quite a tight time limit, but I await the conclusion of the Front-Bench speeches before determining what that time limit should be. I mentioned to the House that the amendment has been selected.
Andy Burnham (Leigh) (Lab)
I beg to move
That this House, whilst affirming its belief that the Care Bill [Lords] is a modest step towards a better social care system that protects some people from catastrophic costs, and welcoming the new rights for users and carers that the former Labour Government initiated, notes that the Bill’s deferred payment scheme will result in people continuing to have to sell their homes to pay for care; disagrees with the Government’s assertion that their proposals will cap care costs at £72,000 given that self-funders will face far higher bills; further notes that it includes provisions which could put NHS hospitals at risk of having services reconfigured without adequate consultation and without clinical support; further notes that the Bill fails to include measures to address the current crisis in care and meet the needs of the UK’s ageing population, including a genuinely integrated NHS and social care system; and therefore declines to give a Second Reading to the Care Bill [Lords] because it is an inadequate response to the scale of the challenge facing social care and fails fully to implement the recommendations of the Francis Report.
The Bill began as a response to the Dilnot report and a reform of social care, but has since taken in major new measures on the NHS. It deals with issues that matter greatly to millions—issues to which that very thin speech we have just heard did not do justice. Worse, it was an inappropriate attempt to turn an occasion such as this into the latest stage of the Secretary of State’s political smear campaign. I refuse to sink to his level, and instead will deal with the important issues before the House today. For clarity, I will take the issues separately—social care, then health.
Providing good care for all older and disabled people and finding a fair way to pay for it is the greatest unresolved public policy challenge of our times. The failure of successive Parliaments to face up to it has left in place today a care system in England which is underfunded, overstretched—[Interruption]—and in danger of being overwhelmed—a malnourished, minimum wage service where care is given in 15-minute slots, with barely time to make a cup of tea, let alone have a meaningful conversation or make someone comfortable.
Alison McGovern (Wirral South) (Lab)
Members can hardly say “Ah!” after the performance that we just saw at the Dispatch Box. On the important issue of social care that my right hon. Friend is coming to, he knows that 100 or more of my constituents turned up on a Friday evening to talk to me about that. They want to hear from us today what we are going to do to fix the culture of low pay and poor conditions in social care, so will he say what he thinks local authorities can do, especially given the level of cuts that they face from this Government?
Andy Burnham
The issues are huge. They affect every family in this country and the worries they have about how they will look after their mum and dad in later life. They did not hear any answers from the Government this afternoon. I hope my hon. Friend will hear a few from me. I know that she has campaigned on the use of zero-hours contracts in our care system. Is it not a sad reflection on both sides of the House that today in England around 300,000 care staff are working on zero-hours contracts? They do not have the security of knowing what they will earn from one week to the next, so how can we expect them to pass on a sense of security to those they care for? Is not the message that we are sending to people who work in our care service, particularly young people coming into the service, that looking after someone else’s mum or dad is the lowest calling they can answer, when really it should be the very highest?
Julie Hilling
Would my right hon. Friend have been as shocked as I was yesterday when I met the carer of a woman who will be 99 next week and discovered that she has a five-minute call at tea time and a 10-minute call at bed time?
Andy Burnham
I would like to say that I would have been shocked, but I know that the system just gets worse and worse each year as the pressure builds and corners have to be cut, and it is older people and their families who are paying the price. How can any “care” be given in five minutes? Of course it cannot. It does not make financial sense in the long run, because we have a care system that does not provide people with support in their own homes, buts leaves them to drift towards hospital, leaving our acute hospitals increasingly and unsustainably full of frail older people.
Richard Graham (Gloucester) (Con)
I am slightly confused, because we have been called to the House today to debate the amendment tabled by the right hon. Gentleman, which states that this House
“declines to give a Second Reading to the Care Bill”,
but I thought I heard him tell the Secretary of State for Health earlier that he is not opposing the Bill’s Second Reading. Will he please clarify that?
Andy Burnham
I would have thought that the hon. Gentleman had been here long enough to know the difference by now. We will not oppose the Bill, in the sense that we will not vote against it on Second Reading, but it contains measures to which we simply cannot give a clear endorsement, as I will go on to explain. That is the purpose of our reasoned amendment. We will not oppose the Bill’s passage on Second Reading, which is why I objected to the Secretary of State misrepresenting my position.
Andrew George
I was going to make a similar point. Is it wise to bring forward an amendment of the type the right hon. Gentleman has tabled, bearing in mind the rather partisan nature of the debate we have had so far? What we really wanted was a debate on the Bill’s contents. Does he not now regret having brought forward such an amendment, because it has precipitated our going down into the gutter of partisan politics?
Andy Burnham
I agree with the hon. Gentleman, which is why I am not opportunistically opposing the Bill. I have tabled a reasoned amendment to put on the record the very serious concerns people have about funding for local authority care in England, the way the new cap will work and, in particular, the proposed clause on hospital reconfiguration—the Lewisham clause. I cannot let those concerns pass without making clear our position on them from the Dispatch Box. That is why we have taken that stand. That is why I am seeking to introduce my remarks in a non-partisan way.
Jacob Rees-Mogg (North East Somerset) (Con)
Will the right hon. Gentleman give way?
Andy Burnham
No, I want to make some progress.
I described the care system we have in England. Surely we can do better. In the last Parliament, the previous Government began a serious attempt at reform. I give this Government credit for continuing some of that work. The Bill contains many proposals originally put forward in my White Paper “Building the National Care Service”, published in February 2010. What most people will remember from the pre-election period was the clash between the parties on funding solutions, but what they might not have realised is that beneath the rhetoric there was much common ground on other matters. I hope that people will welcome that, just as we welcome some of the measures that are carried forward into the Bill.
First, stronger legal rights and recognition for carers are well overdue. For far too long, informal and family carers have been invisible to the system and taken for granted. That simply cannot go on. If statutory services are to be sustainable in the 21st century, they must learn to value informal care and carers and help them do more to help their loved ones. Secondly, we welcome efforts to simplify the social care system. Better information and advice will make a difference to some people. Unifying social care legislation in line with the recommendations of the Law Commission review initiated under the previous Government is sensible and overdue. Thirdly, the idea of a cap on the overall costs of care that individuals can face establishes the important principle that people should not lose everything they have worked for because of their vulnerability in later life.
I am happy to say that those are all important steps forward that we would not seek to oppose. However, let me be clear—this answers the points raised by Government Members—that this Bill is not equal to the scale and the urgency of the care crisis in England. It fails to implement the Dilnot report and does not provide a lasting solution. It does little or nothing to improve care services now or to reduce the costs of care for most people; in fact, it is likely to make things even worse. That is why we have tabled a reasoned amendment to draw the House’s attention to two major problems with the Government’s approach. First, prioritising funding a cap over and above protecting existing council budgets means that the care system will continue to go backwards and get worse, not better. In short, the Government are promising future help instead of helping people right now. Secondly, the proposed £72,000 cap is not what it seems; it is a care con.
On funding priorities, the Government are failing to face up to the scale of the funding crisis facing councils right now. In the cross-party talks on the Dilnot report, Labour stated a clear principle that the cap and the council baseline must be considered together as equal priorities. That was supported by Andrew Dilnot himself, as the right hon. Member for Sutton and Cheam (Paul Burstow) may remember, because he was also party to those talks. As a first step, we called on the Government to use some of last year’s NHS underspend to tackle the care crisis—and, by extension, to ease pressure on A and E—instead of handing the money back to the Treasury. The Government have not listened to that, and this Bill makes matters worse for local authorities by placing new, unfunded and uncosted burdens on them. The fact that it restricts the eligibility of those in substantial or critical need of support is, in itself, a clear admission on the Government’s part that the support system overall is being scaled back.
Mrs Madeleine Moon (Bridgend) (Lab)
I spent 30 years making assessments of people who were in care and addressing the care that they needed, often while working in hospitals to get them discharged. After 30 years, the same problem exists: there is not enough money in local government to pay for the care to get people home early to have the rehabilitation they need at home, with the quality of care to make sure that they do not deteriorate further and end up back in the hospital system. This Bill will not tackle that fundamental underlying problem.
Andy Burnham
My hon. Friend is absolutely right. This Bill promises far-off help for people while services are getting worse right now, because the Government have failed to address the crisis in local government’s ability to fund social care.
Andy Burnham
I shall in a moment.
What are the direct and practical effects of those cuts to council budgets? First, councils have cut eligibility criteria, so more people are exposed to care charges in a way that they were not before. Secondly, those care charges are now rising above inflation year on year, so more people are exposed to higher charges. This means that they are now more likely to pay right up to the new cap that the Government are introducing. That will not feel like progress to the public, and that is why we are making our reasoned objection to the Bill.
The Minister of State, Department of Health (Norman Lamb)
I am sure the right hon. Gentleman agrees it is important that we are accurate about these matters. He suggested that the Bill “restricts”—that is the word he used—eligibility for substantial or critical care. Does he accept that it does not do that, and that any council that wants to have more generous eligibility can continue to do so?
Andy Burnham
I do not disagree with the approach of setting national eligibility criteria and taking a national view, so I agree with the Minister on that. The problem, however, is that if the Government legislate for just critical and substantial levels, they are sending a very clear message to local government that they believe they can only afford to fund it at those levels. Surely the criteria would have been set higher if they were funding local government better.
The truth is that when this Government came to office, many more councils in England were providing social care at “moderate” level. That has been slowly cut back and now only about 23 councils are still providing support to people with moderate needs. It is a fair bet that those councils will soon be unable to provide moderate care and shrink back to providing only critical and substantial care.
Norman Lamb
Does the right hon. Gentleman accept that more than 100 councils were setting the eligibility criteria at “substantial” when his party left office? Is he saying that a future Labour Government would fund eligibility criteria at moderate level? If so, how would he fund it?
Andy Burnham
That is a political point; let me deal with it. When we left government, 38 councils were providing some free care to people with either low or moderate needs. I correct the figure I gave a moment ago: it is, in fact, 15 councils that are now doing that. The care system is being scaled back. Therefore, people are more liable to charges and are more likely to have to pay them, because support is being withdrawn from people in the home.
Andy Burnham
I was about to explain that those charges are increasing quite quickly, but first I will give way to my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley), who has done so much to raise these issues.
Barbara Keeley
I thank my right hon. Friend for giving way and I am surprised and disappointed that the Secretary of State would not give way.
My local council, Salford local authority, is one of the many that are reluctantly having to cut their eligibility criteria this year. Salford tried to stick with the moderate level and this is the third year of cuts. The council has lost £100 million over the past three years and it will lose another £75 million before the Bill’s reforms are implemented. That is a 20% cut in adult social care. How can any of the Health Ministers, whose southern local authorities are not affected in the same way, think that our northern councils can afford this?
Andy Burnham
Those are the facts. The councils that are still trying to provide support to people with moderate needs are not all, but by and large, Labour councils. They are still trying to do that, but they have lost significantly more per head under this Government than councils elsewhere. The situation is about to get a lot worse, because NHS England will meet tomorrow to consider a major change to the NHS resource allocation formula, which will reduce the weighting given to health inequality and increase the weighting given to age. That will have the effect of taking more money out of Salford and Wigan and giving more money to areas where healthy life expectancy is already the longest. The Government are making it impossible for people who want to do the right thing.
Mr Jeremy Hunt
Local authority budgets were indeed cut to deal with the deficit, so will the right hon. Gentleman tell the House whether he would reverse those cuts—yes or no?
Andy Burnham
The Secretary of State may remember that when he came into government he stood on a manifesto promising real-terms increases. He and the Prime Minister have stood at the Dispatch Box every week since the election saying that I said that we would cut the NHS, but that is not the case: I stood on a manifesto promising protection for the NHS in real terms. I said that if there were to be real-terms increases they should be given to social care instead, because it would be “irresponsible”—that was the quote—if the Government overfunded the NHS only to let social care services collapse: it would be a false economy, because it would push more and more older people into hospitals, and hospitals would stop functioning.
Do you know what? That is happening right now. The Secretary of State’s cuts to social care are forcing more and more older people into hospital. That is why he has an A and E crisis—because hospitals are full. On his watch there has been a 66% increase in people aged over 90 going into A and E via blue-light ambulances. If he is proud of that, that is up to him, but I certainly would not be.
Mr Andy Slaughter (Hammersmith) (Lab)
I am not surprised that the Secretary of State wants to change the subject, because if that decision is confirmed tomorrow my clinical commissioning group will lose £29 million—13% of its budget for hospital care. It has some of the poorest health outcomes, but that money will go to places where life expectancy and health outcomes are much better—in other words, Tory-controlled areas. That is a disgrace, coming on top of the closure of fine hospitals such as Charing Cross and emergency hospitals. That is the truth about what this Secretary of State is doing and I am afraid that all we have heard today is political spin.
Andy Burnham
The Secretary of State began by quoting the principles of the NHS. I was always led to believe that one of the principles is that the NHS should respect need—that funds should follow those in greatest need. [Interruption.] The Secretary of State says, “Absolutely.” In constituencies in parts of London, the midlands, the north-west, Yorkshire and the north-east, male life expectancy is 10 years lower than in other parts of the county. There is real need in those communities, but they will be the biggest losers if the change goes ahead. I believe that it is immoral to take money out of those communities to hand it to areas where life expectancy is already longer.
I hope that NHS England is listening to this debate. Quite apart from the morality of whether the change should be made, how is it that a quango can distribute about £80 billion of public money to our constituencies while we seemingly have no locus whatever in such a decision? Should not the Secretary of State be at the Dispatch Box either to defend changes that he makes or to say that such changes will not go ahead, so being accountable to this House? Instead, a quango—the biggest in the world—seems to be about to take money out of some of the most deprived parts of the country.
Kate Green
I was very disappointed that the Secretary of State would not give way to me, because he did not once mention the position of disabled people in his opening remarks. Does my right hon. Friend not agree that councils being forced to raise the threshold to “substantial” or “critical” will pile up costs for disabled people and their isolation? They cannot get access to moderate levels of care, go out to work or volunteer in their communities, but are shut at home unable to participate. That is bad for them, and it is a false economy.
Andy Burnham
I could not agree more. I would guess that disabled people listening to the debate today will be very worried about what they are hearing. The change will restrict support for them, and it is a false economy. If they cannot go out to work, how on earth does that help them or, indeed, anybody? The change will have an impact on disabled people, with some losing their support.
I was going on to make the point that disabled people and older people are already paying much more for care as a result of changes in recent years. As research by my hon. Friend the Member for Leicester West (Liz Kendall) has shown, they are paying almost £740 more a year for vital home case services compared with 2010, up on average by almost £50 a month. That is a hidden cost of living crisis, because who sees that older people have to pay more out of their bank accounts? It goes unnoticed by the media and large parts of society, but the most vulnerable people in society are bearing the brunt.
Dr Sarah Wollaston (Totnes) (Con)
I am glad that the right hon. Gentleman has mentioned older people. Does he accept that although health inequalities are very important in setting funding formulas, age is one of the greatest predictors for establishing need? It is absolutely vital to include such factors as age and rurality in deciding funding formulas, and it is precisely to remove the politicisation of such decisions that we are handing them over to another body.
Andy Burnham
The hon. Lady must have misunderstood me. I am not saying that age is unimportant; I am saying that age is important, but so is need. In my view, those two must have equal weighting in the system, as they do at the moment. As I understand it, the proposal is to deprioritise need or deprivation as part of the funding formula, which will have the effect of removing funding from communities in which the expectancy for a healthy life is already shortest. I do not believe that that is defensible, and I would be surprised if she found that it was.
Dr Wollaston
The right hon. Gentleman is being generous in giving way. The point is that we are discussing the Care Bill and how need relating to age is the single greatest predictor of someone’s need. I accept that health inequality is a very important factor, but the formula currently does not take enough note of age-based need and multiple long-term conditions.
Andy Burnham
I am not sure that I agree with the hon. Lady. Some older people in my constituency probably do not have as good a quality of life in later life as some in her area, because there are ex-miners with chronic obstructive pulmonary disease and other things, who have very extensive needs caused by the dangers they were exposed to during their working life, and that places a burden on our health service. Of course, people are more likely to be living with chronic disease in more deprived areas, and both those things have to be recognised in the funding formula. If the change goes ahead, it will cause great volatility and move a lot of money around the system, but it will not allow areas such as the one I represent to invest in the home-based, high-quality, integrated services that the Secretary of State said he wanted.
To return to the costs of care charged by councils, let us call the hikes in charges what they are—stealthy dementia taxes that seek out the most vulnerable people in our society. The more vulnerable someone is and the greater their need, the more they pay. People who are paying more for care under the current Government and often receiving a worse service will not be convinced by the Secretary of State’s claims for his Bill today. It will feel like a con, and that feeling will only intensify when people understand more about the proposed cap.
Although we welcome the principle of a cap, this one is not what it seems. It is set at £72,000, despite Dilnot warning that a cap above £50,000 would not provide adequate protection for people with low incomes and low wealth. The Health Secretary has repeatedly said that people will not have to pay more than £72,000 for care.
Andy Burnham
The Secretary of State is nodding, but I hope he will be honest enough to admit today that that is simply not the case. In reality, the average pensioner could pay more than £150,000 for their actual residential care home bill—£300,000 for a couple—before they hit the so-called cap. I will explain why. It is because the cap will be based on the standard rate that local authorities pay for a care home place, not the actual amount that self-funders are charged, which is often much higher than the council rate. It is estimated that in 2016-17, when the cap is due to start, the average council rate for residential care will be £522 a week, and the average price of a care home place will be £610 a week. That is because self-funders pay more than councils. However, that will not be taken into account when the cap is calculated.
Paul Burstow (Sutton and Cheam) (LD)
Will the shadow Secretary of State confirm to the House that the use of notional costs, which he is describing, was not a Government proposal but one of the Dilnot commission’s recommendations?
Andy Burnham
I remember that the right hon. Gentleman showed a good deal of support for the Dilnot proposals, as did we, but they worked as a clever package. They were carefully constructed to ensure that the system would work, be progressive and provide support to everybody. They have now been pulled apart and different figures have been introduced.
Andy Burnham
The right hon. Gentleman shakes his head, but a £72,000 cap is not what Dilnot recommended. That is the Government’s problem. As I said before, the cap will not cover hotel and accommodation costs, either. When both factors are taken into account, an average person in England will take almost five years to hit the so-called cap. Based on average stays in care homes, that means that six out of seven elderly people will have died before they reach it.
If that were not bad enough, people are about to find out that the promises that they will not have to sell their home are also a con. The ability to defer payment for care was one of Andrew Dilnot’s central proposals designed to stop people worrying about selling their home while they were alive. He said that old people would be able to borrow from the local council and repay care bills from what they left behind. The Government initially said that they would implement that proposal and introduce what they called a universal deferred payments scheme. I remember when they used to call that type of proposal a death tax, but things have seemingly moved on for the better.
However, on the day when Parliament rose for the summer recess, the Department sneaked out a consultation document saying that pensioners would not qualify for any help under the universal deferred payment scheme until their savings and other assets, such as valuable possessions, had been run down to below £23,250. That new condition will prevent almost half of those who would otherwise have been able to take advantage of that apparently universal scheme from accessing it.
Norman Lamb
Does the right hon. Gentleman accept that that was exactly the same proposal as his party’s Government put forward just before they left office?
Andy Burnham
Just as the Government’s proposal is not the Dilnot report, it is not my national care service proposal. I had a range of different proposals, and that one has to be considered in that context.
As the Minister knows, I proposed a universal approach in which everybody would contribute on the NHS principle—I seem to remember that he and I were in some agreement about that. That was a deferred payment, but this proposal is different. The Government are talking about a universal deferred payment scheme in which people will pay from what they leave behind, but—and this is the point—it will not be available to everybody. That was the promise the Minister has broken.
Grahame M. Morris
My right hon. Friend is making excellent points. On deferred payments, this proposal has been presented as something new, but is it not the case that about 90% or 95% of local authorities currently offer a similar scheme?
Andy Burnham
They are offering a similar scheme but at the moment they are not allowed to charge interest on it. That brings me to the next part of what is wrong with these proposals. What the Health Secretary has not said today is that interest will be charged on his proposed deferred payment scheme, which is not universal because it is not available to everybody. A loan to cover the average length of stay in a care home—two and a half years—would clock up extra costs of £3,500 in interest alone. That interest would not be included in the cap but would be outside it. Again, people will not feel that what they are paying is related to a cap.
Andy Burnham
I noticed that the Secretary of State was not very good at giving way, and I hope in future he will bear that in mind.
Andy Burnham
I was proposing a fundamentally different policy in a national care service. I ask the Secretary of State politely whether it is about time he stopped trying to say that everything is about the past? Why did he not stand there, explain and justify his own policy? Would that have been a good thing for him to have done today, instead of leaving it to me to explain what he is proposing?
Mr Stephen Dorrell (Charnwood) (Con)
In the interests of explaining his policy, will the right hon. Gentleman confirm that the answer to the question posed by the Secretary of State and the Minister was, “Yes”?
Andy Burnham
I say again, with all respect to the Chair of the Health Committee, that I was proposing a fundamentally different scheme to that in the Bill. I was proposing a universal all-in scheme, and several steps were put forward to get us to that. The right hon. Gentleman knows that because the Conservative party and those on the Government Front Bench put posters up about that scheme before the last election. Does he remember that? [Interruption.] He nods, right—that was my proposal, but it is not the Government’s proposal, which is different. I proposed various steps to get to my scheme. Is it about time the Government started answering for their proposal, rather than for mine?
Barbara Keeley
My right hon. Friend is being generous in giving way, and I guess we ought to move on shortly. There is all this harking back to our policies, but I understand—I was here—that steps were taken towards Labour’s national care service, including the Personal Care at Home Act 2010 that would have helped 400,000 people, not the 100,000 who will be helped by this Bill—if, indeed, it ends up being 100,000. Is my right hon. Friend, like everybody else, totally disappointed with the Government’s lack of ambition to help people?
Andy Burnham
I completely agree, and it is unfair that older people have not been given a full picture. People need proper information to plan for the future, and they have not been getting that today. People need the facts. Spin is of absolutely no use to them whatsoever, but that is all that is on offer from this Secretary of State. The truth is that in the end, the Bill will not stop catastrophic care costs that run into hundreds of thousands of pounds, or stop people losing their homes. It will not improve services now as it promises only a vague review of the practice of 15-minute visits, and strips the Care Quality Commission of its responsibility to inspect local authority commissioning, which is often responsible for such things.
Andy Burnham
I will make some progress and turn to part 2 of the Bill and measures related to the NHS. It would help to get a few facts clear. The Secretary of State seeks to denigrate Labour’s record at every opportunity, but let me remind him that the Labour party left an NHS rebuilt with the lowest ever waiting lists and highest ever public satisfaction. The previous Labour Government introduced independent regulation of NHS hospitals for the first time, prompted by previous scandals at Bristol, Alder Hey and the Shipman murders. The Secretary of State should cast his mind back a little further before coming to the House and making unfounded allegations.
As Robert Francis rightly acknowledged in his report, there was no system of independent regulation before 1997. It was the independent regulator that first uncovered the failings at Mid Staffs and, later, at Basildon. As the party that introduced independent regulation in the NHS, Labour has no problem with strengthening it and providing legislative backing for the appointment of chief inspectors for hospitals, general practice and social care, but let us be clear: those were not recommendations of the Francis report.
The Secretary of State accused us of not supporting the Francis report. We do support the report; it is the Government who are not implementing its recommendations. Just as part 1 of the Bill fails to implement the Dilnot report, part 2 fails to implement the Francis report. One of the report’s central recommendations was for a statutory duty of candour for individuals, but the Government are proposing that it should apply only to organisations. How will an organisational duty help individuals to challenge an organisation where there is a dysfunctional culture? It will not, and we urge Ministers to think again. They also need to clarify whether the duty will cover the most serious incidents, and whether it will apply to all organisations that provide NHS services, including outsourced services.
My main objection to part 2, however, is that it embodies the huge contradiction that now sits at the heart of Government health policy. The Secretary of State talks of independence for the Care Quality Commission in the same way as the Health and Social Care Act supposedly legislated for the independence of the NHS, but this is the Secretary of State who has taken to ringing up hospital chief executives who are not meeting their A and E targets. The Secretary of State nods, but that is not “independence of the NHS”. This is the Secretary of State who holds weekly meetings with the supposedly independent CQC, Monitor and NHS England. What precisely is the Government’s policy on independence? People are becoming confused. Clause 118 makes it clear that the Secretary of State wants more control: he wants sweeping powers to close hospitals without proper consultation and clinical support.
Dame Joan Ruddock
Does my right hon. Friend recall that in the case of the failing South London Healthcare NHS Trust, the trust special administrator got his financial projections wrong? He massively overspent his own budget, and failed to point out the consequences for the solvent Lewisham hospital, which was in a different trust and which, as a result, did not consult on them. Does my right hon. Friend imagine that there is any way in which such a consultation could take place and produce good outcomes in just 100 days?
Andy Burnham
I pay tribute to my right hon. Friend. She and the people of her community stood up to an arrogant Government, and won a victory for every community that was worried about the future of its hospital. One would have thought that, following humiliation in the courts, the Government would have backed off gracefully, but no: here comes the Secretary of State again today, like someone who, having been caught breaking in through the back door, has the brass neck to return and try to force his way in through the front. Well, we will not let him get away with it. We give him notice that clause 118 is wrong, that it is an affront to democracy, and that we will oppose it every step of the way.
Hospital reconfiguration should always be driven by a clinical case first and foremost, but clause 118 paves the way for a new round of financially driven closures. It rips up established rules of consultation and the clinical case for change. It allows the Secretary of State to reconfigure services across an entire region for financial reasons alone, which means that no hospital, however successful, is safe. The House needs to stand up to this audacious power grab by the Executive.
Joan Walley (Stoke-on-Trent North) (Lab)
The clause introduced in the House of Lords gives extra powers to the trust special administrator. Are we not now faced with a complete contradiction? Rather than clinical commissioning groups commissioning services, the TSA will commission long-term services, and there has been no proper consultation. In Mid Staffordshire and North Staffordshire, for example, we have had a consultation procedure that has taken no account whatsoever of services in North Staffordshire.
Andy Burnham
That illustrates the confusion that is currently at the heart of the NHS. No one knows who is in charge of anything. What if CCGs and the boards of foundation trusts disagree with the conclusions of the TSA? How will that be resolved? Were we not told that doctors were sovereign? Were they not supposed to decide everything? Was that not the big call when the Government introduced their Bill? It seems that that is no longer the case: everything can be done “top down” by the Secretary of State. It takes power away from every Member and could be used as a back-door way to railroad through unpopular changes.
The real danger of the proposal comes when it is seen in the context of the competition regime created by the Health and Social Care Act 2012. Of course, it is sometimes necessary to make changes to local health services beyond just a failing trust. That is best done through partnership and collaboration, but such sensible changes are now being blocked by the market madness imposed by the Act. We recently saw the ludicrous spectacle of the Competition Commission intervening in the NHS for the first time to stop the sensible collaboration between Bournemouth and Poole. Since when did competition lawyers decide what was best for patients?
Andy Burnham
One reason the Lewisham clause is so worrying is that simple collaboration between hospitals to solve financial problems is no longer an option to ease financial pressures. That is what it has got to do with the Care Bill. The Government are making a case for all hospitals standing or falling on their own, and in that context, the weakest can be picked off by the Secretary of State and closed without consultation. Given the financial pressures on many organisations, this special administration process is likely to be used on an increasing basis, putting more hospitals at risk. That should send a shiver though every community represented in the House today.
Mr Jim Cunningham (Coventry South) (Lab)
Does my right hon. Friend agree that the Government seem to have adopted a drip, drip, drip strategy to discredit the NHS? I can remember him proposing a national care service some months before we left office, but the Conservatives rejected it.
Andy Burnham
They did, and they put those posters up at the election to try to scare older people—I do not know how they thought that was appropriate, in the same way I do not know how their contributions today have been appropriate.
What my hon. Friend the Member for Coventry South (Mr Cunningham) says is exactly what is happening. People are not daft. They can see what is going on. They saw a Government legislate to place the market at the heart of the NHS in a way that means we now have the Competition Commission making decisions and forcing services out to open tender. We also have a Secretary of State who does not waste a day running down the NHS—“uncaring nurses”, “lazy GPs”, “coasting hospitals”; everything undermined, everything wrong—rather than celebrating good care. That is the agenda. They are softening the NHS up for more privatisation.
That will be the big choice come the next election. The Secretary of State can spin whatever lines he wants from that Dispatch Box, but that is the choice: a public, proud NHS under Labour, or a fragmented market under the Conservative party. I know which side of the debate I am on, and that is the choice we will put to people.
Charlotte Leslie (Bristol North West) (Con)
Independent sector treatment centres—the right hon. Gentleman’s party started competition!
Andy Burnham
Across the NHS, people are spending millions on competition lawyers thanks to the Bill that the hon. Member for Bristol North West (Charlotte Leslie) and others passed. That is being cited as the major barrier to the integration that the Secretary of State claims he wants. Let me quote the NHS chief executive to back up that point. He recently told the Health Select Committee:
“What is happening at the moment…we are getting bogged down in a morass of competition law…causing significant cost in the system and great frustration for people in the service about making change happen… In which case, to make integration happen we will need to change it”.
By which he meant the Health and Social Care Act. It could not be clearer. It is the biggest barrier to the integration of care and support for older people. That is understood across the NHS, but the Bill does nothing about it.
Instead, the Government have left an NHS bogged down in competition law. How did it come to that? Who voted for that change? Who gave this Prime Minister and this Health Secretary permission to do something that Margaret Thatcher never dared—put the NHS up for sale? The answer is no one. Ministers talk the talk about integration, but they have legislated for fragmentation and privatisation, and the Bill does not change that. Only Labour will repeal the Health and Social Care Act, and that will be the big choice, as I say. We will bring health and care together, creating a public service working for the whole person. That is the only way we can reshape health and care services around individuals in their own homes.
In conclusion, the Bill makes some sensible changes that we will not oppose, but as our reasoned amendment makes clear, it falls far short of the durable solution that England needs. Social care in England is getting worse, not better, and the Bill does nothing to change that. It will not stop people having to lose their homes and savings to pay for care, and in the end it deceives older people about the amount they might have to pay for care, which is fundamentally wrong. Older people deserve better, and it will fall to Labour to have the courage to deliver it.
Madam Deputy Speaker (Mrs Eleanor Laing)
Order. As hon. Members will be aware, many people have indicated that they would like to contribute to the debate, but we have limited—albeit a long—time available. I must therefore impose a 10-minute time limit on Back-Bench speeches.
Mr Stephen Dorrell (Charnwood) (Con)
I welcome the Bill. I do not propose to follow the shadow Secretary of State into a discussion of competition policy, as there will be plenty of other occasions for that; it is not germane to this Bill. The reason I welcome the Bill is that it begins to look at health and care from a different point of view from the one with which those of us who have participated in health and care debates in this Chamber over a long period are familiar. When a Bill comes before the House, it usually starts off by describing the function of one bit of the bureaucracy—perhaps creating a strategic health authority or re-creating a different bit of the bureaucracy somewhere else on the landscape. This Bill starts in a quite different place.
Clause 1 talks about the “well-being” of individuals and suggests that if we are to build a health and care system that meets the needs of patients and users for the 21st century, we should, instead of thinking of it as a bureaucracy planned from the top down, think about the service that is delivered to individuals who rely on these services. Clause 1 talks about the needs of individuals, and later clauses place an obligation on local authorities to do needs assessments for those individuals.
Clause 2 introduces something that the health and care system has talked about since 1948, but almost never put real resource into, which is preventing the need for the delivery of health and care services, and particularly of acute health care. This Bill’s emphasis is on the needs of individuals and on the need we each feel as individuals to avoid unnecessary health costs and care. None of us wants to be a patient in an intensive care unit if it is avoidable. That is why clause 2 talks about the importance of prevention and avoiding the need for care.
Mrs Moon
Does the right hon. Gentleman appreciate that it is possible to carry out lots of needs assessment—goodness knows, I carried out many of them in my day—but that unless care is available to allow a patient to be discharged from hospital, it does not matter how many needs assessments have been done? In fact, the longer patients are in hospital, the greater their needs will be—they will not be able to walk, their incontinence will increase and so forth. What is important is to put the cart before the horse and make sure that the funding of community-based care is there. It is not there at the moment.
Mr Dorrell
I shall come on to that point, but to react directly to the hon. Lady’s point, surely it is much better to intervene before the patient arrives in hospital in the first place, preventing the avoidable episode of care. The hon. Lady talks about discharge, and she is, of course, quite right, but how much better is it to prevent the case from arising in the first place, which is what clause 2 is about?
Bill Esterson (Sefton Central) (Lab)
I think that is precisely the point my hon. Friend the Member for Bridgend (Mrs Moon) was making. The money simply is not there in local government. When 20% of the adult services budget has been lost, the services are not there and the care managers are not there to do the assessment to decide whether to keep people at home or to help them get out of hospital. The service back in the community, after people have come out of hospital, is not there either. Does the right hon. Gentleman accept that that money has to go back in?
Mr Dorrell
Of course I accept that if we have more money, we can do more, but I do not think that that exempts us, particularly given the public finances we inherited in 2010, from the obligation to see how we can get more for the £125 billion of taxpayers’ money that is already committed to health and social care in England.
That brings me to clause 3. The only way to deliver person-centred care and early intervention to prevent avoidable cases, is to reinvent care on a much more integrated model between the national health service and the social care authorities. That is why there is the obligation in clause 3 to consider integrating health and care. In that way we will not think of the NHS as one bureaucracy and social care as another, but instead think of it, as Mike Farrar said when he was at the NHS Confederation, as a care system that provides medical support when necessary, rather than as a medical system that provides care support when it has got the money—that is how not to do it.
Andy Burnham
The right hon. Gentleman will recall that the NHS chief executive stood before him and his Committee saying that the competition legislation was the biggest barrier to achieving the vision he is rightly describing; he and I agree about the vision of person-centred services in the home. If the NHS is saying that before his Committee, why does he say that the competition regime is irrelevant? Is it not fragmenting care, rather than integrating it?
Mr Dorrell
I did not say it was irrelevant; I said it was not germane to this Bill—and in the seven minutes remaining to me, I am not going to cover that. All I will say to the right hon. Gentleman is that the difficulty with competition policy that the NHS chief executive talked about is a difficulty that health care systems around the world—in north America and in continental Europe—are finding as well. I agree with the right hon. Gentleman, however, that we need to look at how competition policy can be aligned with the policy prescriptions I am describing.
I now want to list the fourth key premise upon which this Bill is based; in what must be a short speech, I can list only four. It is around the well-being of individuals; it is around early intervention and prevention; it is around integration; it is also, critically, for the first time in statutory form, around doing needs assessments that take account of the needs not just of the individual person, but of their carer and social context as well. In that way, the support that is provided to individuals takes account of the context in which they live, rather than treats them as individuals divorced from the carers and people who care for them when the statutory social worker is not there.
The Opposition spokesman said this is an enormously ambitious set of objectives, and I entirely agree that the objective of redefining the delivery of health and social care in a way that matches the aims set out in the first three clauses and clause 10 around carers is ambitious. The objective is to re-imagine care so that we think of the health and care system not as being primarily around acute hospitals, but as a system designed to meet the needs of that majority of people who are the main focus of those who work in the service—people who primarily have a care need with an occasional medical or clinical requirement. In other words, this is about thinking about the system from the front end rather than viewing it from the top of the bureaucracy. I commend this Bill because I believe it sets that framework in statute.
I also commend the Government because they are not just setting out these aspirations as commitments in law. It is one thing to change the law. It is another thing to change the way the service is actually delivered on the ground. The most effective step the Government have taken to achieve this re-imagination of care is the £3.8 billion that my right hon. Friend the Secretary of State talked about. That is £3.8 billion voted into the NHS but available only if the service at local level delivers the joined-up, person-centred care that is set out in the first three clauses of the Bill. So this is not just a set of wordy aspirations; it is a set of aspirations supported by the resources necessary to deliver the change in the care model that the Bill describes. The £3.8 billion is the catalyst that will allow us to deliver the objectives.
With respect to those on the Opposition Front Bench, it is wrong to say that it is only £3.8 billion out of £125 billion. The £3.8 billion is the minimum that the law will require to deliver integrated care within a locality, through the health and wellbeing boards that are much beloved of the right hon. Member for Leigh (Andy Burnham) and which were legislated for by the Government. This is an important step forward. If the health and wellbeing board in a locality can see a way to use health resources to deliver a changed model of care that puts more focus on prevention and on individuals through the delivery of more joined-up services, there is no constraint in the legislation, as I understand it, to prevent more than £3.8 billion from being used for the delivery of that objective.
Resources are important in this regard. This is partly about the £3.8 billion from the taxpayer, but it is also about individual resources. It is about individual users having their right set out in the Bill to engage with their personal budgets and with direct payments, enabling them to make real choices about how joined-up, person-centred care will work best for them. It is the curse of these health debates to imagine that we can gather 650 people together in this Chamber and work out how we are going to deliver £125 billion-worth of care in a way that will work for an individual old lady in her own home. That is nonsense; we need to engage the people themselves in the decisions on how the resources are used. We also need to assure them that they will not be exposed to catastrophic personal losses by making their own contributions to their care. That is why I welcome the fact that, despite what the right hon. Member for Leigh says, the Bill gives effect to the basic propositions set out in the Dilnot report.
The Bill sets out the vision of person-centred, joined-up, integrated care, and the Government have set out plans to commit resources to turn those fine words into deeds. Also, through the establishment of an independent Care Quality Commission, the Bill will provide independent assurance about the quality of care that is provided right across the health and care system. The right hon. Gentleman claims credit, as he is entitled to do so, for the fact that the previous Government took the first faltering steps down the road to introducing proper regulation of health and care provision, but he cannot possibly believe that the Care Quality Commission that he bequeathed was fit for purpose. If he does, he is the only man in the kingdom to do so. I welcome the fact that this Government are putting in place new management and, importantly, a new statutory framework so that the aspirations that might have motivated the Labour Government to set up the CQC will now be delivered in reality.
Hazel Blears (Salford and Eccles) (Lab)
I should like to begin by quoting one of the Alzheimer’s Society’s ambassadors, Arlene Phillips. Talking about her father, who had Alzheimer’s, she said:
“I did everything I could to care for my dad when we discovered he had dementia. Unfortunately, the efforts of one person—or even a family—aren’t always enough. It soon became clear to me that while I could keep Dad safe when I was by his side, I couldn’t be there every minute of every day.”
The words of Arlene, and thousands like her, should provide all of us in the House, irrespective of party, with the greatest incentive to act to support those people who are suffering and need care and, crucially, their carers and families, who are the backbone of the social care system in this country.
A society should always be judged by the way in which it looks after the most vulnerable people in its communities, and it is safe to say that, over the years, we have all failed that responsibility. Today is an opportunity for us to acknowledge that, and to point out that, even today, in a modern 21st century developed industrial nation, we are still failing the people who ought to get a great deal more support and care from us than we are currently in a position to give.
The Bill is a small step forward, rather than the giant leap for mankind that I would have liked. One of the central issues is a lack of ambition. We face the biggest social challenge that any of us could possibly see, yet the Bill’s provisions, some of which are well meaning, do not, when taken together, add up to a whole system’s series of changes that result in a basic reconfiguration. The right hon. Member for Charnwood (Mr Dorrell) spoke about that, and I pay tribute to his championing of integration, change, re-engineering and being ambitious. I do not see that in this Bill.
Instead, I see some perverse incentives. If we are talking about the well-being duty and the duty to prevent, reduce and delay somebody’s need for care, how can we say that we are going to support only people with substantial and critical needs? How are we going to engage the system further up the chain, with people who are beginning to suffer, perhaps beginning to have memory problems and beginning to need social care? How are we going to incentivise the system to invest in the new commissioning in clause 5, which talks about diversity and shaping the market? How are we going to get the system to focus on that if all the focus, after £2.85 billion-worth of cuts in social care, is on how we might manage to look after the people with substantial and critical needs? We should be focusing far more upstream in the system.
Meg Munn (Sheffield, Heeley) (Lab/Co-op)
As my right hon. Friend has said, the backbone of care in this society is provided by friends and family. Should we not be moving towards a system that incentivises the people currently giving care to continue to do so for as long as possible by supporting them at the lowest level, not at the highest level?
Hazel Blears
My hon. Friend makes an extremely powerful point. I am pleased that the Bill strengthens support for carers. I draw the House’s attention to the Bill introduced by the other Member for Salford, my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley), which seeks to make sure that carers have the right to stay in work and the support to be able to do that. We must consider the cost to our economy of people having to give up work in order to care. We have talked a lot today about perverse incentives and false economies, and that has absolutely been a false economy for a long time.
I wish to say a word about diversity of provision and commissioning new models of care that can help with prevention. In my city we have been working on that for a long time, and I look forward to showing the Minister some of our examples when he visits. Social adVentures is a social enterprise that helps people with mental health problems, and one of its projects is “garden needs”. It has taken control of a garden centre, and people with dementia and people with mental health problems are now attending. The way it is keeping people active in the community and able to do many more things than they would if they were isolated and at home is amazing. Unlimited Potential is another fabulous social enterprise, which stands on its own two feet, is not grant-dependent and is able to invest more money back into the community. Last week, I had the pleasure of launching a website called Really Useful Stuff, which is just what it says on the tin—it is a website where people can get aids, adaptations and kinds of social care that are modern, innovative and creative. Those are just a few examples of what is already happening in the community.
I say to the Minister that at a time when money is tight, and will be, no matter which Government are in power, the imperative to innovate and be more creative with the funds we have has never been greater. Therefore, investing, in particular, in the social enterprise sector, which often has these great ideas, and in enabling those ideas to get to scale so that provision can be made across the country, is really important. Another company in my constituency, 2ergo, has recently developed an app for the iPhone where people can see what provision is available in Salford for care, respite care and activity, and how to book it. They can book it over their iPhone—families can do that; they can help the people they are caring for. So this use of new technology is now developing apace, and, again, we have to take advantage.
I commend the Government for organising the G8 summit last week in London—an amazing event where we gathered support from countries across the world. I hope that next year we will be able to expand that to a global event examining dementia, not just one involving the G8 developed countries. Part of that G8 meeting was about how we get more research. I would like to see far more research on the quality of care. There is a lot, but not enough, research on the bioscience, but hardly any research on the interventions we do, particularly for people with dementia. We all know that “singing for the brain” has a great reputation. It helps cognitive development, as do art, drama and reminiscence work. There is no evidence base behind that, so if we are to have a better system of social care, we need better research into therapeutic interventions that work. That will enable commissioners to commission packages of care that they know will make a difference. If money is tight, we need to spend it on things that we know will be effective, and I ask the Minister to support that.
The Alzheimer’s Society has also done a lot of work on dementia-friendly communities. That is not expensive. It is a matter of mobilising the good will of local people, shops and arts centres. In Salford, a taxi firm has trained 400 drivers to look after people with dementia. Such care does not cost a lot of money if we can mobilise ordinary people in their communities. In Japan, 4.5 million people are signed up to be dementia friends. Our ambition is to have 1 million such friends. Again, I push the Government to be more ambitious to see what more we can do.
Clause 5 is about not just diversity and shaping the market, but quality, and that is an area about which we all feel passionate. How can we in this country tolerate a situation in which those who do the most difficult job in caring for our friends and family are actually some of the least regarded workers? It is utterly unacceptable to have zero-hours contracts in the social care sector. The carers who care for my dad come in for 15 minutes. They will do more if they can. They have to ring up to be assessed when they have done 12 minutes. They get no payment for travelling and no expenses for their petrol. They came out one Sunday. They started at 8 o’clock in the morning and went home at 9 o’clock at night, but because they only had five hours of 20-minute slots, they got paid only for five hours. Members should try being out on a Sunday for 13 hours and going home with five hours of minimum wage payment. It is an absolute disgrace and a scandal that we tolerate that in this country. I hope the Minister will assist in bringing such practice to an end.
I want to say something about my own local authority. My hon. Friend the Member for Worsley and Eccles South mentioned the fact that Salford has recently had to change its eligibility criteria from moderate to substantial and critical. We were the last authority in Greater Manchester to have to make that decision, and it was heartbreaking. Our social services have always merited four stars. When I was a councillor 30 years ago, cuts were bad, but we always prioritised social care and nursery care for children. The decision to change the criteria was not made lightly, and the cuts have been absolutely horrendous.
Let me again say to the Minister that we need creativity and imagination to deal with this matter. I want to draw the House’s attention to my unpaid interest in social finance, which appears in the Register of Members’ Financial Interests. We have a real opportunity to draw extra funds into the social care system. If we could have a social investment bond that aimed to keep people with dementia in their own homes for longer, we would save the NHS a fortune. People with dementia are admitted to hospital more often. They stay longer in hospital and many more of them die there. If we could mobilise social investment to offer a reward for keeping people in their own homes, funded by the savings to the NHS, we could bring in some new money, not just what we are getting from local authorities.
Norman Lamb
I am very interested in the right hon. Lady’s proposition, and would be happy to talk further with her about it.
Hazel Blears
I am grateful to the Minister for that. In these difficult times, we all have a responsibility to look at creative and innovative ways of funding and to try to carry them through. The whole area is becoming very exciting. It was the legacy that the UK agreed to take on from the G8 meeting last week. We are global leaders. We have 14 bonds in this country; America only has one. For once, we are well ahead of the United States, and I am delighted that the Minister wants to discuss that issue.
All of us could talk for at least 20 or 30 minutes on that issue. As I come to the end of my contribution, I will just say that the Bill is a step in the right direction. I am disappointed—I say this to the Minister in the kindest way I can—that we have not been more ambitious. If we want to move towards whole-person care, we will have to be much bolder than we have been. I remember when we said, “We are at our best when we are at our boldest,” and that applies in this case. Nevertheless, over the next few weeks and months, I shall keep holding the Government to account, holding their feet to the fire and pushing them on to see what more we can do. We all feel a personal, deep and emotional responsibility for the most vulnerable people in this country who look to us to care for and support them at a difficult time in their lives.
Sir Tony Baldry (Banbury) (Con)
I think that the whole House would agree with the right hon. Member for Salford and Eccles (Hazel Blears) that we must all try to ensure that our constituencies and communities are, so far as is humanly possible, dementia-friendly. I welcome the opportunity to contribute to the debate, not least in my capacity as the Commons chair of the all-party group on carers. I trust that the House will understand that that is why I intend to focus my comments specifically on carers’ needs. Other parliamentary colleagues will talk in detail about other aspects of the Bill, such as the national eligibility threshold, personal budgets and other important issues relating to the social care system. They are all important, but in the time available to me I want to focus on the needs of carers. I may well not be able to say all that I would like to say in the time available, and in those circumstances I will put the full text of the speech on my website, www.tonybaldry.co.uk—even those of us who have been in this place for 30 years can keep up with new technology.
I welcome the Care Bill and the fact that it contains significant new rights for carers, including stronger rights for an assessment of their needs and a clearer entitlement to services for carers and those for whom carers care as a result of any such assessment. I also welcome the fact that as well as introducing new rights for carers the Bill consolidates their existing rights. Over the years, a number of Bills have enhanced carers’ rights. All the recent ones have been private Members’ Bills, taken through the House with the support of organisations such as Carers UK and the all-party group on carers, so I welcome the fact that this Bill consolidates carers’ rights in a single piece of legislation. Clause 1 sets out the well-being principle, which is a hugely welcome overarching duty that will place individual well-being at the heart of the new reformed social care system.
The Bill has, of course, already enjoyed detailed consideration and scrutiny in the other place. It is to the Government’s credit that they have already introduced a number of further concessions, not least those for young carers, following the hard work of parliamentarians and the National Young Carers Coalition. Good progress has of course been made to enhance the rights of young carers through an amendment to the Children and Families Bill, which delivers four key improvements for young carers: the simplification of the legislation on young carers’ assessments; the extension of the right to an assessment of needs for support to young carers under the age of 18 regardless of whom they care for; the fact that it has been made clear to local authorities that they must carry out an assessment of a young carer’s needs for support on request or on the appearance of need; and the provision of appropriate links between legislation for children and for adults to enable local authorities to align the assessment of a young carer with an assessment of an adult they care for. The amendment works closely with the provisions in the Care Bill that focus on a whole-family approach to support, and that is all welcome progress.
There are three further issues, however, that I hope Ministers will consider as the Bill makes progress. First, it places new duties on local authorities to provide information and advice services, which are very welcome and will enable carers to access vital information and advice earlier. As part of the enhanced right for carers, the Bill places a new duty on local authorities to undertake a carer’s assessment for all carers. It is also good news that under clause 2 local authorities must have regard to the importance of identifying carers in their populations with unmet needs with the aim of early intervention and prevention of future needs, but the clause does not mention the NHS. Neither the Care Bill nor the health and social care legislation places any responsibility on the NHS to identify carers.
Ministers might say that there is a co-operation clause, clause 6, that requires health bodies to co-operate with local authorities on all clauses in the Bill, including the that on identifying carers, but the way that clause is drafted gives rise to serious concerns that the onus will remain on local authorities. That could well mean that carers will receive very little help from health bodies in certain parts of the country. It is a matter of common sense that for many carers their point of contact with the wider world and the person with whom they will discuss their wider caring responsibilities will be health professionals, such as their GP.
Macmillan Cancer Support estimates that there are nearly 1 million carers of people with cancer in England, half of whom are not receiving any support as carers, notwithstanding the substantial impact on their lives. It is a matter of common sense that carers of people with cancer come into contact mainly with health professionals who are simply not identifying them as carers, which as a consequence means that only 5% of the nearly 1 million people caring for people with cancer receive a carer’s assessment. Half of carers of people with cancer are not receiving any support in return for giving an average of almost 15 hours of care each week. As the number of cancer patients is likely to double from 2 million to 4 million over the next 15 years or so, so too will the number of carers.
Part of the reason why carers of people with illnesses such as cancer are not receiving any support is that three in five people providing unpaid care to loved ones with cancer do not consider themselves to be a carer. They thus lack awareness of carers’ rights, such as the local authority carer’s assessment, which is crucially important because it is the gateway for carers to get statutory support. There needs to be an explicit requirement in the Bill for health bodies to identify carers with unmet needs, with the aim of early intervention and support. Neither the Care Bill nor the Health and Social Care Act 2012 sets out any responsibility for the NHS to identify carers, which is surprising, given that this was something the Government specifically called for in their care and support White Paper, where they outlined the requirement for
“NHS organisations to work with their local authority partners . . . to agree plans and budgets for identifying and supporting carers.”
The first point that I therefore wish to impress on the Minister is that the Bill should specify that local authorities need to work with health bodies in order adequately to identify carers with unmet needs and provide sufficient services for them, and that there should be a duty on the NHS to identify carers. GPs need to see support for carers of their patients as also being part of their job, because in supporting the patient’s carer, GPs are also supporting the patient. There is, I suspect, a need for a national framework, or guidance, on how the NHS can better identify and support carers.
The second point that I wish to raise is a difficult one. The Government are introducing new and much appreciated rights for carers of adults through the Care Bill, and for young carers in the Children and Families Bill, but parents of disabled children under 18 are not included in either Bill. It is worth reminding ourselves of the recommendations of the Law Commission to strengthen the rights of parent carers in line with other carers, and to consolidate these rights in new legislation.
I appreciate that at a time when we are enhancing and hopefully improving special educational needs in the Children and Families Bill, the question arises whether every parent whose child receives a statement of special educational needs should be considered a parent carer, and I suspect that Ministers would probably respond that in straitened financial circumstances it simply is not possible to give financial support to a child with special educational needs through that system, and at the same time give financial support to their parents as parent carers.
On the other hand, I hope Ministers and the House will appreciate, as I am sure we all do, that for a parent of a seriously and severely disabled child, or a child with serious and severe learning difficulties, those responsibilities as a parent and as a carer can completely take over their life, with little respite. I hope that there will be an opportunity in the Public Bill Committee to consider whether it is possible to give targeted support to parent carers whom, as a matter of common sense, I think we would all recognise merit consideration as carers.
My third point is that the Bill perhaps needs greater clarity to ensure that carers are not wrongly charged for services provided to the person they care for. I know that ministerial colleagues have said that this is not their intention, but I suggest that that is not yet clear enough. Social workers and carer support workers will in due course have to use this legislation to decide on the one hand what is a carer’s service, and on the other what is a service for an older and disabled person. I suggest that this needs to be defined with greater clarity so as to prevent confusion or disputes. I would suggest that we should remove from local authorities any ability to charge for carers’ services. Not surprisingly, many carers are shocked to find, given the support and contribution they are making to caring for a loved one and the amount they are saving the state with the care they provide, that they are being charged for carers’ services.
I hope that during the passage of the Bill through the Commons, the Government will give consideration to these three points relating to carers, but I re-emphasise that overall the all-party group on carers very much welcomes the significant new rights for carers in the Bill, including stronger rights to an assessment of their needs and a much clearer entitlement to services for them and those they care for as a result of such a carer’s assessment.
Barbara Keeley (Worsley and Eccles South) (Lab)
The Care Bill already seems like a wasted opportunity. I worked for four months, alongside right hon. and hon. Members of this House and Members of the other place, on the Joint Committee that scrutinised the draft Care and Support Bill, and I pay tribute to its members for their work. We now have a Bill that contains some measures that are welcome but others that are seriously flawed.
I will talk first about the burdens the Bill places on local authorities and argue that they must be resourced by the Government. Some people—Ministers or Government Members whose southern local authorities are not being cut in the same way that ours are, for instance—might think that perhaps times are okay, but there could not be a worse time to place extra financial burdens on local authorities. Indeed, the situation for my local authority, Salford city council, will be even bleaker in 2016, the planned date for implementation of the Bill’s reforms. As I said earlier, Salford has already lost £100 million in funding since 2010, and it knows that it will lose another £75 million by 2016. I hope that the Minister is listening—he does not seem to be—because funding for adult social care in Salford has fallen by 20%, from £67 million in 2010 to £53 million this year.
Robert Flello (Stoke-on-Trent South) (Lab)
My hon. Friend has already alluded to the fact that that is the picture up and down the country. The Special Interest Group of Municipal Authorities has said that Stoke-on-Trent has been hit the hardest, but the impact is on constituents across the country.
Barbara Keeley
I agree with my hon. Friend.
Changing eligibility from “moderate” to “substantial” this year will mean that the number of people in Salford receiving council-funded care packages will fall by 1,000, to 7,500. To give credit to Salford city council—my right hon. Friend the Member for Salford and Eccles (Hazel Blears) has already done so—it held off making the eligibility cut until the third year of Government budget cuts, but now it must join the nine out of 10 local authorities setting eligibility at the higher level. I am afraid that the Secretary of State’s earlier claim that they do not have to set it at that level will have sounded very hollow indeed.
Talking of things that sound hollow, the new rights for carers set out in the Bill will sound very hollow to carers in my constituency at a time when many of them are losing the few hours of support they have that give them a break. I want to cite the example of an elderly couple in Salford who have cared for their adult son for over 30 years and who have relied upon respite care for a rest or a break. At the last review of their son’s care package, the respite care element was reduced, which has had a detrimental effect on their physical and mental well-being. They are now not even sure whether they can carry on caring for him. I fear that my right hon. Friend the Member for Salford and Eccles and I will hear many more such cases as 1,000 people in Salford lose their care packages over the next year.
Many organisations involved in social care have raised fears about the crisis in care and their view that the eligibility level should be set at “moderate”, rather than “substantial.” Over the past five years, the number of people over 65 receiving publicly funded care has fallen from 1.2 million to less than 1 million, and for people aged 18 to 64 it has fallen from £570,000 to £470,000. That is a serious fall in the number of people receiving care. Some of those who have lost publicly funded care have funded the care themselves, but in other cases the care workload will have fallen on unpaid family carers.
The number of unpaid carers caring for more than 50 hours a week has increased by over a quarter in the past 10 years. As my right hon. Friend said, Carers UK has told us that 1 million carers have given up work to care, which costs the Exchequer £1.3 billion a year in extra carer’s allowance and lost tax receipts. I believe that reliance on unpaid family care with those heavier carer workloads might also have an impact on the health of those carers, particularly those caring at the heavier end.
The Government plan to set the national eligibility threshold at “substantial”. The Care and Support Alliance says that this means that 105,000 working age disabled people will be left without the support they need to live independent lives. That issue was raised by my hon. Friend the Member for Stretford and Urmston (Kate Green), and she is right to do so. We focus an awful lot on adult social care and older people, but we need to think about working-age disabled people as well.
Norman Lamb
I absolutely respect and appreciate the hon. Lady’s concern for carers; she has campaigned vigorously on their behalf for a very long time. Does she accept, though, that when her party left office, 108 councils set “substantial” as the eligibility criterion for support from local authorities? Do we not all face the same incredibly difficult financial circumstances and have to examine the innovation that the right hon. Member for Salford and Eccles (Hazel Blears) talked about? There is not simply a pot of magic money that will appear if ever Labour returns to government.
Barbara Keeley
I do not agree at all. These cuts are far too swingeing, and there is nowhere else for my local authority, Salford, to go. After 20% cuts, the £100 million loss of funding that we have sustained cannot be found with any amount of innovative thinking. Ministers are now at the point of kidding themselves. I am sure that the Minister, like all his predecessors, goes round the country and is shown all kinds of examples of innovation, but innovation without funding will not work.
The eligibility issue interacts with the cap on care costs. The vast majority of older people will fail to benefit from the £72,000 cap on care costs; it will help only those with the most complex needs. As has been said—we need to keep repeating it—a cap set at £72,000 ignores Andrew Dilnot’s warning that it would work only if it were set at a much lower level and if the underfunding of social care were addressed. It is clear from the Government’s own impact assessments that the number of people whose costs will be capped are a tiny minority. It is estimated that just over one in 200 people aged over 65 will be helped in 2016 and that fewer than one in 200 will be by 2026. It is an incredibly sad reflection of this Government’s ambition that they will have spent the whole of a five-year Parliament—in fact, longer than a five-year Parliament—introducing measures on the long-term funding of social care that eventually help only one in 200 people. My right hon. Friend the Member for Salford and Eccles talked about being ambitious; this is not ambition.
On the support needs of carers, I will repeat some of the things that we heard from the right hon. Member for Banbury (Sir Tony Baldry). Full-time carers are more than twice as likely to be in poor health as people without caring responsibilities. I point out to the Minister that this Bill does not do enough to support those full-time carers. The Government have said that carers are the first line of prevention in that properly identifying and supporting them prevents the escalation of demand on statutory services. Given the A and E crisis, we need that prevention. However, identification of carers is not happening and the Bill does not do enough to change that. Macmillan Cancer Support, which has been carrying out surveys on this, tells us that 70% of carers of people with cancer come into contact with health professionals, who are the people who should be identifying them and signposting them for information and advice. Only 5% of that group of carers receive a carers assessment, and only one in three of those surveyed by Macmillan had even heard of a carers assessment. It is meaningless to suggest to people that they have a right to something they have never heard of and are not going to get.
In Salford, we have a project run by the Carers Trust centre to identify carers within the primary care system. I want to pay tribute to the work that the centre does and to mention its manager, Dawn O’Rooke, who is leaving this month after several years of work in this field. Over the years, the project has established a network of links within GP practices to identify carers. Last year, GPs made only 300 referrals to the carers centre, yet we have 23,000 carers in Salford, over 5,000 of whom will be caring at the heaviest levels. The Carers Trust tells us that, nationally, GP practices are identifying only about 3% of carers, but it should be 10% or more. Health bodies must be required—this Bill is the place to do it—to take on the task of identifying carers and referring them for advice and support, because carers are mainly seen in health settings and not by local authorities. The figures I gave about people losing packages mean that 1,000 fewer people in Salford will be seen by, or go anywhere near, the local authority because the person they care for is not getting a care package.
The Minister is aware of my private Member’s Bill, the Social Care (Local Sufficiency) and Identification of Carers Bill, which had clauses to tackle that issue. I am happy to show them to him again and explain how he could go about tackling the issue in his Bill. The clauses would ensure that NHS bodies have procedures in place to identify carers and ensure they receive information and advice. The Government’s own care and support White Paper stated that there is
“still an unacceptable variation in access to tailored support for carers”
and that NHS organisations should
“work with their local authority partners...to agree plans and budgets”.
The right hon. Member for Banbury made that point. Why are there not more robust measures in the Care Bill to make sure that this happens? As things stand, it will not happen. The NHS has been going through an agony of reorganisation and is now going through an agony of finding efficiency savings, and its staff do not have the time, unless they are directed to the right procedures, to take this task on.
As has rightly been said, clause 2, with its requirements for local authorities to provide preventive services, makes no explicit mention of the NHS, and the only duty on NHS bodies is one of co-operation. Anyone who has tried to work in local authorities on co-operation with health bodies, as I did years ago, knows that it does not go anywhere when there is no budget and no duty. Without effective procedures and systems within health bodies, the identification and signposting of carers will stay as it is now—patchy and inconsistent. It is questionable whether cash-strapped local authorities will be able to assess the needs of large numbers of carers alongside giving information and advice to self-funders and doing a lot more assessments. They will not be able to do that in any way that makes it a worthwhile exercise for carers, and carers will not bother with it if it is not doing anything for them. Indeed, the Joint Committee on the draft Bill received many comments via its web forum from people who said that local authority assessments are of little practical help in their caring role.
GPs and other health professionals are best placed to help carers when they start caring, which is when they most urgently need help and advice. During carers week here, I met carers who told me about a whole variety of things that they needed help with but nobody helped them. Nobody told them that there were schemes to help them with the cost of parking at the hospital. One mother had to buy a hospital bed and nobody told her where to find one; she was looking for one on eBay. She had no advice and support on that whatsoever. GPs deal with dementia patients, stroke patients and patients with cancer. The GP and primary health care team is best placed to establish whether there is an unpaid family carer or whether they live in another town or city. The GP can then refer them to sources of advice and support and, if they are local, give them regular health checks. A new duty on the NHS professionals is the only thing that would make it easier for social care and health services to work together to support carers. I believe that that is wanted by Members in all parts of the House.
Given everything that we are talking about, carers are clearly being placed under ever greater strains. It is essential that the Bill is used to ensure that carers are identified and signposted towards the support they need. It is clear from all the statistics that unpaid carers are the most vital providers of care in this country. I urge Ministers not to miss this chance to improve the support that we give them.
Charlotte Leslie (Bristol North West) (Con)
I greatly welcome much of what is in the Bill. I am slightly disappointed by the tone of some—not all—Labour Members, who seem to suggest that the challenges our society faces with social care are in some way new. I looked after an old lady from 2003, during the economic boom times, and became very well acquainted with her care package, care needs and care challenges, and the challenges faced by her social workers. Back then, social workers were expected to get across London in 20 minutes, which was obviously impossible, so the care time that they had with my friend was severely cut down; in fact, sometimes it was 15 minutes, a figure that we have already heard. There was also a massive challenge in terms of raising the status of the profession of social work. Those challenges existed back then, during the boom times, and they still exist now. It is very brave and ambitious for the Government to be making such significant steps in unifying health and social care at a time when the economic situation is very difficult.
Other Members have dealt with the care and support aspect of the Bill more eloquently than I can, and I am sure that others will too. I want to focus my brief remarks on part 2, which is about the response to Francis and care standards.
I think that one lesson we have learned following the Mid Staffs scandal is that making rules does not necessarily mean making change. I remind the House of the 2002 “Code of Conduct for NHS Managers”, which states:
“As an NHS manager, I will observe the following principles: make the care and safety of patients my first concern and act to protect them from risk;…be honest and act with integrity; accept responsibility for my own work and the proper performance of the people I manage”.
Following the unravelling of scandals in Mid Staffs and elsewhere, it is very hard to understand how NHS managers were adhering to that code of conduct, which was written for them, and why none of them has faced the consequences of not doing so. That is a salutary lesson: we need to be wary that putting things in writing does not always mean that they will happen culturally. People have remained unaccountable for a serious breach of that managerial code of conduct, many of whom, I am afraid to say, continue to work in the NHS today.
As the Bill progresses, I want to see more detail on how the contractual obligation for a duty of candour, which is welcome, will be enforced. I understand the desire for a statutory duty on individuals, but I share fears that it may oversimplify the blame culture that this House has discussed at length. Having seen what happened with our hospitals’ complaints system and the cover-up of blame, I am very worried that a statutory duty on an individual clinician could be abused, such that blame could be parked at a clinician’s door by a management system that does not want its own failings to be highlighted. That could lead to unfortunate false allocations of blame by the system in which clinicians work.
If a contract’s duty of candour is not met, what will be the consequences? It is an issue that there have been no consequences for those who have breached things written down in guidelines and codes of conduct. It is important to understand in more detail what the consequences will be of a breach of contract.
I would particularly like to know whether managers, organisations such as NHS England, and Department of Health officials will have the same duty of candour. The reason why scandals such as Mid Staffs have been allowed to go on and on is that it was not just the hospital that was complicit in it; the entire system around the hospital should have been acting in patients’ interests, but it did not.
Some have faced consequences for their actions—their actions were good, but the consequences have been diabolical—namely whistleblowers. I know and understand that real reform of how we treat whistleblowers and enable whistleblowing will require changes to the Public Interest Disclosure Act 1998. If a whistleblower has been found to be correct in raising concerns in the NHS and those concerns are recognised, I would like to know why any future employer would choose not to employ them. If an employer is a good employer, they would welcome a whistleblower into their ranks as someone who would not go native and accept appalling care when others might do so and who would also have the moral fortitude to stand up and talk about failings when others might not. The test of a good employer is how well they employ people who have been proven to be whistleblowers.
People such as Eileen Chubb and David Drew have sacrificed their careers to highlight bad care, but they have not seen the systemic changes for which they made those sacrifices and they are still suffering the consequences. Surely that is a part of NHS and health culture that the Bill should seek to change.
I welcome the fact that the Care Quality Commission will be looking at the issue of whistleblowers and I welcome James Titcombe’s involvement in the CQC. As someone who thought that the CQC brand was so damaged that it should probably just be scrapped and we should start again, I have to say that I think David Prior has made remarkable progress, given what he started out with, in beginning to turn this monolith around.
Statutory independence of the CQC is very long overdue. I think that everyone in the House has been concerned about the fact that the CQC’s mission seemed to be reputation management for itself and the NHS, and not a brave and courageous stand on behalf of the patients it was supposed to be protecting. In order to ensure that the CQC remains independent from Government—independence in words is fine, but independence in culture is what really matters—it might be illustrative to look back to the era before the CQC and other regulatory bodies were in place, when royal colleges used to send their members into hospitals. They would do so not to inspect hospitals as such, but for reasons of medical training. However, by getting a granular view of the training on offer they could see whether or not it was sufficient. If not, the royal colleges could, under bodies such as the hospital recognition committee, withdraw training from a hospital, which gave the inspection teeth. It was the royal colleges that went in—often without any pay at all; just enough to cover expenses—and interviewed junior doctors and consultants individually, and problems naturally came to light because the interviews were often confidential.
A Wigan hospital fell foul of an inspection in 2001 and its chief executive did not take kindly to it. Funnily enough, just after the inspection took place, the chief executive, who was quite close to Alan Milburn and the then Prime Minister, went into the Department of Health and abolished the system whereby professional clinicians could get a granular view of what was going on in hospitals, replacing it with the postgraduate medical education training board and then the medical training application service, which was disastrous. The more we can put those who do not have an interest in bolstering the Government of the day—namely the professionals, clinicians and members of the royal colleges—on the ground and doing granular investigations, the more confident we can be that the CQC will be independent.
Grahame M. Morris
I am not sure that I share the hon. Lady’s enthusiasm about the transformation of the CQC; nevertheless, some progress has been made. Does she share my concern that clause 85 proposes to dilute the CQC’s powers with regard to investigating the commissioning of adult social services and social care by local authorities? Is that not a step backwards, particularly if the hon. Lady is concerned about the issue of 15-minute visits and the impact that has on quality?
Charlotte Leslie
I am afraid that the quality of care and social care could be the next boil of scandal to erupt as we gain a more granular view of what is going on. Organisations need not just more effective tick-box inspections, but more effective granular inspections. I do not agree with the hon. Gentleman: I think the CQC is taking great steps forward. I am very sceptical, but I am cautiously optimistic of progress and will continue to look at what the CQC does.
I will make progress, because I do not want to prevent other Members from contributing to the debate. Essentially, the Bill can only put down regulation. One of my favourite things is to warn against systems so perfect that nobody needs to be good, yet this House really only has levers to change systems. We cannot always enable people to be good, but we can devise systems that enable them to be good. This House is attempting to turn around a massive cultural tanker and it is unrealistic to think that we can do so through the scope of a single Bill. I think, however, that the Bill takes very important steps forward in a very difficult context. I am disappointed that it is not supported throughout the House, although I think that constructive amendments and changes to it will be welcomed in the interests of the patients we are all here to serve. I heartily recommend the Bill to the House.
Meg Munn (Sheffield, Heeley) (Lab/Co-op)
Members on both sides of the House agree that we need to reform and improve how we provide care to those who need it. In the words of the Law Commission, our current legal framework is a complex and confusing patchwork of legislation that is in desperate need of modernisation. However, the premise on which part of the Bill is based is simply outdated. It tries to focus the debate on residential and nursing care costs, which directs our view of care on to issues of the previous century when this should be a Bill for the landscape of the 21st century.
Only a small percentage of older people need to be in residential or nursing care and, thankfully, most of them for only a relatively short period at the end of their lives. Most people want to stay in their own homes if they can. Consequently, it is right to develop care services that make that happen, such as ExtraCare homes, whose options for meals and support for residents can change as their needs change.
Our care system is there not just for when people hit crisis point; it should be preventive, ensuring that those who need moderate care and support can receive it in their own homes. Yet, as we have heard time and again in this debate, because of the Government’s savage cuts to local authority funding, 85% of local authorities now provide care only to those whose needs are assessed as substantial. If the level is also set at substantial in relation to the proposed national eligibility criteria in clause 13, people with moderate care needs will continue to be ignored. Their needs will inevitably move to severe, which will mean even greater cost to both the individual and the state. My hon. Friends have given examples of that.
As has already been said, the vast majority of care in this country is given by family and friends, who provide not just physical care but emotional support. Most do so willingly, but many would benefit from some support through the provision of low-level services, such as a sitting service to allow them time to themselves, or a cleaning service to allow them to concentrate on providing more personal help. Put simply, a small amount of support for those whose needs are at a lower level would lever in a large amount of care by families, who would also be enabled to continue to provide support over a longer period, so saving on much more expensive services.
Robert Flello
On the theme that my hon. Friend is developing, quite a lot of carers are almost borderline in their need for care themselves. What is her view of the fact that without that extra bit of support for carers’ needs, there may be the double hit of two people needing care from the state?
Meg Munn
My hon. Friend is absolutely right. I managed care services when, not the previous Government but the one before that, brought in a health and social care Act. Within the first six months, we found that every single person who ended up in residential care did so because of carer breakdown, as the carer was not getting support. That is why this support is such an important part of what we should deliver.
Care services must be personalised: they have to be about choice, as well as need. If we are to make such personalisation a reality, we need further integration of our health and social care services. The duty on local authorities under clause 3 to promote the integration of care and support with health services does not go far enough in that respect. Indeed, a recent survey of health and wellbeing boards found that most local authorities have not identified integrated care as a priority. Clearly, we must do more to drive forward the development of integrated care. Without such an approach, we will return to the days that I remember well, when there were fruitless arguments about whether a service such as bathing was required on social or health grounds.
The integration of health and social care services is crucial to ensure that we provide carers with sufficient support. As a patron of Sheffield Young Carers, I feel privileged to have seen at first hand the selfless role that even very young carers undertake in our communities, and they should be valued.
As has been said by the right hon. Member for Banbury (Sir Tony Baldry) and my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley), the Bill places a duty on local authorities to have regard to the importance of identifying carers, but that is not good enough. Some 80% of carers have contact with a health care professional, and it makes absolutely no sense to leave the NHS out of the duty to identify carers.
That matter is especially worrying as regards young carers, who quite often need a lot of support. The Children and Families Bill will strengthen young carers’ rights by providing that when a child is identified as a young carer, the needs of everyone in the family should be considered. That of course presupposes that young carers will be identified in the first place. If we do not place a corresponding duty to identify carers on health authorities, we risk young carers falling through the gaps, and we cannot continue to leave them without support.
My remarks would be somewhat lacking if I did not refer to the funding or, perhaps more accurately, the lack of funding that underpins our social care system. The proposals outlined in the Bill primarily concern redistributing the costs of care, and they will not bring any extra funding into the system.
Bill Esterson
My hon. Friend is making an absolutely crucial point. Does she agree that unless investment in social care is made now, it will end up costing far more in the cost of the NHS, as well as that of social care? It is the lack of ambition, as well as the lack of finance, that is really disappointing in what the Government are introducing in the Bill.
Meg Munn
I agree. The demand for services is now greater than ever. Our social care system is being cut to the point of breaking. As has already been discussed, should the proposed health funding reallocation for clinical commissioning groups be implemented, the situation will only get worse. South Yorkshire is due to lose £150 million by April 2014. That is staggering given that, under the proposals, other parts of the UK that already have better health outcomes and longer life expectancy will receive an increase in funding. This Bill seeks only to ration scarce resources; without a completely different approach, we will fail to meet proven need.
As a former social worker, I welcome clauses 42 to 47, which introduce a duty on local authorities to make inquiries when they suspect that an adult is at risk of or is experiencing abuse or neglect. Yet no duty is placed on care providers to report suspected abuse or neglect to the local authority. The Government contend that the present guidance is sufficient, but I disagree. In the light of Winterbourne View and Mid Staffordshire, we cannot afford to have such gaps in protection.
A recent Care Quality Commission report stated that our accident and emergency departments see 500,000 elderly victims of neglect. I am therefore far from convinced that enough has been done to address the issue. Where victims of abuse are imprisoned in their own homes by a perpetrator who denies access to adult safeguarding staff, there are no current legal means by which access can be achieved. An amendment was tabled by the noble Baroness Greengross in the other place to enable a social worker to apply for a court order to access an adult at risk. Between now and the Committee stage, will the Government reflect on that matter and introduce something to address that gap?
The Bill is an opportunity for much-needed reform of our health and social care system, but in its current form it does not make the changes that we need. For that reason, I fully support my right hon. Friend the Leader of the Opposition’s reasoned amendment.
I apologise, Madam Deputy Speaker, that I will have to leave very shortly to read in a carol service.
Paul Burstow (Sutton and Cheam) (LD)
I want to echo the remarks made by the right hon. Member for Salford and Eccles (Hazel Blears): we must keep the dignity and well-being of those who need care and, indeed, their carers at the forefront of our thinking in this debate and as we seek to implement the Bill.
Like the right hon. Lady, the hon. Member for Worsley and Eccles South (Barbara Keeley) made a very interesting speech. I thank her for her service on the Joint Committee that scrutinised the draft Bill. I had the pleasure to chair that Committee, which had a very strong team from both Houses. It made some recommendations to which I will return in a minute.
What struck me during the speech from the Opposition spokesman, the right hon. Member for Leigh (Andy Burnham), is that if so much in the Bill appears to be wrong, surely he should have the courage of his convictions and go through the Lobby to oppose it. There is apparently so much awful stuff in it—so much of it is inadequate, does not reach far enough or does not do enough, or if it does enough, there will not be enough money—that the Opposition should perhaps have the courage of their convictions.
At the same time, we have heard really interesting examples of where social care should be celebrated. Too many speeches have suggested that the picture of what is being done on the ground is uniformly bleak, but examples have been given of dementia-friendly communities, Unlimited Potential and the “garden needs” scheme in Salford. Those are just a few examples, and I am sure that every hon. Member could go back to their constituency and find such initiatives. Many of the initiatives do not require substantial resources because, as the hon. Member for Sheffield, Heeley (Meg Munn) just said, they can lever in additional resources by enabling communities to respond to need. That is an essential part of the Bill.
Paul Burstow
I give way to the hon. Lady because she tried to intervene first.
Barbara Keeley
It is about a year since the right hon. Gentleman and I started four months’ work on the Joint Committee, and I was prepared to commit that time although I still find some aspects of the Bill disappointing. The reality of our situation in Salford now and over the next year is that—week in, week out—I, as a local MP, will find that people and their carers have lost care packages. I invite him to think about the situation of the very many MPs who now see the heart-breaking decisions that families face when they suddenly find themselves without care, respite care or support.
Paul Burstow
I entirely understand that, and I see it in my constituency, where my local authority is grappling with those budget choices, but there is still scope for innovation. There are good, bad and ugly local authorities when it comes to grappling with the resource constraints that the deficit has led to, and I will come back to that in a moment.
I believe that the Bill deserves to be described as landmark legislation, because it will provide a new governing purpose for our social system—the idea of well-being, to which I will return—new rights for carers and, for the first time, parity of esteem between those who are cared for and family members who provide care and support. The new national eligibility threshold will end the postcode lottery for access. We can debate where the line is drawn, but for the first time that will become a national debate rather than simply a local one.
There will also be new obligations on local authorities on behalf of the whole population that they serve. There will be obligations to prevent and postpone the need for care, to ensure quality and choice of services and to ensure that there is good information and advice about the whole range of choices that people might need to make as they approach the point at which they need care. Importantly, the Bill is foundation legislation upon which a more co-ordinated and integrated system of health and social care can be built.
I could stop there, but the Bill will do more than that. It will simplify and clarify entitlements to state-funded support and put personal budgets into law for the first time. That is all before I have even mentioned the Dilnot reforms, about which it is important to give some context. Social care in this country today is not free. That is the nasty little secret that families discover when they are tipped into crisis and have to negotiate with their local authority over whether they will have access to any means-tested support. Most people do not know that, and it comes as a shock and creates anger and dismay in many families. While I was a Minister, Members from both sides of the House showed me letters of anguish from people who felt that the system was letting them down. To understand the value of Dilnot is to make a true comparison not with what people hope the system will be but with what it actually is today—a nasty, mean system that is means-tested. That is why the Government deserve to be commended for having the courage to start to put in place the principles that Dilnot proposed.
The right hon. Member for Leigh gave no direct quotation from Andrew Dilnot in opposition to what the Government are doing. I know why—it is because there is no direct quotation of that sort. Andrew Dilnot supports the changes and sees them as a much-needed step towards implementing all the principles that he recommended in his report.
Of course, it is important that we recognise that not everyone will ever need formal care. A minority of our population will need formal support, no matter where the threshold is drawn. Perhaps some will need it right at the end of their life. Those who do will want the Bill to give them peace of mind, and that is what Dilnot provides to everyone. Some people are confused by the idea of catastrophic costs based on all people needing care, but the reality is that most people will never reach the cap wherever it is drawn, because they will never need to draw down that much resource to pay for care costs. Moving the means test threshold from £23,250—the meanest of means tests in our welfare state—to £118,000 is a huge step forward.
For all those reasons, the Bill can be marked out as a comprehensive reform of our social care system, and it deserves the House’s wholehearted support today. There are other reasons why it deserves support, too. The draft Bill was consulted on extensively and has been subject to pre-legislative scrutiny, of which I am a great fan. As the Minister at the time, I actively sought permission for it to be subject to that approach. By a curious twist of fate, I then found myself chairing the very scrutiny Committee that I had advocated. I was lucky to have cross-party support from both Houses in doing that job, and it was a strong Committee. We made 107 recommendations, the vast majority of which the Government accepted before introducing the Bill. Many of the others have been persuaded upon them through their lordships’ scrutiny, and I am grateful to colleagues in the Lords for what they have done.
All of that will be worth nothing if the Bill is not well implemented. As the debate has demonstrated powerfully, there is a huge knowledge gap that leaves people struggling in a crisis. It means that people do not plan or prepare for care, financially or in other ways. We need not just local information and advice services but a multi-channel, multi-media campaign to inform and educate the public, hon. Members and the people who work in the system. We need to ensure that we manage changes well, such as deferred payments, about which I hope the Minister will say more later, not least because it is not a sufficient defence to say, “Because Labour did this when it was in government, we will do it as well”. I hope the Minister will have a better answer on that point.
I want to give one example of why the implementation challenge is big. There are 300,000 to 400,000 people in this country who already pay for their care. It would make no sense for them all to be told to line up on 1 April 2016 to get their care accounts sorted out. The change needs to be phased and planned so that we do not overwhelm local authorities in April 2016. I hope that the Minister will be able to reassure us about that.
The hon. Member for Sheffield, Heeley, said that the Bill was a look back to 20th-century models of care. I disagree, because at front and centre, in the Bill’s first clause, is the disruptive idea that we should promote individual well-being. It states that well-being is about quality of life, work, leisure, study, the right to be an active member of the community, being in control and maintaining and recovering physical and social function—all things that were anathema to many of the paternalistic models of 20th-century care.
We need only compare current care plans for older people with those for active and working-age people to see the stark difference. The plans for working-age people are about their being engaged with their communities, but for far too many years the plans for older people have too often been about “task and finish”, with tasks being burned down to just 15 minutes or less. That cannot be right, and it has to change. That is why I welcome the fact that the Secretary of State will also be subject to the well-being principle in discharging his obligations under the Act to regulate the system.
I would welcome some clarification of the term “beliefs” with regard to well-being. It would be helpful if the Minister said whether it applies to religious and spiritual beliefs, and whether that point will be covered in guidance.
On prevention, which has an important link to the well-being principle, can the Minister confirm that the duty set out at the beginning of the Bill will be outside the consideration of national eligibility, and that it will be a universal obligation that will not just apply to those who qualify for care? Will the local authority actively have to secure it?
Norman Lamb
I pay tribute to my right hon. Friend for his amazing work in launching the Bill and in its pre-legislative scrutiny. I can confirm that the prevention duty will be universal and have no relation to the criteria for eligibility.
Paul Burstow
That is very helpful, and I am grateful. The fact that the prevention duty will be outside the eligibility criteria gives the lie to the idea that it will be curtailed. That is important to understand. There has been some dispute about that, and the Association of Directors of Adult Social Services now suggests that the change in eligibility will be more generous than many people have thought.
Several Members have touched on the issue of carers. Progress has been made in the Children and Families Bill, and I hope that there will be progress on the identification of carers as well. One of my deep frustrations as a Minister was that, even when I had pulled all the levers available to me to try to get the NHS to do more on carers, it still did not get it. It did not do enough, and although there are beacons in the NHS, the whole thing has not been set afire so that the NHS really changes how it engages with carers. We need seriously to consider legislation on that, and I look forward to the Minister setting out how that might be achieved.
I want to touch on the role of the Care Quality Commission. It might be right to remove its duty to do periodic reviews, but it is important that it can exercise its power to conduct special reviews of commissioners without reference to Ministers. Where it finds that there a provider’s failure is attributable to commissioning failures, it should be able to inspect the local authority in question without having to seek Ministers’ permission. In that way, the special inspection powers could be used much more creatively.
A lot has been said about integration in this debate. I hope that we can make more progress on the matter to include it in all parts of the Bill during its passage through the House. I believe that the Bill deserves a Second Reading tonight, because it offers a transformative vision of how care is delivered in this country. By making well-being the central organising principle, we can deliver a much better quality of life for those who need care.
Nick Smith (Blaenau Gwent) (Lab)
It is a pleasure to follow the right hon. Member for Sutton and Cheam (Paul Burstow).
There are many challenges for the social care sector as we continue to live longer. In Wales, 20% of our population of 3 million is over 65, and that figure is predicted to rise to 25% over the next 20 years. It is essential that our older people live their lives with dignity, respect and in safety. Other Members have mentioned the costs of care and improving hospitals, but I want to concentrate my remarks on regulation and safeguarding in care homes.
The rising number of elderly people, some of whom need residential care, has led to significant private equity investment in the social care market. In 2011, many Members were troubled by the billion-pound collapse of Southern Cross Healthcare, whose quick-buck business model caved in when the global recession arrived. The media have now reported that care providers NHP and HC-One are expected to be put up for sale soon with US private equity interest.
Private and voluntary providers now account for 92% of all residential care and nursing home places, and 89% of care home care hours are outsourced by local authorities. The Care Bill gives the CQC in England extra powers to oversee the social care market, in particular companies that are deemed “too large to replace”. I welcome that, but we may need to oversee better business models at a more local level. The Association of Directors of Adult Social Services budget survey 2013 showed that more than half of directors expect providers in their areas to face financial difficulty, given the squeeze on local authority budgets that other Members have mentioned. Perhaps those oversight powers should better cover small and medium providers too. I hope the Minister will reassure the House that the CQC will have the resources and expertise to assess whether all care home owners are fulfilling their obligations regarding their financial viability. My constituents who went through anxious times with Southern Cross would like more stable care home operators and better financial scrutiny by regulators.
The other issue I wish to address is adult safeguarding. I have previously told the House about the horrendous instances of historic neglect and abuse in care homes uncovered by Gwent police’s Operation Jasmine. The £11.6 million investigation started in 2005 and gathered 10,500 exhibits and 12.5 tonnes of documents. It led our police to brand the negligence discovered as “death by indifference”. There were 103 alleged victims of care home abuse and neglect, yet, like their relatives, I was dismayed that Operation Jasmine secured just three convictions for wilful neglect by carers. Worse, charges brought against a care home owner did not directly relate to poor care for residents in his homes, but instead to breaches of health and safety legislation and false accounting. That cannot be right.
Steve McCabe (Birmingham, Selly Oak) (Lab)
At a time when children’s safeguarding boards are subject to so much scrutiny and questions about their performance, does my hon. Friend share my fear that the Government may be adopting a model that is flawed and needs a great deal more work? If that model is replicated for older people and adults in need of care, we may see a repetition of the same problems.
Nick Smith
My hon. Friend makes a good point.
I was struck when speaking to victims’ families in south Wales that although many were regular or even daily visitors to their loved ones’ homes, they were not informed about bedsores or concerns that their relatives were not eating or drinking properly—such concerns were just brushed aside. Yes, individuals must be responsible for their actions, but what was uncovered was institutionalised neglect, with instructions on cutting back on food and incontinence pads coming from the top.
I am pleased that in Wales the First Minister has agreed a review of Operation Jasmine, led by Dr Margaret Flynn, who wrote the excellent Winterboume View hospital report. Although it will not report in time to amend this Bill, I hope the Government will consider any additional measures that that crucial review may highlight because we know that such issues are not just a problem for Wales. Information supplied by the House of Commons Library shows that, in 2011-12, 65,580 allegations of abuse of vulnerable adults aged 65 or over were made at different locations in England. Of those, 29,555—about 45%—were alleged to have taken place in care homes. This is a big national issue.
Looking to the future, we must improve the law on wilful neglect. If a patient does not die from poor care and does not have a loss of capacity under the Mental Capacity Act 2005, guidance from the Crown Prosecution Service states that a criminal offence is difficult to identify. Given that, respected groups such as Age UK support the proposal that organisations—not just employees—found to have contributed to abuse or neglect in a care setting should be liable to criminal prosecution.
Norman Lamb
The hon. Gentleman is making some serious points. Does he welcome the fact that the Government have consulted on a change so that we introduce fundamental standards of care, and that those providers of care—the organisations, and indeed their directors—can be prosecuted for failures of care? That has not been possible until now due to a flawed regulatory system.
Nick Smith
I welcome that but I am not sure it goes far enough. I think the issue needs to be teased out further in this debate and possibly in the Bill Committee.
Paul Burstow
I know that the hon. Gentleman is campaigning hard on these issues at the moment. Does he agree that we need a clear criminal offence of wilful neglect in respect of people who have capacity, so that they are not left behind, as in the current position? If the Government cannot be persuaded—although I hope we can persuade them—of the case for a power of entry or power to interview a suspected victim of coercive abuse, they should at least adopt some sort of regulatory powers so that they can introduce such a measure later when they are finally persuaded by the overwhelming evidence.
Nick Smith
I thank the right hon. Gentleman for his suggestion. That seems possibly a good idea and something we should pursue in the future.
I congratulate my Gwent colleague, Lord Touhig, who tabled an amendment to the Bill in the House of Lords to introduce the offence of corporate neglect. If we do not get what is needed this time, I would like to table an amendment on the same topic in this House. I hope that following the welcome consultation on strengthening corporate accountability in health and social care that the Minister mentioned, the Government will now make our law fit for purpose.
I support clause 48, which was inserted in the other place and provides equal protection to all users of regulated social care, regardless of where that care is provided and who pays for it. As Age UK says,
“for those at the sharp end of indifference and abuse, it is essential that both the provider and the regulator have clear legal duties to protect human rights.”
As we know, social care and health are devolved issues in Wales, and last week the Welsh Government published a draft “Declaration of the Rights of Older People” to be considered by our older people’s commissioner and an advisory group. I warmly welcome that initiative and think the Government would be well advised to follow the example of Wales and appoint an older people’s commissioner for England—again, I know that the right hon. Member for Sutton and Cheam agrees.
Last Friday I visited the Rookery care home in Blaenau Gwent, now run by Four Seasons after the collapse of Southern Cross Healthcare. I saw how the implementation of the “Pearl” model of care for those suffering from dementia has seen medication levels plummet from around half to just 17% of residents. The staff were dedicated and caring; residents were comfortable and respected. That is the great care that everyone should receive.
A growing, complex market and tightening finances means that effective regulation and oversight is necessary. If neglect or abuse is found, those responsible must be held to account for their failures because the vulnerable and the frail have the same right to justice as everyone else. Older people should feel safe and secure in the place they call home.
Stuart Andrew (Pudsey) (Con)
It is a pleasure to follow the hon. Member for Blaenau Gwent (Nick Smith), who raised a number of serious issues.
Some wide-ranging speeches have been made today, but I shall make a short speech, which will primarily concern the clauses in the Bill that relate to young people and their transition to adult social services. I have spoken on a number of occasions about my experience of working in the hospice movement, particularly the children’s hospice movement, over the last 20 years or so. During that time, I saw some incredible work done by the staff at the hospices, but, more important, I observed the tremendous dedication of the parents and families of the children who worked day and night to ensure that they were given the very best care.
When I joined the last hospice where I worked—Martin House, which at that time served most of Yorkshire—the construction of its new building, Whitby Lodge, had just been completed. The trustees of the charity had identified a real need, the need to look after those who could be described as the “older younger people”. As time has passed, many young people in hospices have been living longer. That is a good thing, but the theme in the children’s hospice became a little bit childish for those who were entering their teens.
In England, more than 40,000 children and young people aged between 0 and 19 currently have long-term health conditions that will eventually end most of their lives, and for which they may require palliative care. Owing to medical advances, more young people with a range of conditions are living into adulthood than ever before. The number has increased by some 30% over 10 years, and the highest rate of increase is among those aged between 16 and 19, who now account for some 4,000—or one in 10—of those aged between 0 and 19 who need palliative care.
When I worked at Hope House children’s hospice in Oswestry, some of the young boys who suffered from Duchenne muscular dystrophy would be lucky to live beyond the age of 18. When I left Martin House, many were living into their late twenties. That is a great thing, of course, but it does mean that we must think about how we can help such young people. The majority of those who may require palliative care have a range of severe disabilities and complex health needs. Contrary to popular belief, cancer represents just under 14% of diagnoses; most of those young people have cognitive impairments, which means that that they lack capacity, and many are cared for over long periods by their parent carers.
Many young people with life-limiting or life-threatening conditions who are more cognitively able struggle to achieve independence and enter education or employment, because plans are not made for them. Those who are unlikely to be cured by treatment are offered palliative care. Palliative care for young people is not simply end-of-life care, but focuses on enhancing the quality of their lives. In their early to mid-teens, young people receive palliative care and other support from children’s services. In their later teens, they start to receive services from adult agencies which assume responsibility at different points after their 16th birthdays. The transition is often complex, and traumatic for families who are already coping with extremely difficult circumstances.
A successful transition needs to address both the transfer of responsibility for young people from children’s to existing adults’ social care, health and education services, and the development of new adult services that are tailored to young people’s additional needs. The transition needs to be planned for years in advance, but, at present, planning is often disjointed and poor. The reduced services and support routinely offered by adult agencies, which are often focused on older people and end-of-life care, come as a distressing shock to many young people and their families. Parents have described the transition as like “standing on the edge of a cliff, about to fall into a black hole”. Poor transitions lead to increased illness, adverse social and educational outcomes, and sometimes even premature death.
Let me ask the Minister some specific questions. Will the statutory guidance on the Bill’s transition clauses which the Department of Health is producing for local authorities ensure that when a child who needs services reaches the age of 14—and is likely to continue to need services as an adult—the local authority initiates advance planning of the care needs that that child will have as an adult? Will it ensure that, from the age of 14 and by the age of 16, every young person who needs services has a five-year rolling transition plan in place, which specifies when his or her needs assessment is likely to take place? Will it ensure that when a child who needs social care reaches the age of 14, the local authority initiates advance planning of the carer’s needs when the child reaches the age of 18? Finally, will it ensure that the full range of services that young people with life-threatening and life-limiting conditions will require as adults—including local authority housing services to help them to live independently—are involved in the transition planning process?
As I have said, it has been my privilege for many years to work with so many inspiring young people and their families. In the hospices where I have worked, I have seen the staff do incredibly hard and great work. They do a tremendous job in trying to help families through the minefield of the care system. I think that the Bill offers us a real opportunity to make things just a little easier for families who are looking after children and young people with life-limiting conditions.
Hywel Williams (Arfon) (PC)
it is a pleasure to follow the hon. Member for Pudsey (Stuart Andrew). I know about the fine work that he did at Hope House, or Ty Gobaith as we call it in Wales. It serves both sides of the border, and that is relevant to some of my later remarks—which I hope will be brief, given that they are slightly tangential to the main thrust of the debate.
I speak as the co-author of a bilingual training package on social care, published in Wales some 20 years ago, entitled “Gofal”, which is Welsh for “care”. It marked the beginning of the divergence of social care in Wales from the care that was previously available in England and Wales. I want to say something about that difference and how it will be addressed.
I always supported real independence, choice and dignity for older and disabled people in my former life as a social worker and a social work teacher. The hon. Member for Sheffield, Heeley (Meg Munn), who is not in the Chamber now, referred to carers’ rights. I was one of the sponsors of the Carers (Equal Opportunities) Act 2004, which was promoted by the hon. Member for Aberavon (Dr Francis).
Let me now draw attention to some details that relate to the working of the Bill. Certain aspects of it are complex, given that social care has been devolved to the Welsh Assembly. In the other place, my noble Friend Lord Wigley asked some questions which, as far as I can see, have not yet been answered satisfactorily. I hope the Minister will tell us—or write to me about it later—what discussions have taken place between his Department and the Welsh Government.
The Social Services and Well-being (Wales) Bill is currently before the Assembly, and has now reached its Report stage. It is an important piece of legislation for Wales, and is similar to this Bill in many respects. It will increase the number of services for which people can claim a direct payment from the local authority, will introduce national eligibility criteria, and will provide for portable assessments to avoid the cost and trouble of reassessments.
Let me make a general point about funding. I understand that the Bill will require additional spending of about £1 billion in England. If I am correct—these are the figures I have been given—it would probably generate about £60 million of Barnett consequential spending in Wales. Will the Minister confirm whether a figure has been agreed, and if so, will he tell the House—or me later on—what it might be?
Particular circumstances apply in Wales. For historical and industrial reasons—the prevalence of heavy industry—Wales has higher levels of disability. Thousands of people retire from England to Wales—they are very welcome, but there is a cost implication. Wales has the highest proportion of older people of any country or region in the UK. Nearly one in four of our people are over 60, and that figure is expected to increase by a further 5% over the next 10 years. Any funding system based merely on total population will therefore inevitably generate inequalities. In passing, I refer to my concerns about the Government’s census proposals. I fear we might not have proper data in the future—but that is a debate for another time.
I am concerned that provisions in this Bill that have an England and Wales remit will impact on the changes taking place in Wales under the Welsh legislation I just mentioned and, equally, that changes in Wales will have implications for cross-border placements and the possibility of care packages. What discussions has the Minister had with officials in Cardiff? Have all outstanding issues been resolved? In particular, have we resolved the issues relating to social services assessments possibly being undertaken in Wales for persons who then move to England, and likewise of care packages for persons moving from England to Wales? It is a particular issue where I live and along the north-west Wales coast. If they speak later, other Welsh Members may refer to that as well.
The difficulties to which cross-border issues might give rise are covered in clause 37 and schedule 1, which relates to cross-border placements. Paragraph (1) deals with cross-border placements from England to Wales, but the schedule does not specify—or so it seems to me at least, but perhaps my reading has not been close enough—who is responsible for paying. Are the provisions in paragraph 1(5) meant to cover this? It is far from clear to me. Might this be a matter for regulations? Again, I would be glad to hear from the Minister, either later this evening or by other means. We need some reassurances on these matters. It is also less than clear that paragraph 6(2) and (3) are adequate to provide full recompense, where relevant, in all cases.
I turn to the proposed health research authority in clauses 107 to 114. Clause 109(3) and (4) state that the HRA’s remit is to promote the co-ordination of standardisation of practice in the UK in the regulation of social care. Particular aspects of social care in Wales require a specific approach. The socio-economic make-up of Wales is different. Gross value added levels in some areas of Wales are as much as 40% below average levels in the UK. The financial profile against which any new policy is set will inevitably differ in Wales and England and will have to allow for Wales’ significantly higher disability levels. Wales has already set a cap of £50 a week on charges for home care.
Finally—and perhaps inevitably for me—I turn to language and culture issues and draw the House’s attention to schedule 1(13). For reasons that will become obvious, I quote directly from the Bill:
“Am ddarpariaeth ynghylch lleoliadau trawsffiniol i Loegr, yr Alban neu Ogledd Iwerddon neu o Loegr, yr Alban neu Ogledd Iwerddon, gweler Atodlen 1 i Ddeddf Gofal 2014.”
That merely means:
“For provision about cross-border placements to and from England, Scotland or Northern Ireland, see Schedule 1 to the Care Act 2014.”
I quote that merely to emphasise that Wales is another country and that we do things differently there. When cross-border assessments are made, language and culture issues are particularly important, and I hope that that will be taken into consideration. Clause 109(4) places a duty on the HRA and the devolved Administrations to co-operate with one another. I am curious to know how such a duty is to be enforced. What happens if disagreement arises, as inevitably it will, between conflicting expectations in Wales, Scotland and England? Does the Secretary of State in England have to act as a referee in such a dispute? I am not against such co-operation—very much the reverse—but the ground rules need to be clear.
Mr David Ward (Bradford East) (LD)
I had to leave the Chamber earlier, Madam Deputy Speaker, for an hour or so, but I assume we have been approached by similar groups and organisations that no doubt will have been quoted in previous speeches, so I might be able to curtail my remarks.
I begin by paying tribute to my right hon. Friend the Member for Sutton and Cheam (Paul Burstow), who has been heavily involved in this issue from day one, with the inception of the White Paper. I thank him for coming to Bradford and talking to people there about local issues, and I welcome his contribution tonight. This is probably the most important Bill we will be considering this Parliament, because it deals with one of the most important areas of public policy that we have to face. There is no choice about it; it is something we have to face. It has been referred to over the years as a ticking time bomb. The good news, of course, is that people are living longer, but that will be accompanied by an enormous cost if we are to ensure that people are provided with the quality of care that they are entitled to and desperately need. It is hugely important.
Like the hon. Member for Gloucester (Richard Graham), I am confused by the reasoned amendment. I come from a place where people say what they mean and mean what they say, so I find it difficult to read a so-called reasoned amendment that is so scathing of a Bill and then listen to people say, “Well, actually, we’re not opposed to it and will not necessarily vote against it.” I do not understand that. Perhaps this is just a really strange place that I still need to spend more time in before I understand those things.
As I understand it, a Second Reading debate is about the principles, which is why I will avoid going into too many details. From my experience of working with many organisations and groups in the past few years, including very closely in the past 18 months or so, it seems to me that the principles in the Bill are pretty well applauded out there. There is a general acceptance that something needs to be done and that this is a pretty good attempt to lay down some basic principles. That was why the initial skirmishes and exchanges were disappointing.
Paul Burstow
My hon. Friend has taken a close interest in, and campaigned on, the Bill during its passage through the other place, and he said how widely welcomed it was outside the House. Would he be interested to know, therefore, that in almost every session of the scrutiny of the draft Bill—
Madam Deputy Speaker (Dawn Primarolo)
Order. Will the right hon. Gentleman face the rest of the Chamber and address the Chair, and while I am on my feet, I should remind him of two things: interventions should be brief, and handheld devices in the Chamber, before or after interventions, should be used with due decorum.
Paul Burstow
I apologise to you, Madam Deputy Speaker. I have been here long enough to know that I should speak through the Chair.
I simply wanted to say that during consideration of the draft Bill, when asked, many people told us they had nothing by way of criticism of the Bill, although they saw areas where it could be further improved.
Mr Ward
I thank my right hon. Friend.
Acceptance of the principles—certainly acceptance of them by myself—is there, but as the Minister knows only too well, as I have bent his ear on the subject so many times, I have some serious concerns, particularly about the FACS—free access to care services—criteria. He will probably not know—it is a recent decision by Bradford council—that the Labour council has decided to move from “moderate” to “substantial” in respect of the criteria. It has to go into a budget process; unfortunately, this will happen. We campaigned hard against that, with a 1,700 names on a petition opposing it, but it is going to go ahead.
What was unfortunate about earlier exchanges was a certain degree of dishonesty. This thing did not happen all of a sudden three years ago. Conservative, Labour and possibly some Liberal authorities—I do not know—up and down the country were from 2005 onwards moving away from “moderate” to “substantial” FACS criteria way before the change of Government and way before the vicious cuts took place as part of the austerity programme. Indeed, it was before the recession really bit, and I regret that. What seemed to be happening was a “follow my leader” approach—“Every other authority seems to be doing this, so why shouldn’t we?” It was seen as a way of reducing the budget. What I argued, continue to argue now and will continue to argue all the way through until this Bill becomes an Act, is that this is a false economy. I have made all those points to the Minister several times, including, in detail, in a Westminster Hall debate.
I believe that eligibility is the gateway to care, but I am not convinced by the proposed savings that are supposed to be made. We worked closely with various organisations, including Scope, which has done a fantastic job of looking at the issue of working age disablement, which accounts for one third of benefit recipients. People desperately need care to live a more fulfilled life, whether it be in education or work. This is just one example—there are many others—where savings can be accrued, but taxation can also be generated if people are given just a small amount of support to become economically active.
Other charities and organisations have raised serious issues. Principles are most important, but data collection is crucial. Charities that exist to help people with Parkinson’s and other neurological conditions identified the fact that they had no idea how many people with Parkinson’s actually received social care. How can that be the case? How can that happen? Something must be sadly going wrong with data collection. Macmillan Cancer Support pointed out that free social care at the end of life needs to be a crucial element of any changes we are looking to make and that, if we aim for true integration, we must have proper identification of carers within their health settings. We should not wait until people are turned out of hospital and go home before identifying who is going to look after the person and provide support. Leonard Cheshire Disability provided further useful information, and I ask the Minister to look further into some of the issues it raised.
Important principles are at issue here. On the national criteria, I may not like the level, but it is important to have standardisation. On the carers assessment, we should be applauding the fantastic proposal to make carers the centre of attention, as they are so often forgotten. How many times have carers ended up being the people who need care because of the lack of support they receive? A young person I know has come to my office on a regular basis to express serious concerns about the people he was caring for, but I have seen with my own eyes that person deteriorate over the last 12 months or so as a result of the lack of support that he has received. The Bill introduces a wonderful innovation, which we should all appreciate.
I have already mentioned the principle of integration. We have the framework: the health and wellbeing boards are still in their early days, but this way of bringing together the different parts of social care, public health and the national health service is so important. The links between health and social care are crucial. I cited a case in the Westminster Hall debate of a man in his 50s who had an accident at work when reversing his vehicle. He had no seatbelt on, as he was just backing into the car park, yet he became tetraplegic. He was in Pinderfields hospital for five months. He received superb support and everyday attention, but when he went home in the ambulance, he could not get into the house because there was no ramp. He had to go away again. Then the local authority provided the money for a ramp and the hospital brought him back again, but he could not get in because it was a wooden ramp and they did not dare take him on it because that would have broken it. That is madness in this day and age, and it needs to be dealt with.
On the cap on lifetime payments, we do of course need to discuss in detail what it should be and how it should be operated, but please let us not talk it down, because an incredibly important new public policy is being put forward here, which we should applaud.
Let us try to forget what happened earlier. It was unpleasant to see and I do not think it truly represents the true passion and commitment of people on both sides of the House to improving social care for the people of this country.
Mrs Anne McGuire (Stirling) (Lab)
For reasons that might become clear later, I am pleased to follow the hon. Member for Bradford East (Mr Ward). Before the hon. Member for Pudsey (Stuart Andrew) drifts away, let me say that his contribution helped to address some of the issues of transition, which can sometimes get lost in this debate.
We should recognise that this issue is not unique to the United Kingdom; it is a challenge that many countries face, and the hon. Member for Arfon (Hywel Williams) recognised that, even within the United Kingdom, the devolved Administrations are looking at how to develop their own social care policies in the context of their own nations.
I want to recognise, as some of my hon. Friends have done, that the Bill makes some progress, but I also want to assert our right to highlight the areas where we think it is failing. That is the justification for the reasoned amendment. We could get bogged down in parliamentary procedure here, but I think it is the right of the Opposition to highlight major issues that we think should have been addressed without undermining our support for the principle of the Bill. I hope that those who think that we are being churlish will think again. It is the right route for an Opposition. Talking about being churlish, let me put it on the record that I have rarely heard an opening statement from a Secretary of State, moving the Second Reading of one of his flagship Bills, that was so churlish, so partisan and, frankly, so disagreeable.
For understandable reasons, the debate on social care often focuses on older people, yet as we have heard—from the right hon. Member for Sutton and Cheam (Paul Burstow) as well as from the hon. Member for Bradford East—a third of those who receive social care are actually working age disabled people. We sometimes overlook their needs, rights and aspirations within the wider debate. Too often “social care” and “elderly” go together, and we need to get ourselves out of that mindset, because although they look the same, I think we would all agree that a younger person’s need for support can be quite different from the support needs of those who are older. The emphasis on older people means that the terms of the debate are often not as relevant as they might be to younger people who require social care. They often want to combine that social care with a life that includes work, education and so forth, and they potentially have a different pace and pattern of life from that of older people.
It was to highlight these issues that the all-party groups on local government and on disability launched a joint inquiry to investigate how social care policy, funding and practice can better meet the needs of disabled adults. The hon. Member for South Derbyshire (Heather Wheeler) as chair of the all-party group on local government, and Baroness Campbell of Surbiton and myself as joint chairs of the all-party group on disability, were delighted when 10 parliamentarians of all parties from both Houses agreed to undertake an independent inquiry. The hon. Member for Bradford East was involved in that.
That report was lodged earlier this year and I trust that the Minister and my own Front-Bench colleagues have had the opportunity to consider its recommendations. What came out from all the evidence from disabled people, organisations and professionals was that the current system is not delivering on basic things such as washing, dressing and getting out of the house for many younger disabled people. If social care is to mean anything to the lives of the disabled working adult, it should be underpinned by a real recognition of the importance of an independent life. So the criteria of what is important should also include how the care dovetails into other important elements of daily life such as participation in work or education.
I acknowledge that in clause 1 the Government have recognised that promoting individual well-being is not just about care. They also recognise that it is about
“participation in work, education, training or recreation”
and
“social and economic well-being”
and
“domestic, family and personal relationships”.
However, those ambitions will not be realised unless the issue of eligibility is properly recognised and the substantial anticipated savings highlighted in clause 2 creating a preventive care system will not happen either. I fear that the national eligibility threshold in the Bill is currently set too high. In Committee in the other place, that was recognised by peers from all parties and none. It will shut out 105,000 disabled people from social care and prevent them from living independent lives with dignity.
Councils are now moving at a rate of knots towards providing social care only to those with critical or substantial needs. We cannot divorce what is happening in social care from some of the other changes the Government are introducing. We are moving towards substantial care in terms of social needs and we are withdrawing disability living allowance from people with less complex needs. We are perhaps moving to a situation where those with severe and complex needs will be taken care of and supported while those with fewer needs will not be, so there will be a double-whammy in terms of social care and the DLA transfer.
I recognise that the Government have transferred some £2 billion from the NHS into social care and into making the transition easier, but this cannot be seen outwith the context of a 33% cut in local councils’ budgets by 2014 and the chronic long-term underfunding of the social care system. Over the past three years, £2.68 billion has been cut from adult social care budgets, which is 20% of net spending, but the number of working-age disabled people needing care is projected to rise by 9.2% and the number of older people needing care will rise by 21% between 2010 and 2020.
Sheila Gilmore
On my right hon. Friend’s list of changes affecting people needing care, does she agree there is also the issue of the independent living fund which has helped working-age people? The Government have lost a court case in respect of their failure to consult properly on that. Does my hon. Friend agree that that should be looked at carefully?
Mrs McGuire
I agree with my hon. Friend and I raised that with the Minister in a Westminster Hall debate. The Care Bill does not address the role that the Department for Work and Pensions plays in supporting social care through the benefit system and the independent living fund is a classic example of that. At present, people who can pay for social care through access to the ILF do not know quite what is happening, because the Minister—as I think he said last week at the all-party group—is still considering his options.
I want to echo a comment by the hon. Member for Bradford East—I can assure him that he will not get so many mentions in any of my speeches again. He pointed to something that I think is often missed, which is that the debate often crystallises around the spend, which is not seen as an investment. I acknowledge the work done by Scope, and carried out by Deloitte, highlighting that for every £1 invested in care for disabled people with moderate needs a saving of £1.30 is generated. The figures are pretty staggering. There would be a £700 million saving to central Government through an increase in tax revenue and a reduction in welfare spending. This Government always tell us that they want to reduce welfare spending; well, there are opportunities to do so without doing some of the things that they are doing. There would be a £570 million saving to the NHS and local government, and £480 million would be saved by local government by avoiding the need for disabled people to enter expensive residential and crisis care.
The Minister knows that there is considerable political and organisational support for a lower eligibility threshold. The draft Care and Support Bill pre-legislative scrutiny Committee recommended that, when setting the national eligibility threshold, the Secretary of State should have regard to the duty of local authorities to promote individual well-being. The report of the joint inquiry I have mentioned also highlighted the issue of eligibility.
We in this House often talk as though we are somehow divorced from the beneficiaries of the legislation we pass, but I say to Members that we are talking about ourselves here. Any one of us could walk out of this Chamber tonight and be in need of social care tomorrow. If we want a good social care system, we should ask ourselves this question: what would we want for ourselves if we had a stroke or a car accident or fell down those marvellous marble stairs outside and cracked our head? That is the criteria that we should be using. This Bill makes small progress, but there is a lot more to be done.
Anne Marie Morris (Newton Abbot) (Con)
For my constituents this Care Bill is one of the most important pieces of legislation we have seen in my time in Parliament. That is because the west country attracts a lot of people wanting to retire to our very beautiful countryside. In Newton Abbot, 23% of residents are over the age of 65, compared with the national average of 16.5%. Social care is therefore a very important issue for us.
I congratulate the Government on what they have done, because they have introduced an holistic framework that sets the scene for ongoing legislation to flesh out that framework. They have listened to Dilnot and to Francis and that is very much to their credit.
Integration of health and social care has been the watchword on everybody’s lips. All Members will have come across examples in their surgery case loads of where that does not work, and I am very pleased to see the integration—the balancing provision—that we already have in the Health and Social Care Act 2012 now reflected in this Bill.
On the adult safeguarding framework, I say well done! This is crucial. This is the first time we will have had anything like this for vulnerable adults. In my constituency, I am regularly addressed by carers who are frustrated not only by the challenges of those they care for but by the lack of support they receive. The Bill will provide the answer in the form of care plans and proper assessments. It is not often that individuals come to me who have fallen into the gap between the care plan for a child and the plan for an adult, but it does happen, and I am pleased to see that the Bill will mean that that will change.
One of the big challenges is dealing with the cost of care, and it is to the Government’s credit that they have started to look at that difficult question. How much is it right for the taxpayer to pay, and how much for the individual? This is a good Bill, but there are many things that I am sure all of us would like to see added, improved, amended or clarified. For me, one of the challenges is the role of the local authority in its commissioning and provision of care services. It seems bizarre that it should do both, because that must surely give rise to a conflict of interest. How can it commission and provide? The conflict was recognised in the NHS, and a split was introduced. It is now time to introduce such a split in this regard as well. Now that local authorities will have a key oversight role, it would be madness not to review that situation.
An important change involves the concept of true integration, and the challenge will be to identify the stakeholders who should be included in that integration. Clearly, it must involve the NHS, the local authorities and housing, but one area in which there is often no acceptance of stakeholder responsibility is that of transport. Transport to get people between care homes and hospital appointments has almost reached crisis point in my constituency, and there is huge reliance on the voluntary sector to fill the gap. There is clearly some provision for the NHS to provide that transport, but the rules are so broad that, when times are tough, transport provision becomes limited.
So who provides the transport? The volunteers in my constituency are brilliant, but they can afford only so many vehicles that are equipped to take wheelchairs, and there are only so many drivers. That issue needs to be properly addressed. In the guidance on integration that is to be given to local authorities, the NHS and other stakeholders, we must look seriously at the transport question and ensure that appropriate responsibility is taken for it and that it is properly funded. We cannot assume that the voluntary sector will continue to fill the gaps.
The assessment will form a critical piece of the jigsaw, and the Government are to be commended for trying to clarify the process, to avoid confusion and to get agreement on this. I understand their need to limit mandatory provision by a local authority to those in substantial need and above, but I fear that there could be confusion over the interpretation of the word “substantial”, and I would welcome clarification on that from the Government, in guidance or elsewhere.
Having looked at the definition of substantial need, we then need to consider who is to be involved in agreeing the care package. This is about the process of assessment, and it will be crucial for all the stakeholders to be involved. I have seen diverse levels of application in my local authorities. In some, this is very much a matter for the local authority, and it can sometimes almost seem as though a care package is being imposed on an individual. In other authorities, however, the individual, the carer, the family and the care home are all involved to ensure that the package is understood, agreed, accepted and fit for purpose. It would be extremely valuable if guidance could ensure that that always happened, when the Bill becomes law.
Having assessed the individual’s need, we need to ensure that the quality of the provision is fit to meet that need. I welcome the introduction of the new, almost Ofsted-like categorisation of quality, which will give us a real insight into what is on offer, and what “good” and “average” look like. That in turn will give rise to further questions. Once we know what they look like, we shall have to answer a much more difficult question: to what level should the taxpayer pay, after which there should be a personal top-up? That issue can be addressed only when we have some experience of those categorisations.
If there are to be different levels, the option of a top-up has to be real and available. It clearly exists, but I have seen a reluctance to make it happen in practice in some local authorities. In some ways, that is understandable. The contract is with the local authority and the care home, and not with the relatives or, more usually, the individual picking up the extra cost. The local authority will be concerned that, should there be a problem of affordability for the caring relatives, it would be left to pick up the bill. The top-up therefore needs to be reviewed. If it is to be available, it must be meaningful, and that might involve looking at whether relatives can be part of the contractual arrangement.
In the longer term, following the successful passage of the Bill, there is a lot more that could be done. The Bill will undoubtedly put in place the framework, and we can then begin to look in more detail at the strategies needed for those living in their own homes with support. Historically, we have asked what we should be doing for those in residential care or in hospitals, but once we have the framework, we will have the opportunity to look at a much more concrete strategy. That is something I would very much like to see.
Given the financial circumstances in this country at the moment, we can afford to support only those with substantial needs as a minimum requirement, but the Bill makes provision for local authorities to offer advice as well as providing services, and we should perhaps give more support to those who have only moderate needs. Their needs could be better explored, and they could be better championed and provided for.
The final word needs to be that change is not just about legislation. This is also about a culture change. That will always be a challenge, and it is incumbent on all of us in the House, whatever happens to the Bill, to follow it up and ensure that it becomes something meaningful in practice that will benefit all our residents, who very much deserve it.
Heidi Alexander (Lewisham East) (Lab)
It is a pleasure to follow the hon. Member for Newton Abbot (Anne Marie Morris), who made a measured, thoughtful speech. It is sad that the Secretary of State did not strike the same tone at the beginning of the debate. I want to speak briefly about the proposals for the funding of elderly care and express my deep concerns about the Government’s proposed changes to the trust special administration process.
I have spoken before in this place about the care crisis in this country, not least because of my own family’s direct experience. When my nan had to move out of her home seven years ago, my family had no idea what was about to happen to the very modest assets she had built up over her lifetime. My nan was not an extravagant woman. She never once went abroad. She simply worked hard and brought up her family. When vascular dementia took hold of her mind and her body, she could no longer stay in the semi-detached house in Swindon she had bought with my grandfather. She had to sell it. She moved to sheltered accommodation but, after a few years, she deteriorated rapidly and soon had to move to a nursing home. Before she died, she spent £130,000 on care in that home over three to four years, using up all but £23,000 of her lifetime assets. If she had known that, it would have broken her heart. She would not have thought it fair that everything she and my grandfather had worked for could not in any meaningful way be passed down to her children. My family are neither rich nor poor; we are like families up and down the country for whom the hand of fate intervened resulting in catastrophic care costs for their loved ones.
The Bill’s proposals to cap those costs and to raise the amount of money that an individual’s family can keep after paying for care should be welcomed, but we should welcome them cautiously. The cap does not cover all care costs, and the complexity of the process of valuing people’s assets and calculating their personal contribution means that many people will still end up paying very significant sums. Presenting the proposals as the answer to the country’s care crisis is disingenuous and risks spreading even more confusion about what support from the state families can expect.
If individuals are to pay less, the state will pick up more of the tab, and the financial front line in that respect will be local authorities. They are already buckling under the strain of providing social care. London Councils, the body representing the capital’s local authorities, estimates that the costs of resetting the means-test threshold, added to the rising demand for care, will see social services departments facing a shortfall of more than £1 billion in the years between 2016 and 2020. The money set aside by the Government to deal with that is inadequate. Be it this Government or the next one, we have to wake up to the scale of the financial challenge and answer the tough questions about where the money is going to come from.
I could speak for much longer about the care proposals in the Bill, many of which I welcome, but I now wish to address part 3, chapter 4, which extends the powers of special administrators appointed to failing hospital trusts. The changes are only a small part of the Bill, but they have serious implications for hospitals and the health service across the country. The introduction of even more draconian powers for special administrators will hamper the public’s ability to have their say on key hospital services and could lead to a chaotic and rushed system of hospital reorganisations that will not be in the best interests of patients or our democracy.
Grahame M. Morris
My hon. Friend is making important points about clause 118, which has become known as the “Lewisham clause”. Given the recent experiences of the length of time the trust special administrator has to consult the general population, does she think that 100 days is long enough?
Heidi Alexander
In my experience, it is wholly inadequate. The consultation period is being slightly extended through this Bill, but I still do not believe it can lead to a genuine, open and honest debate between the people trying to lead change and the public, who have a right to make their voice and views heard.
I wish to discuss our experience in south-east London of the first ever use of the trust special administrator regime when the South London Healthcare NHS Trust was placed into administration last year. It is important for the House to understand that this process is totally different from any other hospital reconfiguration. It is a very fast process—roughly six months from start to finish—led by an administrator who is brought in from outside the organisation primarily to balance the books. The administrator is appointed to a specific failing trust, but what happened in our corner of London was that the administrator determined that in order to sort out the financial problems of the failing trust he needed to look beyond its confines, and that is where Lewisham hospital came in: a separate, successful, neighbouring hospital was told that its full accident and emergency department, its maternity service and its excellent paediatric department would have to go to solve the financial problems elsewhere.
The people of Lewisham did not think that that was very fair. The case was fought in the courts and the Secretary of State was told, not once, but twice, that he was acting unlawfully—hence clause 118; he fought the law and lost, so he is now trying to change it. He wants administrators to be able to specify and force through massive service changes at hospitals that are not part of the trust to which an administrator has been appointed. In effect, he wants to do elsewhere what the courts told him he could not do in Lewisham. When the trust special administrator regime was first legislated for, guidance was issued by the Department of Health stating that the process should not be used as a “backdoor approach” to reconfiguration. That is precisely how it was used in Lewisham, and had the law not been on our side, our full A and E and maternity service would now be closing, and half our hospital would be up for sale.
The TSA process is a brutal and rushed one. It starts with the need to save money, with questionable clinician input. When the starting point is the accountant’s bottom line, the public are understandably sceptical about whether the medical and clinical input has just been shaped to suit the desired financial end point. The speed at which the process takes place leads to shoddy and haphazard work. The administrator in south London recommended to the Secretary of State that he make decisions about Lewisham hospital based on an understanding that the whole process would cost £266 million and would take three years to implement. After the Secretary of State took his decision, it emerged, from the office of the trust special administrator, that it would cost twice that and take twice as long. The quality of the condensed public consultation was atrocious: people were struggling to find copies of the consultation document in local libraries; we had an online response form that did not even contain a direct question about Lewisham’s A and E; and hundreds of people had to stand outside packed public consultation meetings because they could not get in. That is not the way to deal with a subject that understandably arouses such passions in people. People care so much about the health service because it is often where they experience the worst and best moments of their life. They want to have their say in how their services are organised, and giving even more draconian powers to special administrators erodes their ability to do that.
I understand that hospital services have to evolve—some services will have to close or be relocated—but to get public support for change, we have to get the process right for persuading people of the case for change. An augmented special administrator process, acting as a steamroller for the closure of hospital services, makes it less likely that those arguments are won, not more. These changes are at complete odds with the Conservative party’s manifesto commitment to
“stop the forced closure of A&E and maternity wards”.
The changes take power from the very doctors the Government say they are giving power to and could destroy trust in those who are central to leading the case for change and improvement in our NHS. For that reason, as well as others, I will be voting for the Opposition amendment, and it is why I believe that clause 118 should be deleted from this Bill as it progresses through Parliament.
Mr Robert Buckland (South Swindon) (Con)
When I say that it is a pleasure to follow the hon. Member for Lewisham East (Heidi Alexander), that is not a mere formality; it really is a pleasure, and it was fascinating to hear the family experience of her late grandmother in Swindon. As the Member of Parliament for some other members of her family, I was particularly interested in, and concerned to hear, that story. Clearly there is a measure of consensus about the progress that the Bill allows us to make. Although I understand and appreciate her concerns about the process that was successfully challenged in the courts in relation to her local hospital, and the detail in respect of clause 118, I do not think, with respect to her and to the Opposition, that that is sufficient for the reasoned amendment to pass tonight. I say that because I think of the thousands of families like hers who, over the years, have had to wait for change and for politicians to come up with a decision. We have procrastinated and prevaricated, and had review after review, so surely time is now up and decisions have to be made. That is why this Bill comes not a moment too soon.
I want to address an aspect of the Bill that has been dealt with by other Members: the care of adults with learning difficulties, and especially with autism. I speak in my capacity as chair of the all-party group on autism. I also declare an interest as the parent of a child who one day might fit some of the criteria of the Bill and as the parent of a young carer. I say with enthusiasm that I welcome those provisions in the Bill that relate to the assessment of young carers. They were very much part of a cross-party campaign with which my right hon. Friend the Member for Sutton and Cheam (Paul Burstow) and the hon. Member for Worsley and Eccles South (Barbara Keeley) were involved. A necessary change was made to allow young carers’ rights and needs to be assessed as well. Let us not forget that while this Bill makes its way through this House, the Children and Families Bill is making its way through the other place. We must ensure that both Bills dovetail in a way that is truly effective. In particular, I am thinking of the provisions of the Children and Families Bill that extend the education, health and social care plans to those young people between the ages of 18 and 25. We must ensure that the social care aspects of this Bill dovetail properly with the needs of those young people, because this Bill affects adults from the age of 18 and onwards.
This is a hugely important Bill, and I want to address it in the context of the Autism Act 2009. That groundbreaking legislation was passed in this House with all-party support and following the work of my right hon. Friend the Member for Chesham and Amersham (Mrs Gillan). I pay tribute to all Members, and former Members, who played their part in that legislation. As a result of it, an adult autism strategy was passed in 2010, which committed both national and local government and the NHS to improve the lives of adults with autism.
However, here we are in 2013, and there is still some way to go to meet the aims of that legislation. The strategy is currently under review. Ahead of that review, the National Autistic Society launched its “push for action” campaign, which identified some of the most important barriers to implementation and outlined the key challenges that adults with autism continue to face. Some of those challenges can be met by this Bill.
I am particularly pleased with clause 2, which places new duties on local authorities to prevent the needs for care and support from developing in the first place. Change in that area for adults with autism has been slow and patchy. A third of adults with autism who responded to a survey by the National Autistic Society said that they developed serious mental health problems because of a lack of services. Support at a low level can allow people with autism to become more independent, work, socialise and take part in their communities. At the same time, it can prevent an escalation of care needs.
Back in 2009, the National Audit Office found that providing such low-level services is cost-effective and helps people to avoid the use of in-patient mental health care, which costs between £200 and £300 a day. The NAO said that if just 4% of adults with Asperger’s syndrome or high-functioning autism are identified and supported, that would become cost-neutral over time.
I am glad that the right hon. Member for Stirling (Mrs McGuire), who is no longer in her place, referred to the Deloitte economic model, which quite clearly shows that for every pound spent to support people with autism and other disabilities, there is an average return of £1.30 for central Government, local government and disabled people and their families. Clear duties that prevent mental ill health are essential if we are to make the aims of the adult autism strategy a reality and to save money. I would be grateful if my right hon. Friend the Secretary of State and the Government ensured that local authorities’ understanding of prevention is wide ranging and includes the very types of low-level support that can make this prevention aspiration a reality.
Let me turn now to the existing duties of local government and the NHS. I welcome the Bill’s intention to bring together in one place statutory guidance on care and support. However, the statutory guidance that was published as a result of the Autism Act is slightly different. As opposed to the Care Bill, the 2009 Act also places important duties on the NHS. I want to ensure that those duties on the NHS are not unintentionally omitted from this Bill.
There is still much progress to be made with regard to the duty to develop a diagnostic pathway for adults with autism. I am happy to say that in Swindon the local social enterprise SEQOL has already done that, and has developed an important diagnostic pathway, which is also followed up by meetings with and assessments by clinicians. That has resulted in adults as old as 50 and above being diagnosed with autism or Asperger’s for the first time. The issue of what happens next will be key if we are to make this Bill, and the good intentions behind it, work for people with autism.
A common problem reported by families of people with autism is that far too often the person carrying out the care assessment does not sufficiently understand the condition or how to communicate effectively with someone on the spectrum. I am therefore encouraged by the recent amendment to the Bill to enable regulations that will specify where community care assessments should be carried out by assessors with specific expertise. Assessments for adults with autism must be covered by those regulations, because that will reinforce the obligation already placed on local authorities by the Autism Act and the statutory guidance to train those who carry out community care assessments. The NAS found that, at the moment, only just over half of local authorities have specialised training available for their staff, so, quite clearly, more work needs to be done to deal with that.
The right to advocacy is essential to enable people who find it hard to communicate to exercise their rights. I pay tribute to the work of the Swindon advocacy movement, which, as a result of its efforts and funding from the local authority, is now extending advocacy to adults with autism and Asperger’s, who have never had that support before. What often makes us parents lie awake at night is the question of who will speak for our children when we are gone. Who will be there to carry out that advocacy? This service is essential to provide peace of mind to parents and carers of sons and daughters with autism who will outlive them. My hon. Friend the Member for Newton Abbot (Anne Marie Morris) mentioned the definition in clause 68 of “substantial difficulty”. This debate on Second Reading is about the principle of the Bill. I am sure that we will be able to iron our further details when the Bill goes to Committee. None the less, I commend it to the House as an overdue attempt to address the concerns of real people in our communities, and to help people with disabilities, including autism, lead fulfilling lives.
Bill Esterson (Sefton Central) (Lab)
The hon. Member for South Swindon (Mr Buckland) speaks with great passion and knowledge in support of children with autism. He made an incredibly important point when he asked who cares for vulnerable children once the parents have gone. Indeed, who cares for all those we care for once we are gone? That is a powerful and important point.
I agree with the hon. Gentleman that this debate is about the principle of the Bill. He talked about the need for action, which is why the Bill is welcome. We have an opportunity to improve services for many people, but Labour Members feel that the Bill should be more ambitious, which is why the reasoned amendment is so important, and it is what the reasoned amendment is saying. I also agree with him about the need to integrate what happens under the Children and Families Bill with what happens under this Bill. The crossover he mentioned between children’s service and adult services as children grow up is important. The Children and Families Bill and this Bill create significant new responsibilities for the NHS and local government, and the big question for the Government is about where the resources will come from to deliver them. I was a local councillor for more than 15 years under both previous Governments and it was a familiar story for local councils to be given new responsibilities without necessarily always being given the resources to deliver them. That is an important point about this crucial Bill.
The hon. Member for Bradford East (Mr Ward) mentioned the need for free social care at the end of life. That was an important point, but at what stage should social care be free? What do we mean by end of life? What criteria should we set? How much earlier than the end of a life should that care come? How do we fund free social care and how do we fund social care at all? That is one of the big concerns and that is why the reasoned amendment mentions our concerns about where the cap has been set.
My right hon. Friend the Member for Stirling (Mrs McGuire) mentioned the concern that the needs of disabled people may have been overlooked. The London School of Economics cites the fact that 97,000 fewer disabled people have been in receipt of social care since 2008—the figure for older people is 250,000. The LSE cites £2.8 billion as the figure required for councils to set eligibility at moderate, in the context of an overall budget spend for health and social care of £120 billion. The fact that it would take £2.8 billion to set the criteria at moderate speaks volumes about what could be done if we got this right.
My hon. Friend the Member for Lewisham East (Heidi Alexander) mentioned her family and I am going to talk about my family now. My dad cares for my mum. Let me describe my mum’s experience this year, because it is the experience of many older people and their families. In the early part of the year, she was being cared for by my dad and she gradually declined until she was rushed into hospital. I think it happened because no health professionals or social care professionals were keeping a close enough eye on her. She ended up in hospital where, happily, she received very good care. Her wish was met and she was able to go home, and the health service provided a hospital bed that she could use there.
Once she got home, the lack of service in the community became a problem again. There was not the rehab, the physio or the support to enable her to return to some kind of active life. Now, many months later, it is too late—that will not happen. My mum rarely gets out of bed any more. For many people, such an experience is all too familiar. It happens because of how social care and health have been allowed to operate over the years, with no proper integration and without people in the two services talking to each other. My parents receive a care package now, with carers coming in. My mum’s social care needs are met but the lack of proper support has meant that things are not as they should be. I do not think that my mum’s case is the worst, by any means, but it is indicative of where things are missing.
The Government have made a proposal and they have talked a lot about integration between health and social care. I remember looking at integrated health and social care teams many years ago as a local councillor and there was success then. There has been more success recently and there are good examples of health and social care professionals working together, but cuts to social care, in particular, mean that the money simply is not there any more.
I cited the figures earlier. In Sefton, we have seen a 40% cut in local government funding. The care managers are simply not there any more. They are not there, as Members have said, to help people in the community stay in their own homes; they are not there to help people who have gone into hospital go home again. Those situations are combining to leave a crisis in A and E—we will have that debate on Wednesday, but that is what has been allowed to develop. I am afraid that the reorganisation of the NHS during the first years of this Government, with clinical commissioning groups being created, meant that administrators and managers in the health service were concentrating on setting up new structures and not on ensuring that health services were delivered properly. These things do not happen by accident. When £3 billion is spent on reorganisation and not on patient care, that is the sort of situation we end up with. The question is what should we do. We have a proposal for a £72,000 cap on care, but my hon. Friend the Member for Lewisham East described the sum that her nan had to pay, which was £130,000. For many people, the £72,000 cap will be no help, and other Members have given the details that show that.
There are a number of ways of funding social care, one of which is to have a cap. However, let me return to the comments made by the hon. Member for Bradford East. If we are considering free social care at the end of life, or, as I said, a lot earlier than that, perhaps the time has come for Members to debate free social care as part of a health and social care service that is free at the point of delivery and at the point of need, like that which my right hon. Friend the Member for Leigh (Andy Burnham) has mentioned before. Perhaps the time has come to say that that is the ambition that we, as Members of Parliament, should have.
Tinkering at the edges will not solve the problem. The debate we must have—and it must be a cross-party debate—is about how to pay for such a service. As people get older, that is what will be needed. Sooner or later, we as legislators will have to deliver exactly that service. Anything short of that will not solve the problems; things will only get worse. I put it to Members from all parties that that is what is needed. We have made a start with the Bill and tonight’s debate, but we will need to move down the route of free health and social care and of whole-person care. That is the only way we can solve the challenge of an ageing population.
Dr Sarah Wollaston (Totnes) (Con)
It is a pleasure to follow the hon. Member for Sefton Central (Bill Esterson), who speaks so compellingly about his family’s experiences and sets out the case for why we must get social care right.
I welcome the Bill. It was a pleasure to serve on the Joint Committee on the Draft Care and Support Bill and I think the legislation has been greatly improved by its passage through that Committee and through the House of Lords. It establishes that we need a social care system that works around the needs of individuals, as well as the well-being principle and the vital prevention principle set out so compellingly by the hon. Member for Sefton Central. The Bill also consolidates a confusing patchwork of legislation that I remember coming up against in my time in the NHS. People were not sure what their eligibility was, and they could move from one part of the country to another and find that they no longer qualified in the way that they used to.
There are many things to welcome in the Bill. The hon. Member for Lewisham East (Heidi Alexander) compellingly set out the effect of losing everything in the ghastly lottery of eligibility. Setting a cap on costs and raising the threshold from that paltry £23,250 to £100,000 is very welcome. So too is the focus on better information, advice and advocacy, and the assessment and better support for carers. My hon. Friend the Member for South Swindon (Mr Buckland) made some important points about child carers and the transition from children’s services to adult services.
There is a huge amount to welcome in the Bill and I could talk for 10 minutes on why all these aspects are important. Unfortunately, we also need to focus on the challenges. The predominant challenge is demographic. Nationally 2.2% of the population are over 85, but in my constituency we got there 31 years ago. By 2020-21 2.9% of the population will be over 85, but for Torbay that figure will be 4.9%. That represents an enormous demographic challenge. We were discussing with the right hon. Member for Leigh (Andy Burnham) the reasons why age is so important in assessing need. Because of their demographics, places such as Torbay and wider south Devon face additional challenges with rurality, which means that they are under pressure like never before. Although I fully understand that we must take into account deprivation and health inequalities, unless we take sufficient account of age and need in assessing the formulae, the system will collapse.
I should point out that Torbay is not only nationally renowned but internationally renowned. As a member of the Health Committee, when we visited Copenhagen and Sweden, I ended up being shown slides of Torbay—how Torbay organises health and social care. If we look at the challenges facing Torbay, we see that it was those demographic and financial challenges that were the driver for looking at how health and social care could be better integrated and—I refer to the experience of the hon. Member for Sefton Central—how avoidable admissions could be reduced. Enormous progress has been made. Waiting times for occupational therapy have been reduced from two weeks to two days, for physiotherapy from eight weeks to 48 hours, and for urgent equipment to help keep people at home from four weeks to four hours. As a result, Torbay has the lowest hospital admission rate for elderly vulnerable people in the whole of the south-west.
Norman Lamb
I am grateful to my hon. Friend for giving way. Does she share with me the excitement at the plan for Torbay as a pioneer to bring mental health back into primary care, properly to integrate that part of patient care? We have seen in other places that this can do an enormous amount to prevent a deterioration of health.
Dr Wollaston
Absolutely. I welcome the fact that Torbay will be part of one of the integrated care pilots, and particularly that focus on mental health, as my hon. Friend says.
Services in Torbay have been transformed through the use of care co-ordinators, so that only one phone call is necessary. There has been transformational work in sharing information and records and in rapid response to a crisis and putting prevention in place. The challenge that Torbay now faces is financial. Unfortunately, the elastic can stretch only so far before it snaps. Torbay’s funding is set to fall from £71.2 million this financial year to £63.6 million in 2014-15. Those cuts are in addition to the demographic challenges, the challenging situation in relation to children’s services, and the fact that we know that across the country 2015 is set to be a crunch year for NHS funding.
I welcome the £3.8 billion transfer for better care. We heard in the draft Bill Committee and in the Select Committee how such joint funding arrangements are the best driver to integration. A formula for integration cannot be dictated. What works for central London or central Manchester will be very different from what works in south Devon and in rural areas, but the fund will force people to work better together in a way that fits their area. That is very welcome.
Bill Esterson
Would the hon. Lady advocate a single service, and has she any thoughts on how that would operate? I am interested to hear her views.
Dr Wollaston
Indeed. It operates very well already in Torbay, but it cannot be dictated centrally. We need to get the hurdles out of the way, allow people to work together locally and facilitate that. We heard on the draft Bill Committee that joint funding streams were the best way to move that forward.
Unfortunately, in Torbay in the crunch year 2015 we will see the funding drop below 90% of projected expenditure. At that point, rather than driving further integration, it will cause systems to start to fall apart because people need to protect their own silos. That is a real danger. As the Bill proceeds to Committee, I hope we look very carefully at the effect of the funding gap and make sure that we are not setting a system up to fail. One of the problems with the Bill is that it sets up many new statutory responsibilities. Councils will have to fund care accounts, which will undoubtedly be complex, bureaucratic and subject to challenge. Councils will have responsibilities for carers’ assessments. There will be increasing numbers of eligible people as the thresholds and caps change. We will see safeguarding adults boards, more rights to information and advocacy, and for many, deferred payments, if they have not already been making those.
Once we create these additional statutory responsibilities, there will be less money to go around for the very things that are at heart of the well-being and prevention principle. That is what concerns me. Would it not be a tragedy if we set up carers’ assessments but there was no funding left for services to respond to needs? Voluntary organisations in my community can function incredibly efficiently on very little money. They do not need to be fully funded, but they need some funding. If that money dries up, I worry about how we will move forward with a genuine well-being and prevention principle.
I want the Bill to succeed. In the remaining minutes I shall touch on those aspects that I think are, sadly, still missing, which were recommended by the draft Bill Committee. One is how we calculate care costs according to their actual cost, not the cost to the council. For a person living in their own accommodation, it sometimes costs a great deal more to access support than it would cost a council to provide it. We need to look at that again.
There is a small but important area relating to powers of entry in exceptional circumstances for those who are subject to abuse in their own home. It would be wrong for us to ignore that possibility. Although the overwhelming majority of carers of course do a wonderful job in challenging circumstances, there are occasions, sadly, when people can be at risk from those who love them. Very often that is as a result of the intensely challenging circumstances that carers face. We need to reserve a power of entry in exceptional circumstances where there are very serious concerns about individuals who may be vulnerable and unable to communicate easily.
Another issue is free social care at the end of life. We know that 73% of people would like to be able to die at home. In my experience working as a GP in rural areas, where that broke down for most people was as a result of a lack of social care, and the challenge of caring for somebody right at the end of their life, when they may, for example, be doubly incontinent. Until people are in that situation, they may not understand how incredibly demanding it is to have to be with someone 24 hours a day, trying to stay awake and provide the intensive support they need. Allowing everybody to access free social care in those terrible final days would be a very important step forward.
Finally, the duty of candour we have introduced for foundation trusts is welcome, but I think that it should be extended to social care.
Dr Wollaston
I thank the Minister for that clarification. Also, an offence of wilful neglect already exists with regard to adults who lack capacity, but I would like the Minister to consider extending it with regard to those who have capacity.
We heard earlier about reconfiguration. We need to streamline reconfiguration processes. It is not right that the NHS’s valuable resources should be spent on long, drawn-out and expensive legal challenges. We know that in many cases we need to reconfigure in people’s best interests. Let us take out the party politics and get it right. Let us ensure that people have the right care and that we face the financial challenges in the NHS in a mature fashion.
Grahame M. Morris (Easington) (Lab)
I am pleased to have the opportunity to speak in this debate. Like several colleagues who have spoken, including the hon. Member for Totnes (Dr Wollaston), I served on the Joint Committee on the draft Care and Support Bill, under the chairmanship of the right hon. Member for Sutton and Cheam (Paul Burstow), and I also serve on the Health Committee, so I have a particular interest in this Bill. I had originally intended to make a more wide-ranging contribution, but I will confine my remarks to part 1, which deals with care and support.
I had hoped that the Secretary of State would conduct a hearts and minds exercise in trying to selling the Bill, so I was rather disappointed that he turned it into a political knockabout, jumping straight into the most contentious elements, and clause 118 in particular, which sets out the trust special administration arrangements.
I do not think that we can consider the Bill without giving some thought to the background. Let us not forget that over this Government’s tenure, £2.68 billion— at 20% of the net adult social care spend, that is not an inconsiderable sum of money—has been cut from council budgets. Although we were talking about the principle of well-being in relation to clause 1, which I think all Members support, in practice cuts of that level mean that fewer people are getting help with paying for their care and more people are being charged for vital services, such as help with getting washed and dressed and with eating—the basic things that most of us take for granted.
I have no doubt that councils, particularly those in the north that I am familiar with, are doing their best to save money and provide services efficiently by changing the way care is provided and, where they can, working more closely with the NHS. However, the scale of the cuts means that they are being forced dramatically to reduce services and increase charges to balance the books. All the evidence that has come to the Select Committee and the anecdotal evidence that Members receive indicates that is the case.
The Secretary of State got into a little argument in his opening statement with regard to eligibility thresholds, which is a really important point. In 2010-11, 38 councils provided free care to people with “low” or “moderate” needs, and 114 provided free care only to those whose needs were considered “substantial” or “critical.” Those needs really are substantial and critical, as we can see if we look at the definitions, which are set out in the guidance. Now, however, only 15 councils continue to provide care and support to people with “low” and “moderate” needs and 137 provide care only to those assessed as having “substantial” or “critical” needs. That means that in many areas preventive services have all put disappeared. Setting the threshold at such a high level is therefore a false economy.
According to Age UK, as a result of tightening eligibility criteria, 800,000 people in the UK have a care need but are not getting any support. As my right hon. Friend the Member for Stirling (Mrs McGuire) mentioned, there is another care crisis, because a third of the total of those requiring care are working-age adults. Indeed, four in 10 working-age disabled people who receive social care say that it does not meet their basic needs, including eating, washing, dressing and getting out of the house. One in three says that cuts in social care have prevented them from working or volunteering.
Charges for vital care services, such as home help and meals on wheels, are increasing fast. In effect, that is a tax on some of the most vulnerable people in our society, people who have already been hit the hardest by benefit changes. Some Government Back Benchers talked about the need to cut the deficit. There is a need to address the economic situation, but not on the backs of the poorest and most vulnerable. To my mind, it is a question of political priorities. I am proud that my party has pledged to scrap the bedroom tax, which I think brings great shame on the coalition Government because of its impact on disabled people.
Other Members have mentioned the consequences of price variation. I do not want to repeat those arguments, but it certainly is a factor when calculating the care costs for the cap. For example, in Tower Hamlets home care is free, but in Cheshire East—I am not sure which hon. Member represents it—it costs £20 an hour. In east Durham, the area I represent, it is about £10, so there is wide variation in costs.
We cannot improve the quality of care for older and disabled people without improving the working conditions of the 1.5 million people employed in adult social care, many of whom are on low pay and lack job satisfaction. In many cases that can lead to poor care for some of the most vulnerable people in society. Care workers do an incredibly valuable and important job, yet the TUC has estimated that between 150,000 and 220,000 of them are not even paid the legal minimum wage, and over 300,000 are employed on zero-hours contracts.
Sheila Gilmore
Does my hon. Friend agree that the problem of low pay and poor conditions, which he is outlining so well, is a concern for not only the workers, but ultimately the people receiving the care, for example because of the lack of continuity of care?
Grahame M. Morris
My hon. Friend makes an excellent point. That ties in with home care visits. The United Kingdom Homecare Association has indicated in a briefing that three quarters of home care visits now last 30 minutes or less and that one in 10 last only 15 minutes. There must be deterioration in care if carers are there for only 15 minutes. Care rationed in 15-minute slots is simply unacceptable, and I think that the House should reflect on what is happening. This is important because older people end up in hospital unnecessarily and stay longer than is necessary. There has been a 42% increase in delayed discharges from hospitals since figures were first collected in August 2012. Indeed, last month saw the largest number of delayed days in hospital ever recorded, and there were 78,400 such days in October alone. These delayed discharges now cost our NHS £20 million each month. That money could be used to fund about 1.5 million hours of home care for vulnerable older people and help to keep them out of hospital when they can be supported in their own homes.
Ministers claim that they want joined-up services, but through the Health and Social Care Act 2012 they legislated for fragmentation. Their integrated transformation fund contains no new money but is made up of £3.8 billion that is coming out of existing NHS and social care budgets. I accept that the Bill provides a framework and establishes important principles, and there are things that we can agree with. However, fine words are all very well, but we need immediate action such as the measure proposed by my right hon. Friend the Member for Leigh (Andy Burnham) to use £700 million from this year’s NHS underspend to help tackle this crisis now. We need some vision from all parties but especially from the Government parties.
I looked at some old early-day motions to see how some of these proposals were tackled in the past. My hon. Friend the Member for Sefton Central (Bill Esterson) suggested that this should be paid for through general taxation, and I agree. In one old EDM, a number of Members from all parties agreed with that principle; I see some of them nodding now. It is not such a radical or revolutionary step.
We clearly need a wholesale change in how we deliver health and social care. We need a whole-person approach and a national care service. We need the same ethos that applied during the establishment of the NHS, which brought together disparate entities and groups into one body. We need to bring health and social care together into a single service that provides all the care an individual will need throughout their life.
The Bill has many positives, but it is fundamentally important to deal with the eligibility threshold. If it is set above “moderate”, it will do little to help working-age disabled people.
If the Minister does not mind, I would like him to clarify whether the duties of openness and transparency in the Bill will apply equally to all organisations that provide NHS services, including private contractors who provide outsourced services; he will be aware of my ten-minute rule Bill. I urge people to consider the Bill and to support Labour’s amendment.
Mrs Sharon Hodgson (Washington and Sunderland West) (Lab)
I am grateful for the opportunity to speak in this debate, not least because this Bill, particularly part 1, is being followed very closely in my constituency. I am pleased to follow my hon. Friend the Member for Easington (Grahame M. Morris), who spoke very well about the issues at hand. Given the high level of interest in my constituency, I recently held a listening event that was kindly supported by Age UK Sunderland and Sunderland Carers. I wanted to find out what the people who would be affected by the Government’s planned reforms thought of them. In the time available, I will give a potted account of that discussion.
Before I do so, I want to say a few words about young carers. After concerted lobbying by Members on both sides of the House, particularly my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley), we now have clauses in the Children and Families Bill providing for young carers’ needs assessments and there are clauses in this Bill covering a young carer’s transition to adulthood—a very welcome step forward. I pay tribute to the Minister and to his predecessor, the right hon. Member for Sutton and Cheam (Paul Burstow), who are both in the Chamber today, and to the children’s Minister, the Under-Secretary of State for Education, the hon. Member for Crewe and Nantwich (Mr Timpson), for listening to Members and campaigners on this very important matter. However, I would like the Bill also to include a duty on medical professionals to identify and refer young carers so that they can benefit from those needs assessments. Family doctors are by far the best placed professionals to be able to identify where a child or young person is probably providing support to their parents, and it is not unreasonable to expect them to make sure that that child or young person has their needs assessed by the local authority. I very much hope that we will see more progress on this issue as the Bill continues its passage through the House.
Turning to the main provisions of the Bill on social care, if the Minister thinks that my constituents are happy with the package we have before us at present, he is very much mistaken. People’s first question is understandably, “Will this benefit me or my family members?”, and many of them, when they look beyond the press releases at what the Bill actually says, are finding out that it does not. They know that only people who are eligible for care will be covered by the headline-grabbing £72,000 cap on care costs. Therefore, if the Government say—as looks likely—that only those with the most severe needs are deserving of help, very few will be covered by the cap at all. Even if they are covered, £72,000 will not be the maximum amount they will have to pay; they will also have to pay hotel and accommodation costs of £230 a week, as well as any difference between the rate the local authority is able to pay and the actual care costs. All in all, they could be looking at an extra £300 a week that does not count towards the cap. That means that, over five years, a pensioner would have to find an additional £78,000.
The situation may be different for the Secretary of State’s constituents, but I cannot think of many pensioners in my constituency who would be able to afford that kind of bill without selling their home. Of course, there will be a deferred payment option, but that is just a more expensive version of what 95% of councils do already and it will not be available until a pensioner has run down all their other assets. Assuming they do qualify and they defer five years of care home charges, they could end up clocking up an extra debt of £13,800 in interest, on top of the £78,000 charge and the £72,000 cap.
Norman Lamb
I am grateful to the hon. Lady for acknowledging the change we made in the Children and Families Bill with regard to young carers. Does she welcome the fact that we are massively extending the means-tested support by increasing the threshold from £23,250 to £118,000, which means that people with assets right up to that level will get some contribution to their care costs for the first time ever?
Mrs Hodgson
But that is only if they and their needs are eligible. In all the cases I have looked at, no one has been able to convince me otherwise.
The average price of a home in my constituency is £150,000, so someone needing care for five years could see the entire value of their home gobbled up. Whether the home is sold before or after they die is academic, because it will still need to be sold and all but £23,000 will be called on to pay for care bills and the interest on them. The only real difference I can see between that and the current system is that people will pay interest for the privilege of deferring their home sale, and that is why the Opposition say that this is nothing more than a care con. Ministers have been keen to gloss over those facts, but they cannot con my constituents, who are wordly wise and have seen straight through all the spin.
The next thing my constituents asked me at the listening event was whether the Bill will improve the quality of care that they or their loved ones can expect to receive. The issue of quality of care quite rightly hits the headlines every now and again when particularly shameful examples of the treatment of the elderly or vulnerable are exposed. Those peaks in interest only reinforce the worries people already have about either moving into residential care or becoming dependent on strangers who come into their homes on a daily basis.
There are tens, or even hundreds, of thousands of very capable and dedicated care workers out there who do what they can in an extremely challenging job and often on terrible terms and conditions, examples of which we have heard today. The Bill does very little to tackle the problems of long hours—or even zero hours—and those of low pay, no training and low staffing ratios that can lead to demotivation and desensitisation with regard to the dignity of the people being cared for. Ultimately, that is what brings down the standard of care that everyone who needs it should have a right to expect.
On the quality of care that people receive and the impact is has on their quality of life, I received an e-mail today from my constituent, Steve Hudson, regarding clause 48, which has been inserted in the Bill thanks to my noble colleague, Lord Low of Dalston. Clause 48 extends the protection of the human rights framework to everyone receiving regulated social care, whether they are in residential care or their own home and whether they are self-funding or in receipt of local authority support. Frankly, I was surprised that that was not the case already. As the Equality and Human Rights Commission said in its briefing, closing that loophole would be extremely beneficial in ensuring that the dignity and basic human needs of every person receiving care are at the forefront of every manager and business owner’s mind. I therefore hope that if the Bill progresses tonight, the Government will not seek to remove that provision in Committee.
The final big concern that my constituents shared with me at my listening event relates to funding constraints. It is clear to everybody that cuts to local authority budgets have a knock-on effect in the NHS, with beds, clinical staff and other resources unnecessarily tied up while care packages are put in place or even just reasonable adjustments to accommodation are made. It is no coincidence that delayed discharging is at an all-time high and costing the NHS some £20 million a month at a time when many local authorities are at financial breaking point and struggling to see how they can provide even the services they are legally obliged to provide over the coming years, let alone the kind of preventive services that they provided until recently.
Of course money is tight, but because it is tight, we should use the money we have in a smarter, more innovative way, as my right hon. Friend the Member for Salford and Eccles (Hazel Blears) said so eloquently. That means pursuing the ideas put forward by my right hon. Friend the Member for Leigh (Andy Burnham) and my hon. Friend the Member for Leicester West (Liz Kendall) for a whole-person care approach and the full integration of health and social care.
My constituents do not hate this Bill—they are pleased that there is a Care Bill—but they are frustrated by its lack of ambition and disappointed that the Government have watered down and cherry-picked the Dilnot recommendations so much that very few people will actually be any better off in the long run than they would be under the current system.
The Bill is inadequate and the House should decline to give it a Second Reading today, so that the Government can go away, have one of their famous pauses and come back with a version that meets the challenges that our health and social care systems will face over the coming years. Most importantly, the Government need to come back with a Bill that lives up to the hype that Ministers have tried to generate, and which does what all our constituents want and need it to do.
Jim Shannon (Strangford) (DUP)
It is a pleasure to make a contribution in this debate. I thank hon. Members who have made what I would call very passionate, compassionate, knowledgeable, personal and spirited speeches.
The Bill will affect every person in the UK in some way or another. As such, it is incumbent on us to get it right. I have been contacted by a great many bodies and constituents and I have also been in contact with the Health Minister in Northern Ireland, as it is imperative for us to take into account what has been put to us by those on the front line who are providing the services catered for in the Bill.
The vast majority of the Bill’s provisions will apply to England and Wales only, but some legislate on Northern Ireland devolved matters. As the House will know, health is a devolved matter in Northern Ireland, but the Bill deals with some specific issues. One of those provisions is the abolition of the Health Research Authority as a special health authority, and its establishment as a non-departmental public body.
Another such provision relates to the enabling powers for cross-Administration care home placements. The Bill will introduce a four-way reciprocal arrangement, which will enable clients to be placed in care homes across all four UK jurisdictions. That was referred to by the hon. Member for Arfon (Hywel Williams) in relation to Wales. The Bill document is very clear about the arrangement between the four regions—it is good news—that will enable that to happen.
Other such provisions are the associated cross-Administration social care provider failure protections, which will extend across the whole of the United Kingdom. The Bill will introduce continuity of care protections for clients placed across the four jurisdictions in circumstances in which providers fail due to a business failure. It is important to have cross-communication between all four regions within the United Kingdom of Great Britain and Northern Ireland to ensure that there are protections for all.
As I mentioned, social care is a devolved matter, so the Executive and my Assembly colleagues have agreed two legislative consent motions. As Members will see from the Order Paper, the National Assembly for Wales has also passed two legislative consent resolutions in respect of the Bill. The principle has therefore been agreed, but the devil is in the detail, which comes in the Bill.
The Bill also covers changes to how care and support is funded, with planned reforms including the introduction of a cap on contributions to care costs and changes to the means test on capital limits. As social care is a devolved matter, those changes will apply in England only, but I always like to inform the House of what is happening in Northern Ireland. It will interest Members to know that the Department of Health, Social Services and Public Safety is taking forward a three-stage process to reform adult care and support. The first stage was a six-month consultation on the discussion document “Who Cares—The Future of Adult Care and Support in Northern Ireland”. The consultation concluded on 15 March and a report analysing the responses and summarising the comments that had been made was published on 14 August.
The Department is now taking forward the second stage, which will involve the development of proposals for reform and will be subject to a full public consultation in due course. The proposals will include changes to both the type of support that will be available and how services are funded, including how people pay for residential care, which is an important issue in Northern Ireland and the whole United Kingdom.
The third stage will be the development of a final strategic document setting out the agreed future direction on the funding of adult care and support, along with the reforms required. It is likely that legislative change will be required thereafter, so the whole process will take some time to complete. However, I believe it is key to ensuring that Northern Ireland has a care and support system that is sustainable and fit for purpose for many years to come.
I ask the Minister what discussions have taken place with the devolved regions to ensure that we have a system that provides the same level of care across the board, not simply a postcode lottery. Perhaps he will clarify how he intends to ensure that the NHS will continue to be a national health service, not simply a regional health service, and that we have similar levels of care across the whole UK.
I wish to highlight an issue that Marie Curie Cancer Care has brought to my attention. At present, terminally ill people and their families can wait weeks to get social care while local authorities test their means and their level of need. That could be rectified through a duty on local authorities to process applications for local authority-funded care swiftly. We need to add a bit of zip and eagerness to the process to ensure that care can be delivered, particularly for those with cancer. Last week a meeting took place in the Methodist hall across the way, at which a shadow Minister spoke. The Conservative party also had a representative there. Everyone outlined the need for help for those with cancer, and that is one issue that really needs to be addressed. There were people from across England and Wales in that room who had specific needs because of cancer.
The situation for terminally ill people and their families is difficult, and NHS continuing health care is supposed to address it. However, local variations and the way in which CHC funding is allocated mean that few terminally ill people gain access to care through CHC, even though it is available. In this age, how can that be? In Northern Ireland, the Assembly has put in place a commissioner for older people and tasked her specifically with looking after the concerns and needs of the elderly population and highlighting their issues. I took the opportunity to bring the commissioner down to a public meeting in my constituency to give people the chance to express their concerns about residential homes, their money, their benefits and their social and health care.
Social care is vital to terminally ill people and their families. A study by the Nuffield Trust showed that terminally ill people who had access to local authority-funded social care were far less likely to use hospital care. Currently, more than 50% of people in the UK die in hospital, despite only 2% saying that that would be their preference. The National Audit Office estimated that 40% of people who die in hospital have no clinical need to be there, and that is thought to be a conservative estimate. If those people were moved to a community setting, supported by social care, they would receive the care they wanted, and it would free up hospital resources for people who need curative interventions. Will the Minister tell the House what progress has been made on securing fast-track access to social care for terminally ill people? Those are vital issues for the people we represent.
Although the new amendments seek to address such issues, I have been informed that concerns remain because the clause does not require local authorities to provide fast-track care for terminally ill people. If local authorities have the option to fast-track social care for terminally ill people and their families, but no incentives to do so, that could lead to a high degree of variation across the country in the availability of social care. Again, that goes back to my earlier point about whether we have a national health service or a regional health service. It is important that the service is the same across the United Kingdom, so that what people get in Scotland is the same as they get in Wales, Northern Ireland or England. I believe we should have such services everywhere, and they should not be different for anybody, no matter what their strata in life.
One major issue is the cap on care provision. Although I welcome the steps taken to alleviate financial pressure on individuals, they do not go far enough. I am joined in that belief not only by most Members of this House, but by the Royal College of Nursing, which stated,
“at £75,000 we are concerned about how many people this will positively affect. The RCN believes that too many may be left unaffected and still face agonising decisions over how to pay their care bills.”
One issue that has come to my office on a regular basis over the years is that of families and those of a certain age who are considering how they will pay for their health care over the next period. Many Members have made passionate speeches today, and it was a pleasure to have been in the House to hear them. They were also very personal speeches, and people spoke of their own relatives who have had to deal with this issue. The RCN continued:
“The RCN calls upon the Government to reflect on its decision around the figure set as the cap and to revise it to one closer to that advocated by the Dilnot Commission of between £25,000 and £50,000.”
I support that as, I believe, do other hon. Members.
Time has beaten me and I am unable to speak about the other issues that have been raised. If the Minister hears only one point from my contribution, let me be clear that we need a national health service rather than a regional health service, with the same level of care and service. That service must be affordable without people having to sell all they own to pay for their health and well-being.
Mrs Emma Lewell-Buck (South Shields) (Lab)
It is a pleasure to follow so many passionate and marvellous speeches, and I hope that my speech does them justice.
Prior to joining this House I was involved professionally and personally in the adult social care arena. Throughout that involvement I met some amazing, dedicated and brave people, many of whom were being denied the full service they deserved, and working in a system that hindered their ability to deliver fully what they knew their clients needed.
There is nothing worse than having to tell a person who is already struggling with daily life because of their condition or that of a family member that, due to funding cuts, they will get a reduced service or get no service at all anymore from their local authority. My local authority, like many others, has been restricted to offering care only to those who meet the critical and substantial criteria of fair access to care. In reality, that means that an elderly or disabled person who was struggling with laundry and housework, or who was given support with daily living or to access services or employment, may no longer receive that vital support.
The Bill is a missed opportunity to make such scenarios a thing of the past because it does nothing to address the funding crisis in adult social care. That funding crisis has led to the collapse in support for those most in need, leaving many people without access to essential services. It is not only the Labour party that has raised concerns about the absence of any funding plans in the Bill; Age UK, the Local Government Association, the Care and Support Alliance, Carers UK and the Royal National Institute of Blind People share the same concerns. According to a report published today by the Personal Social Services Research Unit,
“the scale of reductions in spending and provision…are almost certainly without precedent in the history of adult social care.”
I know from consultations I have led that people in my constituency want to remain in their homes and receive care at home for as long as they can, but those people often end up suffering from chronic loneliness and isolation, receiving, perhaps, a 15-minute visit perhaps twice a day. We need to think urgently about how we can prevent people who remain in their homes from becoming socially isolated. Although loneliness may not be seen as an illness as such, anyone who speaks to people who have suffered day after day, alone in their homes, will hear that that is what hurts them the most: the loneliness. Age UK describes loneliness as the “hidden killer”. It is therefore disappointing that the Bill removes the Care Quality Commission’s existing duty to inspect and assess the way in which councils commission adult social care services. That could have been one of the few safeguards against the proliferation of 15-minute visits.
Labour recognises that improving care standards for service users means improving things for care workers themselves, and that is why we have launched a review of exploitation in the social care sector. I welcome the review, because my husband works in the care sector. He is currently on a zero-hours contract, with irregular hours and at the mercy of his employers, and is constrained by the limited time that he can offer his clients. My husband did not seek employment in the care sector to swell the coffers of those who make money from care for the vulnerable in our society; he did it because he wanted to make people happy and comfortable in their homes. My husband and I know that the benefit of improving the standards of care at home, and enabling more people to receive care at home, is that we will see fewer people in hospital and fewer residential care admissions, which are both stressful and incredibly costly.
The local authority covering my constituency is the seventh hardest hit in the country. Its central funding has been cut by an average of £262 per person. We have higher-than-average proportions of people aged over 65, over 75 and over 85. We also have more than 1,000 people with dementia, and a higher than average number of people suffering from long-term conditions. Between 2011 and 2012, a higher than average number of people were subject to completely new social care assessments. Our rate of permanent admissions for people to residential care is 71% higher than the national average, and we currently have just under 6,000 adult social care clients receiving a service.
The year 2020 is often described as “year zero” for council budgets. Only core front-line services are expected to be delivered, and they are expected to be delivered at a reduced level. If preventive services continue to be cut and if there continues to be an impact on early pathways to care, people will be eligible for care only when they have deteriorated to the point at which their need is urgent and their care needs are significantly more costly.
Given the situation in my constituency, it is no surprise that the fear expressed repeatedly by people in South Shields is that they will not be able to afford their care in later life. For my constituents, the measure of the Bill’s success will be whether it forces them to sell their homes to pay for care in their old age. It seems that it will fall well short, because, as my right hon. Friend the Member for Leigh (Andy Burnham) pointed out at the beginning of the debate, people will still have to sell their homes.
The Dilnot commission proposed a £35,000 cap on care costs; the Government have set the cap at £72,000. The commission proposed a universal scheme for loans to help to cover care home fees; the Government have means-tested it. That means that it will take the average person nearly five years to hit the Government’s cap. It is estimated that six out of seven people will die before receiving any help from their local councils. My constituents deserve to know the truth so that they can plan for their futures, and it is a shame that the Government are not prepared to share it with them.
The fact that money is scarce does not mean that we should withdraw from our responsibility to care for the elderly and the disabled. Our response should be to rethink radically the way in which we deliver those services. We do not need to dismantle what is already in place; we simply need to think about how the services can work better together, and how we can meet the needs of people now and the needs of future generations. More crucially, however, we need to set out plans to fund this adequately. We know that the Government have legislated for fragmentation and that health funding in areas such as mine is being stripped back. We also know that if the Government wanted immediately to address the funding crisis in our social care system, they could implement Labour’s plan to use £700 million from this year’s NHS underspend. Will they do this and do right by the people who need the services the most?
I support elements of the Bill, but I am not sure how, without explaining how our future adult social care will be properly funded, any of these proposals can become a sustainable reality. I make a plea today, not just on behalf of my constituents, but in memory of all the people I have worked with—my deceased grandmother, uncle and elderly neighbour, all of whom I helped care for, and all the strong and amazing people let down by a system that can no longer support them. I hope the Minister is listening and that he will support our amendment.
Sheila Gilmore (Edinburgh East) (Lab)
Health and social care are devolved to the Scottish Parliament, so I rarely contribute to debates on those issues in the House, but one aspect of the Bill is very relevant to my constituents—the portability of care packages between England, Scotland, Wales and Northern Ireland.
My argument is best explained by reference to the case of my constituent, Neil Kenny, who raised his concerns about the lack of portability of care packages back in 2010, when I was first elected. Mr Kenny suffered a broken neck while serving in the Army. He is paralysed from the chest down and uses a wheelchair. Although he is originally from Edinburgh, he lived in London in the early 1990s, during which time he received funding for his care package from Greenwich council. In 1996, he decided he wanted to move back to Edinburgh to receive additional support from his family, but when he informed Greenwich council of his intentions it indicated that it would be unwilling to continue to contribute to his care package and that if he wanted to move he would have to contact Edinburgh council, which he did but which also said it was unwilling to support him.
The disagreement revolved around the two councils’ conflicting interpretation of the social work group Act 1968, particularly two clauses, one relating to the “authority of the moment” and the other to “ordinary residence”. This impasse continued from 1996 to 2000. In October 2000, Mr Kenny resorted simply to moving to Edinburgh, with help from his family physically to do so, and paying for his own care, which put him into a lot of debt. Although Edinburgh eventually agreed to pay for his care, he should never have had to experience such difficulties. Disabled people should be as free as anyone else to move from one local authority to another—something that simply is not possible at present, it would appear, owing to the ambiguity of the law governing this area.
When I took up the case with the Department of Health in 2011, the former Minister, the right hon. Member for Sutton and Cheam (Paul Burstow), indicated that it would be addressed in the Government’s care and support White Paper. This was published in July 2012, but although it contained a short section on portability between local authorities in England, it made no mention of transfers between England, Scotland, Wales and Northern Ireland. When I raised the matter again in September 2012, I was told that a clause to facilitate cross-border placements would be put in the Care Bill.
Schedule 1 to the Bill makes provision for cross- border placements across England and the devolved Administrations, but this is limited to residential care and does not include community-based packages. As many people have eloquently said today, Government policy has long encouraged people with disabilities and health conditions to live in the community, integrated into society rather than segregated in residential accommodation, so the decision to facilitate the portability of residential packages and not community-based care packages is very disappointing. I wrote again to the Minister expressing my disappointment, and the response emphasised the differences in the care systems and the difficulties of applying rules across borders and suggested that officials were still working with the devolved Administrations to develop principles for how transferring community care packages might work in future.
Given that both the UK and Scottish Governments have known about this issue for a considerable number of years, it is deeply frustrating that it has not moved further forward. The difficulty of applying rules across borders appears to have been resolved within the Bill in respect of residential care, so it is unclear why it is impossible to do the same with community-based packages. I have been in communication with the Scottish Government as well, and they have given largely identical responses to those of the Department of Health. Clearly, both recognise the problem, but have yet to give it sufficient priority to find a resolution.
I hope that I can persuade the Government to recognise the issue fully, and they have the opportunity to do so with this Bill. I shall table an amendment either in Committee or on Report to facilitate the portability of community-based care packages. Today, however, I would be grateful if the Minister provided a more comprehensive explanation of why this has not been provided for in the Bill. That is the specific individual issue that I am particularly keen to see addressed, but let me also offer a few comments and observations from the perspective of north of the border.
In today’s debate and others I have heard during my time at Westminster, a great deal of discussion on the cost of care is about the “who pays?” element. Does the state pay? Does the individual pay? At what point do we take a decision? They are all important questions, but if we spent all our time looking at the cost of care only from that perspective, what would get forgotten is the need to put additional funding into care to make more care possible.
I can look at that from a Scottish perspective because we have been part-way down this route already, albeit only a very small part, with the introduction of free personal care in Scotland nearly 10 years ago. I emphasise that the Scottish provisions apply only to a relatively small part of personal care. After people have heard all the hype about free personal care in Scotland, they tend to assume that everything about it is free, but then discover that it clearly is not. Creating even this relatively small part of care and making it “free” meant that the financing was transferred to the Government, to the taxpayer, to all of us.
At the same time, however, not an extra penny was put into the care system at a time when, as much discussed today, demand was steadily rising. If we add to the mix the difficulties of local government in Scotland—we have had six years of council tax freeze and the reduction of councils’ overall budgets—the result is that my Scottish constituency is affected by exactly the same issues as people have raised here: rising thresholds for care, for example, which mean that only those with substantial and critical needs get any care at all.
I have seen items that can be charged for going up in price. I have seen the outsourcing of many care contracts to save councils money, but at the expense of the care workers and, indeed, the care recipients. I have seen the poorer conditions that lead to the 15-minute care times that we have heard about. We see them in Scotland, which was brought home to me very clearly when my mother-in-law was terminally ill, having been a fit person up until then. The first time the care giver came I was in the house, and I thought I would go on the computer and do a little work. The computer had only just fired itself up when the carer popped her head around the door and said, “That’s it, I’m off now”. It was barely 10 minutes. That situation is very real.
We should talk about who pays and how we divide the payment up—I am not saying that there are easy solutions—but if we do not address the question of the quantum of resource being put into care, we will continue to have these problems. I can assure everyone that this is exactly the situation in which we find ourselves in Scotland.
John McDonnell (Hayes and Harlington) (Lab)
First, may I apologise to the House? I was here for the early stages of the debate and listened to the Front-Bench speakers and others, but then had to leave. Tomorrow’s announcement on aviation, and the fact that we seem to have yet another Government who want to build over a third of my constituency, means I have been at other meetings to deal with that.
I will not take up much time, but I just want to raise a couple of issues that have been raised with me by constituents, and in particular by Jonathan Kaye. I would welcome an intervention by the Minister if I have got this wrong, but Mr Kaye’s first concern is about the regulation of carers who are recruited as a result of direct payments. In my constituency, the borough has moved progressively towards direct payments, where the individual recruits carers on the open market. That is extremely difficult, but at least they have some choice. I want to be clear about whether these carers are included in the regulation system of the Care Quality Commission, as set out in the Bill. Who will inspect them, and how will their performance be monitored?
Norman Lamb
Personal assistants are not part of the CQC regulatory system. That has always been the case, including under the previous Government. We would certainly encourage personal assistants to seek to secure the new care certificate qualification, however, so as to demonstrate their care skills, but they are not part of the formal system.
John McDonnell
I think Mr Kaye would like me to press that at some stage during the Bill’s progress. His view is that they should be regulated in the same way as others, and that there should be appropriate inspections as well. I understand the difficulties, particularly in terms of family relationships with regard to carers. I understand the subtleties of that, but there does seem to be a gap in the Bill as it stands. I might want to look at that in Committee, and certainly on Report.
The second point is that I believe that in the other place Baroness Greengross or Lady Greengross—I am never sure of the titles of the bourgeoisie—moved an amendment to cover the whole range of abuse. That was partly a response to the lobbying for abuse by carers to be properly covered by this Bill. I hope the Government’s attitude is that the amendment will remain in the Bill. I am happy to give way again to the Minister if he wants to respond; perhaps he will do so later.
The third point Jonathan wanted me to raise was about assessment and reassessment. I do not know what other Members find in their constituencies, but I find that the process of assessment can be extremely difficult—first, getting an appropriate person who can do the assessment, then getting that appropriately skilled person to do the assessment, and then the bizarre continual reassessment after reassessment that amounts almost to harassment. Some people with severe disabilities —with permanent conditions who, to get a cure, would need a trip to Lourdes, to be frank—get reassessed time and again. That becomes worrying for them, and some individuals can lose some element of their benefit through this process.
Meg Munn
I have a great deal of sympathy with what my hon. Friend is saying. In my experience there seems to be a tendency of wanting to assess people and then reassess them, rather than putting effort into providing services for them. If we quantified the time that goes into assessment as opposed to provision, I think we would see some way in which we could shift some of these very scarce resources into helping people properly.
John McDonnell
I was with a constituent last Friday and the issue under discussion was disabled facilities grant. Again, there seem to be more assessments and more spent on assessment than on getting the work done at times. There needs to be a clear understanding of the issue of permanent conditions and how we can make sure people do not have to go through the trauma of assessment
That brings me on to the issue that was raised by Age UK—I apologise if others have raised it before—which is about the individuals who will do the assessments and the level of their qualifications and of their specialisms. My whole community has been traumatised by what happened with the Atos assessments, and I would not want to see another process implemented in the same way under this Bill. Age UK wants us to ensure that appropriate assessments are carried out by appropriately skilled and qualified assessors.
That leads me to a further point, and I apologise if others have already raised it. Part of the issue for people who have to undertake the assessments is ensuring that they have the right advocacy support. In my area, we have DASH—the Disablement Association Hillingdon—which provides excellent support and advocacy, but it is struggling, as is every other voluntary organisation in the area, as a result of local government cuts and the demands and challenges that are placed on it. It is important that, as we introduce this legislation, we look at the role of advocacy and the importance of supporting it through appropriate funding from local government and elsewhere.
I want to talk briefly about the report from the personal social services research unit. It was mentioned by my hon. Friend the Member for South Shields (Mrs Lewell-Buck), whose superb speech set out, drawing on personal experience, exactly how many of us experience the services of carers. I am not sure whether other hon. Members have gone through this matter in depth in the debate today. If they have, please will they intervene to tell me, so that I do not need to go through it again?
The report has usefully confirmed all that we have experienced and understood anecdotally in our constituencies. Even I was shocked at some of the statistics that it contained. The report was produced by the personal social services research unit of the university of Kent and the London School of Economics, and it is an objective assessment of expenditure and of the numbers of people receiving services from local authorities between 2005-06 and 2012-13. Its findings confirm what most of us have experienced in our constituencies—namely, that there have been
“widespread reductions in the period 2005/06 to 2012/13 in both the observed and standardised estimates of number of adults receiving state-funded social care services”.
It also found:
“Across all user groups, approximately 320,000 fewer people received local authority brokered social care in 2012/13 than in 2005/06. This represents a 26% reduction in the number of recipients of care.”
If we look at the standardised assessment, we see a
“decrease of 453,000 (36%) individuals being served”.
That reflects what I am finding in my constituency. People who should be receiving a certain level of care and who would previously naturally have received it are no longer doing so. The report goes on to state:
“Reductions in the number of clients are particularly acute for older people; 260,000 or 31% fewer older people received services in 2012/13 than in 2005/06…The standardised estimate of reduction was greater: 333,000 or 39% fewer clients.”
That means nearly 40% fewer older people are receiving services now than five years ago. The report goes on:
“Approximately 37,000 or 24% fewer adults aged 18-64 with physical disabilities received social care support in 2012/13 than in 2005/06. The standard estimate showed a reduction of 50,000 or 33%. A reduction of 30,000 (21%) was observed in the number of service recipients aged 18-64 with mental health problems.”
I find that staggering but, at the same time, it reflects what is happening in our constituencies. Why is this happening? It is fairly straightforward, really. It is a result of the cuts that local government is experiencing.
Although the report covers the period between 2005-06 and 2012-13, it emphasises that the vast majority of the cuts have been made in the past two years. The coalition Government have brought forward this level of service withdrawal over a very limited period of time. According to the report,
“our analysis suggests a drop in need-standardised net social care expenditure between 2005/06 and 2012/13 of approximately £1.5 billion…Moreover, almost all reductions in expenditure are concentrated in 2010/11 and 2011/12.”
That is a cut of £1.5 billion overall. It goes on:
“The largest reduction in expenditure levels is concentrated on services for older people”.
That again reflects the anecdotal evidence that we can bring back from our constituencies. The report suggests that there has been a £1.6 billion cut in services to older people. This is not a party political point; this is independent, objective research, which we should all take on board in the debate as it goes forward.
The report continues:
“For adults 18-64 with learning disabilities”—
there has been—
“a significant increase in observed and standardised expenditure in 2012/13 relative to 2005/6 worth just above £1 billion”.
So there has been some increase in some areas but dramatic cuts in others. Worryingly, the cuts seem to be focused on older people and those with mental health problems. The interesting thing is the point made by my hon. Friend the Member for Edinburgh East (Sheila Gilmore) and others about how this is disproportionate; it is not being done right the way across the board, and the impact on areas is geographically uneven. It appears that the most deprived areas are being hit the hardest.
The report said:
“Approximately 95% of local authorities in England were observed to have reduced the number of older people receiving services in the period…Of these, the number of older people receiving services had fallen by 40% or more in approximately a third…of authorities.”
So this is focused on a limited number of local authorities, and again it appears that they are the most deprived. I find that extremely worrying.
Although we welcome the Bill as a first step, as others have said, Dilnot did make it clear to all of us that the social care crisis has to be addressed before we move on to other changes in legislation, or at least simultaneously. Introducing new legislation when the Government are introducing this scale of cuts will completely undermine the credibility of the new legislation. That is why I hope that as part of the debate as the Bill moves forward we can reach a consensus on not only the legislation—where I hope we can take on board some of the points made in the reasoned amendment—but on the level of investment required over the coming period if we are to support the most vulnerable in our society.
The study I mentioned is objective and it reflects what I am experiencing in my constituency surgery on a weekly basis—I believe it is the same for other Members of all political parties. The social care services in our areas are under intense stress and, as a result, people with even critical and substantial needs are not being addressed—those with moderate needs, which are still significant and should be within the system, are being ignored completely. We need to address this matter with some seriousness now and try to reach some all-party agreement on the way forward, not only on the Bill, but on the investment strategy for care needs.
Julie Hilling (Bolton West) (Lab)
Like my constituents, I was relieved when the Government said they would act on the Dilnot report and cap the cost of care, and I was pleased when the Secretary of State told me in this Chamber that money spent on home care would be treated as part of that cap. But the legislation that this Government introduce never lives up to expectations, and it is deeply disappointing that the Bill will still leave people having to sell their homes and does not solve the care problem facing people every day of the week. Many thousands of people will be deciding today whether or not to put their loved ones into residential homes or whether or not to sell the family home. This is a very real, very live issue.
The lack of joined-up care is also presenting big problems for our accident and emergency departments. There has been a 66% increase in the number of people over 90 being “blue lighted” into A and E, and the number of over-65s admitted to hospital with avoidable conditions has been increasing—last year, it reached half a million. Of course, we also have a problem at the other end, as we cannot discharge people because of a lack of care in place. There has been a 42% increase in delayed discharge, and in October alone 78,400 delayed days were lost, so people who are admitted, often because of the lack of appropriate care in the first place, are not being discharged because of the lack of appropriate care to deal with them when they come out.
The Government cannot wash their hands of the problem and say that it is down to local authorities, because their drastic cuts to local authority budgets have had a drastic effect on local services. Bolton has had to find £100 million of cuts, which has meant that it can no longer give support to the nearly 2,000 people who have “moderate” care needs. They may be moderate to the decision makers, but they are still care needs; we are talking about care that enables people to stay safe and well in their own homes in the community and to lead independent lives. Bolton has reluctantly had to make cuts to day care and respite care, which is a real problem for real people.
Other Members have mentioned the financial cap and other elements of the Bill, so I will use the rest of my time to talk about the realities of home care, which do not appear to be solved by this Bill. As many Members know, I have a vested interest in the issue of care. Like millions of others, I entrust the care of my mothers to carers every day of the week. Most of the carers are lovely, but they are paid only just above the minimum wage and only for the time they spend with the person they are looking after; they are not paid at all for their travelling time. I find that absolutely disgraceful, but it is normal in this sector. I have been told that it is common for carers to be on zero-hours contracts, and I have been told today of the pressure put on workers in Manchester to work beyond 70 hours a week or else lose their jobs.
Caring for disabled and elderly people is a precious job, and the Bill does nothing to address the fundamental flaws in the way that care workers are treated, which of course impacts on the care that people receive. Yesterday, I met a woman and her 98-year-old mother—I will call them Valerie and Lilian. Valerie told me about a few of the problems she was encountering and why she had to change the care provider for Lilian for the second time. She told me about the endless stream of different care workers who do not know Lilian or her needs. One carer had written in the logbook that Lilian had already washed and dressed herself one morning. How did they know that she had washed, and why did they think that the bed jacket she was wearing was appropriate clothing?
Another carer wrote that Lilian was eating toast for her tea when she arrived. How did they think she had made the toast? Of course she was eating the remnants of her breakfast, and her tea, which was made by the morning carer, was still sitting untouched in the refrigerator. Another carer left Lilian with her food tray in her lap, which meant that she was unable to move until the next carer arrived a few hours later. It is no wonder that Lilian’s carers make mistakes. Her tea-time visit is a mere five minutes, and her bedtime visit is only 10 minutes. Lilian only got the tea-time visit because she now attends a day centre for two extra days, which freed up some money to spend on the visit.
Lilian lives in sheltered accommodation where, years ago, there would have been a warden who made regular visits. Now there is just a housing manager whose role does not include checking on the residents. Valerie told me about the strain being put on her because of the expectation that she would be available at all hours. As she said, she is nearly 70 herself. She has already suffered a stroke and cares for her 76-year-old husband. Once she has taken her own medication, she cannot go out in the middle of the night, but there is no other support.
Valerie and Lilian’s story is just one, and a depressingly familiar one. The reality is that carers themselves are ageing and the elderly and disabled are not getting the care that they need. I was told just this morning of a carer who left an elderly person in bed in the morning when she should not have done. When the lunchtime carer turned up, the person could barely breathe. The lunchtime carer called the doctor who, after some prevarication, came out. He left a prescription on the elderly person’s table. I do not know how he thought it would miraculously be filled in or how this ill person would miraculously be able to take the necessary medication.
I have seen first hand the distress that is caused when a carer turns up more than an hour late. There is chaos when different carers turn up and do not know what to do. I understand too the realities of inadequate care. I have also experienced the unresponsiveness of the system when care needs change temporarily. Indeed, Marie Curie Cancer Care has raised the issue of the time it can take for a terminally ill person to get care. They can often wait weeks while local authorities test their means and their level of need. Sadly, some people die before they ever get any help at all.
Care should not be determined by the cheapest provider. This most fundamental service of the most personal nature needs to be provided by workers who are appropriately trained and remunerated. I hope the Minister will confirm that every home care worker will have to be trained and qualified. We entrust the care of our most precious loved ones to strangers every day of the week. The Government should use the Bill to ensure not only that our loved ones are treated properly but that the care givers are treated properly too.
Mr Tom Clarke (Coatbridge, Chryston and Bellshill) (Lab)
I apologise for not having been in the Chamber for most of the debate, Mr Deputy Speaker, because of other parliamentary activities. I have found the speeches that I have listened to of enormous interest and I wanted to speak in the debate given that I am the co-chair, with Lord Rix, of the all-party group on learning disability.
I felt I owed it to Mencap and the Care and Support Alliance to, at the very least, bring out some of the points that were made in the other place, not least by Lord Rix and Baroness Hollins. Those points are dear to me, as I followed the debates in the other place carefully. I welcome the fact that we have a Bill and that we are having debates. I do not want to be too critical of the Government—not just because it is the festive season—but we have talked about many of these issues for a long time. When I read what was said in the other place, I reflected that when we talk about carers we all share compassion for and concern about their role, but that that has been the case for as long as I have been a Member of this House. I can understand that some carers are perhaps becoming a little sceptical and cynical and if we can do something about the Bill, that might perhaps help us along the way.
Above all, I want to speak about advocacy. In the Lords, the Government tabled welcome amendments that introduced a right to advocacy in respect of social care assessments and for some of those involved in safeguarding inquiries for some people. That has the potential hugely to improve the process for people who would otherwise struggle to be involved in the assessment and care planning process. It also provides real rights and protection for those who are suffering abuse such as that at Winterbourne View and Mid Staffordshire, and I hope to have time to return to that later.
Furthermore the measure builds, if I may say so, on the principles of the Act that I was privileged to pilot through this House, the Disabled Persons (Services, Consultation and Representation) Act 1986. Those who are still around from that period will recall that advocacy was at the heart of what the Act sought to achieve. The demand for that advocacy is still there today. Advocates support people to articulate their needs and to make informed choices, and they make the process less intimidating. They support planning and reviewing care and help people to speak out if they are dissatisfied with care or when safeguarding issues arise.
Those who receive the support of an advocate will undoubtedly be better able to engage with the range of professionals and service providers with which they come into contact, and as a result they are more likely to experience positive outcomes. Although the Government’s amendments were welcome, we seek clarity in a number of areas. I know that this view is shared by Mencap and many other organisations, although I do not necessarily speak for all of them.
The Bill deals with facilitating involvement, for example. The clause on advocacy and safeguarding states:
“The relevant local authority must…arrange for a person who is independent of the authority (an ‘independent advocate‘) to be available...for the purpose of facilitating his or her involvement in the enquiry or review”.
It is not clear what
“facilitating his or her involvement in the enquiry or review”
means and whether it is constrained in any way or subject to some form of arbitrary decision. Perhaps the Minister might clarify that tonight.
Timely advocacy at the start of safeguarding inquiries seems to me to be essential. There have been countless examples of serious abuse and neglect affecting people with a learning disability which have been overlooked for a host of reasons. It is vital, therefore, that a person with a learning disability receives the support of an advocate at the early stages of a concern being raised, and local authorities must take this into consideration. Mencap is concerned that the local authority needs to arrange advocacy only if it is not satisfied that there is an appropriate person to represent and support the adult with a learning disability. It would like assurances from the Minister that this will not become a default position for family or friends.
Some family members may in some cases have the skills and the background to be an effective advocate and may wish to do so. Others, however, will be unable or unwilling to do so, and Mencap thinks it would be highly inappropriate if those family members felt pressurised so to do. Good advocacy is delivered by individuals skilled and knowledgeable in delivering appropriate, independent and empowering advocacy, and the local authority should ensure that this is the case.
I turn to the issue of abuse. Some time ago, after the Winterbourne report, I secured a debate in Westminster Hall and I am very glad that that matter was then discussed. As the Bill makes its way through the House, we have to deal specifically with the definition of abuse. The Bill needs to be strengthened. Only financial abuse appears and is defined on the face of the Bill. This seems to give prominence to one form of abuse, although others clearly take place. Lord Rix and Baroness Hollins tabled amendments in another place which sought to strengthen the clause and include other forms of abuse, such as neglect, which we know is more prevalent, and also physical, sexual and psychological abuse and so on.
Responding in another place, the Minister felt that abuse was a commonly understood definition and that defining it further in the Bill might restrict the scope of local authorities’ duty to inquire. Although Lord Rix agreed with the argument that a long, exhaustive list would be unreasonable, he said surely we must ensure that
“local authorities do not suddenly think that only financial abuse is to be considered when they look at this Bill”.—[Official Report, House of Lords, 14 October 2013; Vol. 748, c. 341.]
I believe that reference only to financial abuse is unbalanced and critically makes other forms of abuse appear less relevant or important. Again, recalling the recent institutional abuse and neglect highlighted by Winterbourne View, Mid Staffs and the confidential inquiry into the premature deaths of people with a learning disability, it is crucial that other forms of abuse are set out in the Bill. They may be covered by guidance, but evidence has shown that this has not protected people with a learning disability who may well be subject to multiple abuses. I agree with the Government that an exhaustive list might be wrong and difficult to defend. However, the Bill should be amended to include reference to physical, sexual and psychological abuse, as well as neglect. It can make further reference to “other as guidance may specify”.
I am delighted to have had the opportunity to take part in the debate. We have a lot of work to do. I have great regard for the Minister who is responsible for the Bill and I think he will do a very good job, but when we look at issues like assessment, choice and the rest, we must remember that we have given promises before and we have given commitments. This time we all hope they will be real and meaningful.
Liz Kendall (Leicester West) (Lab)
Today’s debate has been about one of the most important issues facing Britain today: how we care for the increasing number of older and disabled people. The Care Bill is the result of the Law Commission’s review of adult social care legislation, which was initiated by the previous Government. The Opposition welcome the Bill’s emphasis on prevention, promoting well-being and new rights for users and carers.
I want to pay tribute to the work that has already been done to improve the Bill by members of the Joint Committee on the draft Care and Support Bill and by Members of the other place. It now promotes the integration of care and support with health and housing, which is really important, and requires local councils and the NHS to work together in relation to the needs of young carers and, in that regard, I want to thank my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley), in particular, for her tireless efforts.
The right hon. Member for Banbury (Sir Tony Baldry), my hon. Friend the Member for Blaenau Gwent (Nick Smith), my right hon. Friend the Member for Coatbridge, Chryston and Bellshill (Mr Clarke), my hon. Friends the Members for Edinburgh East (Sheila Gilmore) and for Hayes and Harlington (John McDonnell), the hon. Members for Pudsey (Stuart Andrew), for Strangford (Jim Shannon) and for Totnes (Dr Wollaston), and my hon. Friends the Members for Washington and Sunderland West (Mrs Hodgson) and for Worsley and Eccles South all spoke about further changes that should be made to the Bill, for example to ensure that NHS staff identify carers, to support parent carers, to improve the safeguarding of people in social care, to improve the assessment process and advocacy, to ensure an effective transition of support from childhood to adulthood, to transform end-of-life care and to deal with portability, particularly of community care packages, in the devolved Administrations. I am sure that we will return to those issues in Committee.
The main concern, raised repeatedly by hon. Members today, is that the Bill does not address the fundamental issue facing elderly and disabled people and their families or put in place the really bold reforms we need to tackle the growing care crisis in England. It is true that council care budgets have been under pressure for many years, but this Government’s decision to impose the biggest reduction in any Department on local councils has the pushed care services that hundreds of thousands of people rely on to “the brink of collapse”—not my words, but those of Age UK.
Adult social care budgets have been cut by £2.7 billion under this Government. The result is that fewer people are getting the care they desperately need, particularly at home, which is the key issue for the future, as my hon. Friends the Members for Sheffield, Heeley (Meg Munn) and for South Shields (Mrs Lewell-Buck) pointed out. Frail, elderly people are receiving home visits that last barely 15 minutes, or in some cases only five or 10 minutes, as we have heard. Disabled people are being trapped in their homes, denied the basic opportunities to work, train, volunteer or have a social life that other people take for granted, a point powerfully made by my right hon. Friend the Member for Stirling (Mrs McGuire). Paid care staff on zero-hours contracts are not even earning the minimum wage, let alone a living wage, and unpaid family carers have been left struggling without the help they need to look after their loved ones, which means that their own health suffers, too. At the same time, more people are being charged more for vital services such as home visits and meals on wheels, which are up by £740 a year since the election.
Reducing care budgets by that scale hurts some of the most vulnerable people in society. It is also a false economy, because as more elderly people do not get the help they need to stay at home, they are ending up in hospital in increasing numbers, which costs the taxpayer far more. Delayed discharges from hospital have soared by 42% since the election, as my hon. Friend the Member for Easington (Grahame M. Morris) rightly said. Delayed discharges have costs taxpayers £225 million this year. That could have paid for almost 17 million hours of home care. It is spending money in the wrong place in a way that is not good for the people using the services and does not provide value for money.
Families are also paying the price. As my right hon. Friend the Member for Salford and Eccles (Hazel Blears) said, one in three carers now has to give up work or reduce their hours because they cannot get the help they need to look after their loved ones, and this costs the Treasury £1 billion in lost tax revenues alone. The Bill will not solve these problems. The new rights it contains and the new focus that it places on prevention and well-being risk being meaningless as care budgets are reduced to the bone.
Nor are the Government being straight with people about their plans to reform long-term care funding in future. Any measures that protect people from catastrophic care costs are welcome, but Ministers have not spelled out the reality of their plans. They have repeatedly claimed that no one will have to pay more than £72,000 for their care, but this is not the case. People’s care costs will start to count towards the so-called cap only if they are assessed as having eligible care needs. Nine out of 10 councils provide care only for those with “substantial” or “critical” needs. If someone needs help to stay living at home but their council assesses their needs as “low” or “moderate”, what they pay for home visits will not count towards the cap.
With regard to residential care, the cap will not be based on what someone actually pays for their home care but on the standard rate paid by their local council. I see that the Secretary of State is being informed by the Minister about the reality of these plans, so I hope that he listens to more of my speech. The standard rate paid by local councils is currently, on average, about £470 a week. Government Members, as well as Labour Members, will know that many of their constituents pay far more than £470 a week for their care home, but these extra costs will not count towards the so-called cap. People will also, rightly, have to contribute towards their hotel and accommodation costs. The Government are setting this contribution at £230 a week—much higher than Andrew Dilnot recommended—and these costs will not count towards the cap either. Taking both those factors into account, it will take elderly people almost five years, on average, to hit the so-called cap, during which time they will have clocked up, on average, £150,000 for their care home bill, and much more in many cases. Because elderly people stay in a care home for about two and a half years, on average, six out of seven people will be dead before they hit the cap.
Ministers have repeatedly claimed that people will not have to sell their homes to pay for their care; again, this is not the case. The Bill puts a duty on councils to offer deferred payment schemes—care loans that will have to be paid back by selling the family home after the person has died. The loans will not be universally available, as Andrew Dilnot recommended, but means-tested. Interest will be charged on the loans, but that interest will not count towards the cap. Although the Government are raising the upper level of the means test, that will not help many pensioners on average incomes because of how the test works, whereby councils take a notional income from the remaining assets in a person’s house and add it to what they get from their pension and any savings or second pension. For many pensioners on average incomes, this combined total will take them over what their local council will pay for care, and they will therefore not qualify for any extra support.
Elderly people and their families deserve to be told the facts about the Government’s plans so that they can properly plan for the future rather than have Ministers attempt to pull the wool over their eyes. One of the main claims made by the Prime Minister about the Government’s reforms is that they are so clear and straightforward that lots of insurance products will emerge so that people can insure themselves to pay for their care in future. I would be very interested to hear from the Minister how many of these new insurance products have emerged so far.
Barbara Keeley
I chair the all-party group on social care and when the Dilnot recommendations were made we implored the Government to have a national debate so that all the issues my hon. Friend is raising so well could be explored. Judging by the look on the Secretary of State’s face, he needs to be given some of that information, too, so perhaps we need a national roadshow on what his Bill will actually do.
Liz Kendall
My hon. Friend makes her points diplomatically. It is only owing to the efforts of Members in the other place that the Bill includes a requirement for councils to provide people with clear information. These are huge issues for elderly people and their families. We are asking the Government to be straight and I hope that when the Minister responds he will confirm what I have been saying.
On top of everything—I hope the Minister will also address this—we learned in June that the Government will top-slice £335 million from existing council budgets to pay for the start-up costs of the new scheme in 2015-16. They propose to take money from existing users who are already desperately struggling to pay for reforms that will benefit a small number of future care users in five, six or seven years’ time. I think that many people will be astonished, particularly after the Government had claimed that all the additional costs for their proposals would come from elsewhere. I hope the Minister will explain whether I am correct in saying that that £335 million will be top-sliced from council budgets.
Labour Members will continue to focus on the reality of this Government’s actions, not on their rhetoric, and we will continue to expose their true record on the NHS and social care. Instead of making the real reforms needed to improve front-line services, they have wasted three years and £3 billion on a back-room NHS reorganisation that nobody wanted and that nobody voted for. Instead of working with clinicians and patients to make difficult decisions on the future of hospital services, they now want to give the Health Secretary unprecedented powers to impose changes without the consent of local people. As my hon. Friend the Member for Lewisham East (Heidi Alexander) said, the Government are taking away control from the very people to whom they pretend they want to give power. Indeed, National Voices—the voice of patients—says that the proposal is
“wrong in principle and counterproductive in practice”.
Instead of championing the full integration of health and social care to enable a powerful shift towards prevention and fully personalised care, as Labour proposes, the Government’s unambitious proposals bring together only 3% of the total NHS and social care spending. Instead of holding serious cross-party talks on long-term care funding reform, the Government chose to go it alone, water down Dilnot’s proposals and spin the results beyond recognition. That is why we have tabled our reasoned amendment and why I urge hon. Members to join us in the voting Lobby tonight.
The Minister of State, Department of Health (Norman Lamb)
I thank everyone who has taken part in what has been a lively and interesting debate on a subject of the utmost importance for the future and for many very vulnerable people in our country. I absolutely share the view of the shadow Minister, the hon. Member for Leicester West (Liz Kendall), on that. Incidentally, I also share her view that it is not possible to get great care on the back of exploiting low-paid workers. We have been very clear about that.
I do not anticipate having time to be able to respond to every point that has been raised—there were many excellent contributions—but I will write to hon. Members who participated in the debate so that everyone will get a full and proper response, including on the cross-border issues raised by the hon. Members for Arfon (Hywel Williams), for Strangford (Jim Shannon) and for Edinburgh East (Sheila Gilmore) among others.
The effect of passing the reasoned amendment would be to defeat the Bill, which is why the Government are so dismayed by the decision taken by the Labour party on what we regard as a Bill that will be groundbreaking in its overall impact. It seeks to modernise the law on care and support, shifting the focus from a very paternalistic system to one that is acutely personal and focused on an individual’s well-being. The Chair of the Health Committee, my right hon. Friend the Member for Charnwood (Mr Dorrell) and my right hon. Friend the Member for Sutton and Cheam (Paul Burstow) both focused on the important principle of well-being, which will be new in legislation, but is absolutely central to what we seek to achieve. There is also a focus on preventing ill health and—
Norman Lamb
I will just finish this point.
There is also a focus on protecting everyone from catastrophic care costs, ensuring that people will no longer have to sell their homes during their lifetimes to pay for care. The Bill reforms a fundamentally unfair system, drives up standards in GP surgeries, hospitals and care homes through the new chief inspectors, adds a new statutory duty of candour so that hospitals, care homes and other care providers are open with patients when mistakes are made, and introduces valuable new rights to carers. Of enormous significance is that it signals the first ever big step, as the Chair of the Select Committee said, towards joining up our health and care systems through the better care fund, which is worth £3.8 billion.
The best description of the Bill was in a letter forwarded to me by a Labour MP, which said that the Bill is a groundbreaking piece of legislation that has the potential to make a big difference for older people. Despite that, the Labour party is declining to give it its support.
Norman Lamb
I give way to the right hon. Member for Salford and Eccles (Hazel Blears).
Hazel Blears
The debate this evening has been fabulous and has engaged people from across the House on one of the biggest challenges we face. Earlier in the debate I asked the Secretary of State whether, on reflection, he thought that he could have been more ambitious about the integration of health and social care. The costs to our system are now unsustainable, and this was an opportunity to seize the moment. The Minister has tinkered around the edges of integration, so may I press him to be more ambitious, to think bigger and to be more committed to greater integration that will benefit us all?
Norman Lamb
I note the challenge, but I have been passionate about integrating care for many years. I made the case for it on many occasions when I was my party’s spokesman in opposition, and I remember not getting much of a response from the right hon. Lady’s party when it was in government. The Bill is really ambitious and marks the potential for a fundamental change in how our system works.
The right hon. Member for Stirling (Mrs McGuire) welcomed the principles of the Bill and rightly said that it is the duty of the Opposition to challenge and to probe. However, to use her expression, I think that many Opposition Members have been “churlish” in their response, with a few honourable exceptions, including the right hon. Member for Coatbridge, Chryston and Bellshill (Mr Clarke). I say that because in 13 years, Labour had two manifesto commitments, one royal commission, another promised commission, a Select Committee report, a White Paper, a Green Paper and numerous independent reviews on the issue, and what was the net result of all that talk? Absolutely nothing. In 1997, Tony Blair told the Labour party conference:
“I don’t want our children brought up in a country where the only way pensioners can get long-term care is by selling their home.”
That is exactly what happened throughout Labour’s time in government. In contrast, the coalition Government are getting on with reform.
Even now, we have no idea what the Opposition’s policy is. The shadow Health Secretary has hinted that he prefers an all-in approach—everything free, paid for by new taxes on death and by cutting hospital beds—but he has clearly failed to persuade his own colleagues about the plan or to set out how he would pay for it. Opposition Members’ criticisms can only be of any real value if they can answer the question about how they would pay for anything that costs more. So it was good to hear the right hon. Member for Salford and Eccles, who seemed to be about the only Opposition Member who recognised the scale of the challenge that we face, whoever is in power, and the fact that we need to think afresh about where money can come from. Her ideas about innovation using social investment bonds are welcome, and I would like to talk further to her about them.
We want to reshape care and support so that it is focused on enabling people to live more independent lives and giving them a good life. The Bill provides a new framework that places people’s well-being right at the centre and empowers them to take control of their care and support. It consolidates 60 years of legislation and pulls a dozen Acts together into a single legal framework, and it has been roundly welcomed. The King’s Fund has said:
“The government’s proposals for funding reform are an important achievement against the odds in a daunting fiscal and economic climate.”
Baroness Pitkeathley of Carers UK has described the Bill as the “most significant development” in the history of the carers movement.
Norman Lamb
I did not get much of an impression of that in the hon. Lady’s contribution, but I give way to her.
Barbara Keeley
I thank the Minister for eventually giving way. I am surprised and disappointed that he is repeating the same type of inaccurate information that we heard from the Secretary of State earlier. Will he think about the point that I made in my speech? How hollow is it to talk to carers in Salford, 1,000 of whom are involved in families who are losing their care packages, about new rights? What rights are there for someone whose family member has lost their care package? That is what people face this year.
The Minister has also just repeated the ridiculous notion of the £3.8 billion for the integration of health care. That is not new money. It includes care—
Norman Lamb
I note the position in Salford, and I recognise that finances in local government are tight. However, the Opposition have not recognised that 108 councils were already providing social care with substantial need as the eligibility criterion before the general election. They never mention that, but it is the truth.
Baroness Campbell has called the continuity of care provisions a “landmark reform”. Although we have heard the suggestion that we have somehow moved away from what Andrew Dilnot suggested, he has said:
“For the first time you don’t have to be terrified of the consequences of needing care…this system will radically reduce anxiety…It doesn’t seem to me that it’s so different from what we wanted.”
Several references have been made to the funding of social care, and as I have said, I fully recognise the tough financial settlement that local government has faced. However, that has been necessary because of the dire state of the public finances that we inherited from the Labour Government, and we have sought to protect social care. Despite what the hon. Member for Easington (Grahame M. Morris) and others have said, a recent budget survey by the Association of Directors of Adult Social Services showed that most of the savings that local councils have made have come through efficiency changes, and that services have largely been protected. [Interruption.] Well, that is what the survey showed.
As the population continues to age, our health needs become more complex, and it is essential that we continue to adapt. We need to ensure that the care and support system is sustainable, and the Bill lays the foundation for that sustainable system. At the top of the agenda has been the issue of how we pay for care. The current system simply does not work and is not fit for the 21st century. Too many people have faced catastrophic care costs and had to make impossible financial decisions at a time of huge personal crisis. It is deeply unfair. If someone who has worked hard all their life and budgeted carefully is unlucky enough to be diagnosed with dementia or some other condition, they lose pretty much everything they have ever worked for.
Through the Bill, we are putting an end to that unfair system. We have addressed how people can plan and pay for their care, following on from Andrew Dilnot’s recommendations. We have listened carefully to what he and his colleagues have said, and we have been absolutely consistent about how these reforms will support people to plan for their future effectively. From April 2016, extending the means-test support to £118,000 will immediately result in 35,000 more elderly people receiving financial help with their care costs. That figure will rise to 100,000 people getting extra help by 2024-25.
Andy Burnham
Can the Minister guarantee to older people listening to the debate this evening that nobody will pay more than £72,000 for their care—yes or no?
Norman Lamb
Of course we have made it clear that people can choose to spend more, but I can say absolutely that by 2024-25, far more people—100,000 people—will be getting more financial support than under the system we inherited from the Labour Government. Everyone will be protected from catastrophic costs through the reassurance provided by the cap on care costs.
Norman Lamb
I need to press on.
Many people will pay significantly less for care than they do now. People will not be forced to sell their home within their lifetime to pay for care because we are introducing a universal, nationwide system of deferred payments to prevent that.
On deferred payments, there is total confusion about what Labour stands for. Lord Lipsey in the other place, apparently supported by the shadow Secretary of State and the shadow Minister, has attacked the threshold for our deferred payment scheme, which is currently under consultation. He argued that the threshold should be lowered so that those with bank accounts or shares worth considerably more than £23,000 will have access to the scheme. In the previous Government’s 2010 White Paper, however, the same £23,000 threshold was considered acceptable under the universal deferred payment scheme. Which is it—do the Opposition support a low threshold of that sort, or do they want to give more help to people with money?
Liz Kendall
I thank the Minister for giving way because I want to press him again about the care cap. On 11 February, the Health Secretary told The Guardian in relation to the cap, that
“that is the maximum anyone will have to pay.”
Does the Minister agree with his Health Secretary?
Norman Lamb
It is the maximum people have to pay once they have reached the threshold for care, but they can choose to pay more if they wish. The hon. Lady has refused to answer the question about what Labour Members believe is the right threshold. They have been utterly inconsistent. The shadow Secretary of State has also attacked our plans to charge interest to cover the costs of the deferred payment scheme, yet his 2010 plans proposed exactly the same thing. The only difference was that Labour’s plan was hidden in the impact assessment, not set out in the consultation for everyone to see.
Throughout these reforms we have worked alongside people involved in the care system, and tried to address the needs of people receiving services, their carers, local authorities, the NHS and voluntary groups. We wanted to build a consensus around the future of care and support in England and we have been willing to amend the Bill in the other place to address the concerns raised. The result is a powerful reform package that includes the well-being principle, legislation for personal budgets, incredibly important new rights for carers that have been widely welcomed, and legislation for adult safeguarding for the first time.
Many hon. Members have recognised the powerful case for integrating and joining-up care, and the hon. Member for Sheffield, Heeley (Meg Munn) highlighted the fact that many councils do not place integrated care high on their agenda. That is why the Better Care Fund is so important—it gets every local area talking now about the importance of joining up care and preventing ill health. Around the country we have 40 pioneers in integrated care, demonstrating how things can be done differently and how we can provide better care with less money.
I visited Barnsley, Torbay, Greenwich, Worcestershire and Islington—all have inspiring local leaders who are redesigning a dysfunctional system to provide better care for their citizens. This is a quiet revolution in care, but the changes will resonate across the country. I am immensely proud and grateful to my right hon. Friend the Member for Sutton and Cheam for producing the original draft Bill and for his support since then. Colleagues in the Lords have made important improvements to the Bill, and when—I hope—it becomes law next year, the Care Bill will be the most valuable legacy in health and care reform for a generation.
Question put, That the amendment be made.