King’s Speech

Lord Best Excerpts

Thursday 9th November 2023 Lords Chamber

[Lord Best (CB)]

My Lords, I declare my various housing interests on the register, including as chair of the Devon Housing Commission, whose work informs my comments today. I welcome the Government’s proposals in the Renters (Reform) Bill and the announcement of important legislation on leasehold reform. I am sure that there will be significant work for your Lordships when these legislative measures reach us in the months ahead. But today I will concentrate on the bigger picture and the need for a longer-term national housing strategy to address a housing situation that, I believe, has taken a serious turn for the worse, even in the last few months.

I suggest that there are three areas crying out for long-term forward planning. First, we must dramatically increase the amount of new accommodation created each year; the 300,000 homes per annum target is a start. Secondly, we must have a plan for upgrading the standards and energy efficiency of outdated existing properties to address health inequalities, fuel poverty and climate change imperatives. Thirdly, in respect of building new homes and upgrading existing homes, we must target that half of the population where incomes are below the median.

My starting point for believing that the situation has become more urgent over recent months is the evidence from the temporary accommodation statistics. The numbers in this predicament have seen an alarming increase. We have the extraordinary statistic that one in 50 Londoners, and one in 23 children, are classified as homeless. But this phenomenon has spread nationwide. For example, the position in the unitary council covering Cornwall demonstrates the crisis: from having to house 200 households in temporary accommodation before Covid, the figure today is around 800. This has a drastic impact on local authority finances at a time when, as we all know, these are badly stretched. The national bill for temporary accommodation—which is often entirely unsuitable and far from friends and family—is now approaching £2 billion per annum across the country.

Of course, housing shortages, while most painful for those on the lowest incomes, also affect many people who have expected to become home owners. The number of first-time buyers has fallen by 22% this year. The cost of becoming a home buyer has doubled as a percentage of earnings, now compounded by higher interest rates. But, because of supply shortages, prices have not fallen. Overall, home ownership has declined to around 64%, from its peak of over 71%. Some 4.9 million people in the 25 to 34 age group are now living with their parents. Even where a couple have been able to purchase on their combined income, the price has often been paid in being unable to start a family.

Private renting will be the only option, but there is recent evidence that even the private rented sector is proving unable to help the next generation. Although rents are up 27% since the pandemic, the industry reports an average of 24 would-be tenants for every vacancy. For 23 of the applicants, there is nothing but disappointment if not the horrors of homelessness. The reason is that demand has risen but landlords are exiting the market. This is because of taxation arrangements rightly intended to deter speculative investors, necessary requirements for higher standards, the higher interest rates that affect the two-thirds of PRS properties that have mortgages, and much-reduced prospects of making capital gains.

I should add, drawing on the work of the Devon Housing Commission, that the decline of private renting has been exacerbated by the advantages of switching to short-term lettings of the Airbnb kind. This is hastening the loss of homes for locals to rent in almost all rural and seaside locations. Although remedies are in the pipeline, they will close the stable door only after this horse has, I fear, bolted.

This is the background to my contention that we need a long-term plan to massively increase production of new homes, while embarking on a programme of modernisation of poor-quality existing accommodation. Although these are necessary measures, they are not sufficient to ensure that the benefits reach those in the lower half of earnings. It is the not-for-profit sector—the housing associations, councils and community-led housing providers—that has the potential to step up new production and, indeed, to acquire and modernise existing substandard properties, but even this sector faces new challenges. It must invest heavily in its own existing housing stock to rectify building safety problems, to upgrade outdated council housing of yesteryear and to decarbonise homes. It is hit by both inflation, with building costs rising by more than rents, and escalating interest rates, so, regrettably, boosting this sector will not come cheap.

In conclusion, there will be valuable changes for this House to make to improve forthcoming housing legislation, but a much more ambitious, longer-term national housing strategy is required to address the underlying issues of land acquisition, planning, construction skills and so on—a road map with a timeline to chart progress over the next 25 or 30 years. Action to bring this together desperately needs to start now.

Health and Care Bill

Lord Best Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

[Baroness Greengross (CB)]

My Lords, I am in favour of the amendments in this group in the name of the noble Lord, Lord Howarth, specifically Amendments 59, 67, 71, 77, 80 and 82. My own Amendment 290 will be debated in group 41 and specifically addresses the importance of social prescribing for people with a dementia diagnosis and how this can form part of a wider care plan.

Social prescribing plays a very important role, not just for people with diagnosed conditions but generally, as part of wider brain health. Research by Arts 4 Dementia found that music-making provides a tool for a total brain workout and improves plasticity in the cortex, which enhances the ageing brain’s cognitive abilities, perception, motor function and working memory. It also improves cardiovascular strength while reducing stress. The Coda Music Trust provides a range of musical social ensembles and bands, as well as courses and classes for learning and well-being. In other studies, drama and poetry have been found to improve concentration and cause new neurons to develop and adapt.

Social prescribing has been recognised as playing an important role. It is part of the NHS long-term plan, and the Department of Health and Social Care has allocated funding to establish a national academy for social prescribing. This growing recognition of the role that social prescribing, specifically of music and art, can play in overall health is a welcome development because many of the programmes that exist at present rely on the voluntary sector.

During the pandemic, these programmes, like most of the voluntary sector, have struggled with funding and with being able to continue their work under Covid-19 restrictions. We also know that many arts venues have struggled through this time and many theatres and music venues now face an uncertain future. This sector therefore needs much more support right now if it is to continue its work. It is crucial that integrated care boards are empowered to promote social prescribing and can work with organisations that provide these services.

Although the evidence for the benefits of social prescribing is growing, more work is needed to research what types of social prescribing are successful for specific conditions, a point that I will elaborate on when we debate my Amendment 290, which addresses social prescribing and dementia. To help promote social prescribing, we need more training for GPs and other health professionals on how and when to prescribe these services. We also need to include arts awareness for mild cognitive impairment in the medical and social care educational curriculum.

There also needs to be greater availability of these services, with links to every GP. The current NICE guidelines for dementia recommend referring patients for these services only post diagnosis when, in fact, to promote overall well-being and brain health, we should encourage them much earlier from the onset of symptoms. For this, we need training, and integrated health boards must prioritise the availability of these services.

I thank the noble Lord, Lord Howarth, for these amendments and fully support their inclusion in the Bill. I look forward to the Minister’s response. I also want to take this opportunity to thank the noble Lord, Lord Kamall, whom I have often heard recently. He confirmed that his blues band, Exiled in Brussels, will play at an event supporting Music for Dementia later this year.

[Lord Best (CB)]

My Lords, I thank the noble Lord, Lord Howarth of Newport, for his inspiring speech. I declare an interest as a vice-president of the Local Government Association. I also chair the University of Oxford’s Commission on Creating Healthy Cities, which brings together academics, policymakers and practitioners. We hope to support city leaders and their citizens by shedding light on the policy interventions that are most likely to be effective in enhancing the health of their cities.

The Oxford commission is not due to report until later this year, but it is already clear that the two core issues raised by the noble Lord, Lord Howarth, in this group are likely to be central to our conclusions. The first relates to the wider determinants of health creation that take us beyond the integration of health and social care services towards recognising the relationship of public and personal health to other non-clinical services, including those affecting the built environment. The second issue relates to the value of engaging local and community organisations in a variety of ways in achieving health outcomes.

Elderly Social Care (Insurance) Bill [HL]

Lord Best Excerpts

2nd reading
Friday 16th July 2021 Lords Chamber

[Lord Best (CB) [V]]

My Lords, I congratulate the noble Lord, Lord Lilley, on bringing forward this Bill and on seeking to address the long-running concern of home owners that care costs could necessitate the sale of their home and deprive their heirs and successors of their inheritance. I declare my interest as a vice-president and past president of the Local Government Association.

I have three points to share with your Lordships. First, drawing on the extensive work of the APPG on Housing and Care for Older People, I would emphasise that the best way to address rising care costs is to prevent or postpone the need for personal care and, in particular, the need to move into residential care. The APPG has spelt out the significance of ensuring that older people have a manageable, accessible home through adaptions to their existing accommodation or through rightsizing to somewhere more suitable. So, my first point is that the most positive way of tackling care costs comes from investing in better housing for later life.

Secondly, if a care insurance scheme is to be considered, this Bill’s version seems to have some flaws. The voluntary nature of this scheme may mean a low take-up for multiple reasons, and it may be unworkable because of adverse selection—take-up mostly by those who feel fairly sure that they are going to need personal care, perhaps because they have underlying health problems, are overweight, are smokers, have early signs of dementia and so on. However, insurance could be a practical solution to meeting not the costs of care but the “hotel” costs, which, at around £25,000 per annum, are roughly half the total charges for living in a residential care home. But these costs are outside the scope of the scheme proposed by the noble Lord, Lord Lilley.

Thirdly, in supporting the excellent report from your Lordships’ Economic Affairs Committee, chaired by the noble Lord, Lord Forsyth, I would both affirm the urgency of an immediate injection of additional funding for local authority adult care services and underline the core recommendation for free personal care in the future in place of the current unfair, complex, underresourced arrangements. To illustrate just how long these same conclusions have had widespread support, I must quote from a Joseph Rowntree Foundation inquiry—incidentally with Sir Andrew Dilnot among its members—which reported exactly 25 years ago. This inquiry concluded that artificial

“distinctions between ‘health care’ and ‘social care’ … should be rejected. Both should be free at the point of delivery”.

The inquiry spelt out how national insurance contributions could help fund this. So, a quarter of a century later, my third point is that the Bill proposed by the noble Lord, Lord Lilley, must not distract, postpone or undermine progress towards our Economic Affairs Committee’s radical but affordable conclusions.

Health

Lord Best Excerpts

Thursday 26th November 2015 Lords Chamber

[Lord Best (CB)]

My Lords, I am delighted to follow the maiden speech of the noble Baroness, Lady Redfern. She comes to us as a distinguished council leader whose insights, not least from North Lincolnshire, will add an important localist dimension to our deliberations, as she has so impressively shown today. Greg Clark, the Secretary of State, said last year that she was,

“one of the Conservative Party’s most effective politicians”.

Wearing my hat as a past president of the Local Government Association, I am particularly pleased to see the voice of local government strengthened by her presence here. We all look forward to her future contributions in your Lordships’ House.

I, too, am grateful to the noble Lord, Lord Crisp, for initiating and organising this debate, and for his insightful and excellent opening speech. I want to fasten on to the first words in the title of our debate—“building a health-creating society”—and to make a connection between the buildings we inhabit and the health we enjoy.

Housing and health have long been intertwined. For the first half of the last century the Minister for Health doubled as the Housing Minister, so close were the two issues. In the ageing society of the 21st century that linkage needs revitalising and reinforcing. Unsuitable accommodation carries with it a series of dangers to our health and well-being. Overcrowding and poor conditions can create endless ailments and mental health problems. All families have a fundamental need for a decent home in which children have the space and security to develop.

Speaking as chair of the HAPPI group—Housing our Ageing Population: Panel for Innovation—and as co-chair of the Housing and Care for Older People APPG, I want to concentrate on the housing and health equation as it affects older people. So many older people spend virtually every hour of every day inside their home. It can be a trap, a virtual prison, if mobility problems mean that steps and stairs become an insuperable barrier, or if your spouse or your carer must carry you upstairs for a bath. If your central heating has not worked for years because you cannot afford to replace the old system and if the two steps at the front door get icy in bad weather, sooner or later your home will let you down—or indeed, may be the death of you.

As research by Professor Sir Michael Marmot has shown so clearly, cold conditions in this country’s homes lead to respiratory and circulatory diseases and premature winter deaths, contrasting with the outcomes from the far better-insulated homes in Scandinavia, where mortality rates do not vary with the seasons. Trips and falls in the home account for a high proportion of hospital admissions by older people. It is the unsuitability of the home that prevents so many older people being discharged from hospital, or causes them to be readmitted after they have left. You may want to go home, and the hospital certainly wants the bed you occupy, but if your accommodation is totally unsuitable, you must stay in hospital and the NHS is left with an escalating bill for a service you do not want.

Conversely, decent, well-designed housing enhances our enjoyment of life and our ability to live independently and well for longer. If our homes are well insulated, warm and efficient, as well as being well ventilated; if they are light and bright, with sufficient space; if they are lifetime homes—fully accessible, even when we may need a wheelchair—we are unlikely to require hugely costly residential care, and our later years can continue to be fulfilling. I welcome the spending review measures to raise funds for social care, but the biggest savings can come from preventing the need for residential and other care.

Housing designed specifically for older people can also combat that scourge of later life referred to by the noble Baroness, Lady Redfern—loneliness from isolation and a lack of social contacts. Retirement villages, age-exclusive apartments, extra care and assisted living—today’s version by housing associations of the sheltered housing of yesteryear—are all housing solutions that can provide companionable, engaging communities for people with similar ages and interests.

In my five minutes I cannot spell out the range of steps that could be taken by central government in joining up housing with health and care, supporting the creation of new accommodation and funding grants for disabled facilities and home improvement; or by local government in planning policies on integrating housing, care and health, with joint assessment and commissioning, not just in new combined authorities with devolved powers but through health and well-being boards everywhere; or even by each of us past retirement age who should not just wait for a crisis before considering downsizing to sustain our own independence, free up our family homes for the next generation and save the resources of the NHS, social care budgets and our own funds. I must satisfy myself with simply making the plea that all those interested in the health of the nation should never forget the immense significance of housing.

Care Bill [HL]

Lord Best Excerpts

Tuesday 29th October 2013 Lords Chamber

[Baroness Greengross (CB)]

My Lords, I was the third member of the delegation, so to speak, with whom the noble Earl met and I thank him for the time he put in to clarifying the issue through our amendment and his response.

I was worried about the same points as those raised by the noble Lords, Lord Lipsey and Lord Sharkey, particularly for the people who need rather different kinds of advice from that which we take for granted in financial advice. I refer to those people who might need additional advice on their housing or other needs that are broader than or slightly different to pure financial advice. The word “facilitating” is key. Local authorities must enable people, as well as they possibly can, to get the correct financial advice they need for their particular circumstances. I believe that we have arrived there and I thank my colleagues, and in particular the noble Earl, for meeting our requirements so well.

[Lord Best (CB)]

My Lords, speaking as president of the Local Government Association, I can confirm that the LGA supports this amendment and underlines the importance of sound professional advice before people, particularly elder people with care needs, make major financial decisions, not least in relation to the use of their homes as a source of finance for meeting care costs.

Facilitating access to such advice, of course, will add to the duties and burdens on local authorities. That must be recognised, as with the implementation costs for the so-called Dilnot arrangements, in the financial settlement that central government makes with local government. The costs involved for local authorities may not be very great but they should nevertheless be acknowledged. With that point in mind, I am delighted to give firm support to the amendment. I am sure that, as always, the noble Earl will respond helpfully and wisely.

[Lord Hunt of Kings Heath]

My Lords, perhaps I may raise a couple of points with the noble Earl, Lord Howe, on this. First, to reinforce the point made by the noble Lord, Lord Best, about the cost falling on local authorities in providing facilitation to independent, regulated financial advice, there is a much more general point about the capacity of local authorities to implement the measures in this Bill. The Bill leaves us, albeit with many amendments, with an underlying concern about whether local authorities will have the wherewithal to implement a raft of new responsibilities over the next few years.

Secondly when the noble Earl argued against similar amendments on Report, he spoke of the concerns of local authorities that they might be held liable if they referred a person who comes under the Act to a financial adviser who subsequently gave poor financial advice. We have heard from the noble Lord, Lord Best, that the LGA supports the general thrust of my noble friend’s amendment. Can the noble Earl confirm, first, that a regulated financial adviser will be subject to FCA requirements and come under its disciplinary and regulatory codes? Secondly, can he reassure local authorities that they can offer names of regulated financial advisers in the way that I understand a number of local authorities do at the moment without fear of subsequent action being taken against them? I was puzzled by the argument put forward on Report and it would be good to have this cleared up at this stage.

Care Bill [HL]

Lord Best Excerpts

Wednesday 9th October 2013 Lords Chamber

[Lord Hunt of Kings Heath]

My Lords, in moving Amendment 11, I wish to speak also to Amendment 30. I also support the amendments in this group tabled by the noble Lord, Lord Best, but may respond to those later.

In Committee, we debated amendments promoting further integration of health and social care. As my noble friend Lady Wheeler said, we supported the view of the Association of Directors of Adult Social Services and the Local Government Association that the Bill should include a specific duty on NHS bodies equivalent to the duty on local authorities to integrate services and that this shared involvement should be enshrined in the Bill. Joint strategic needs assessments and joint health and well-being strategies should provide a strategic overview of how the health and well-being of local communities can be improved and health inequalities reduced. ADASS has long maintained that local health and well-being boards are pivotal in the delivery model in this respect and that the Bill must reflect this to bring about a wholly integrated accountable system that meets identified local needs and objectives.

The noble Earl, Lord Howe, said in Committee that he had no argument with the sentiments expressed by my noble friend and relied on Clauses 3 and 6 of the Bill and various other pieces of legislation, including Section 116 of the Local Government and Public Involvement in Health Act, which requires local authorities and clinical commissioning groups to have regard to the relevant joint strategic needs assessment and joint health and well-being strategy in exercising any of their functions, which would include their duty to co-operate and promote integration. The noble Earl also prayed in aid the prominence of health and well-being boards being strengthened through their role in signing off joint plans required as part of the £3.8 billion pooled fund between local authorities and the NHS to support joined-up and integrated working.

I certainly accept and understand those points but I would like us to go further. I argue that the measure should be much more explicit in the Bill in relation to the National Health Service’s duty of co-operation. We know that the current crisis in accident and emergency services which seems to be extending through the early autumn period is symptomatic of a health and social care system that is under huge pressure. If reductions in social care funding and support for the third sector mean that patients cannot be discharged from hospital that has a knock-on impact throughout the whole system. This Bill places major responsibilities on local authorities. Without the full co-operation of the National Health Service they will be very hard pressed to discharge those responsibilities.

The noble Earl is relying on this Bill and existing legislation but the fact is that so far this has not been sufficient. I refer him to a report published today by the University of Birmingham and Birmingham City Council entitled Turning the Welfare State Upside Down? The report says that our social care system is broken and increasingly unfit for purpose and that we need a big and bold response to tackle the crisis and ensure a decent and fair system for the future. The report is right to emphasise the need for close co-operation between social care and the NHS and to shape services around the needs of the individual. The problem is that the Government through their 2012 Act have created a disintegrated system instead of an integrated one and a system where fragmentation is rejoiced at and where the operation of a market is meant to drive a wedge between people who ought to be co-operating together.

I do not want to go back over this afternoon’s Oral Question, but clinical commissioning groups would have been surprised to hear the noble Earl suggest that it was entirely up to them whether or not services were put out to tender. They have been absolutely pressurised by NHS England to do that. NHS England is clearly under the direction of the Secretary of State: how could it not be when, according to government briefings over the last two weeks, the appointment of its chief executive is going to be the Prime Minister’s decision?

There is real concern that we have conjured up a very fragmented sector. As the noble Earl knows, we already have a system where physical health, mental health and social care have found it very difficult to integrate their services. As we have more older people with vulnerabilities and co-morbidities, the need for the systems to work together becomes ever more paramount.

Amendment 11 would put in the Bill an explicit requirement for the NHS, through the health and well-being boards, to play its full part in the integration of services. In Committee, the noble Earl was sympathetic to these sentiments but not to the amendment. I hope that, in the spirit of accepting wise words in this House, he will be prepared to be more sympathetic on this occasion. I beg to move.

[Lord Best (CB)]

My Lords, I rise to speak to the two amendments in my name and in the names of the noble Lord, Lord Hunt, and the noble Baronesses, Lady Eaton and Lady Barker. These amendments are carried forward from five which I tabled in Committee, all of which sought to give more prominence in the Bill to housing. I declare my interest as chairman of the Hanover Housing Association, which works exclusively for older people, and as president of the Local Government Association.

The overarching case for these amendments is that everyone's care needs are inseparably connected to the place where they live and where, for most older people, they spend all their time. The right accommodation can sustain our independence and well-being even if we face the illnesses or long-term conditions that afflict many of us in older age. The right accommodation can pre-empt and prevent the need for domiciliary and residential care and hugely reduce costs to the NHS and local authority social services. For younger adults with care needs, the right accommodation can enable a fulfilling life within the community, not hidden away in an institutional setting. The wrong accommodation can cause accidents and, indeed, mental health problems; keep people in hospital because their home will not have them back; and can force people into costly residential care.

This Bill is the chance to incorporate housing into the health and care equation so that these three interlinked dimensions can really work together. The noble Earl has worked hard over the recess to bring back improvements to the Bill. In relation to the housing issues, the noble Earl has noted that our concerns are shared by a number of Peers who feel that the Bill gives insufficient emphasis to the question of housing. He fully accepts the integral role of housing in helping meet care and support needs, and has told us that he sympathises with the arguments he has heard. I am very grateful to the noble Earl for the two amendments he has tabled to give greater prominence to the link between health, social care and housing. His response will be greatly welcomed by the Care and Support Alliance and, within that group, the National Housing Federation, which drafted the original amendments.

Government Amendment 28 to Clause 6 extends the duty of local authorities to co-operate with partners so that this duty will encompass housing associations—registered providers of social housing—which is a very significant step in absolutely the right direction. Government Amendment 12 to Clause 3 ensures that, in terms of the integration of services, housing will be classified as “health related” and will therefore be taken on board by clinical commissioning groups and the NHS Commissioning Board, NHS England. Both these changes are really positive and I congratulate the noble Earl for his farsightedness, once again, in improving the Bill in these two ways.

At the risk of appearing slightly churlish, however, perhaps I could press the noble Earl on the two issues that remain outstanding and are covered by the two amendments in my name, which have support from all parts of the House. In relation to advice, Amendment 15 to Clause 4 would ensure that people have access to good information on the options available to them in relation to housing requirements, spelling out both ways in which their current home could be made more suitable and the choices that they could make about a move to supported or retirement accommodation, such as assisted living and extra care housing.

Although the Bill ensures that advice on care services will be made available, the Joint Committee on the draft Bill strongly recommended that advice on housing options also be included. So far, this recommendation has not been taken on board. It is not an onerous extra requirement to include housing advice in the mix, particularly given that many local authorities already ensure that people get this advice. Indeed, the Local Government Association supports this amendment. The Minister pointed out in Committee that information and advice on specialist housing options should be included when housing information is supplied. This amendment adds the prompt for such housing advice also to be included when guidance is given on care matters.

A move to a more suitable place can be suggested for a younger adult with care requirements. Sources of support for helping an older person to downsize, perhaps in decluttering the attic or sorting out the garden shed, can be recommended. For those who stay put, there is often so much to be done of a practical nature in making life easier for an older person and reducing their dependency on paid carers or family carers. From replacing hard-to-turn taps with long-handle lever taps for someone with arthritic hands, or fitting firm banister rails to the stairs, right through to converting the bathroom to fit a walk-in shower or installing a stair lift, all such adaptations can delay or prevent the need for more intrusive and expensive care provision. With good advice, paying for those adaptations can be covered by disabled facilities grants or equity loans, just as advice for a younger adult with care needs can be given on how the costs of renting a more suitable home can be covered.

Last Friday, I had the great pleasure of visiting the brilliant Centre for Independent Living in Knowsley, jointly funded and staffed by the health, social care and housing services in this borough. The centre brings together all the key elements of a truly holistic service. The occupational therapists are there, as are the care and repair team who can organise reliable builders and advise on grants, the wheelchair and aids teams, and the handy persons who do small improvement jobs. All the different disciplines and specialisms come together in Knowsley’s centre. It helped some 5,700 people last year. About half were referred by GPs, and health needs are therefore often the trigger, but the solution may well be in meeting the individual’s requirements within their home or, indeed, in pursuing a housing solution elsewhere, such as a move to extra care. So when a local authority gets it right, as in Knowsley, it really can do a fantastic, joined-up health, care and housing job. Good advice that covers the housing dimensions is the start of this process.

Amendment 23, the second amendment in my name and those of the noble Lord, Lord Hunt, and the noble Baronesses, Lady Eaton and Lady Barker, would complete the picture. This amendment again does not add significantly to the burden of responsibilities for local authorities. It falls within the “have regard to”, not the “must”, part of Clause 5, but would mean that in seeking to manage the market for care provision, local authorities should have regard to the housing situation facing those with care needs in their area. It raises the profile of housing in this context so that the different parts of local government all take it into account in their policies and strategies.

The amendment would mean that those within local councils responsible for social care would concern themselves with housing requirements, no doubt by feeding the necessary information into the planning system to influence future housing provision. In devising their strategies, health and well-being boards would consider whether more and better housing should be a priority, whether more disabled facilities grants or support for home improvements could play a greater part in preventing the need for intensive personal care, or whether extending a handy person service would not pay for itself almost instantly. This amendment would mean integrating housing considerations into the shaping of care markets, as well as integrating care considerations into the shaping of housing markets. That would benefit everyone.

I congratulate the Minister on the two important government amendments which give added emphasis to housing. I hope that he is able to go further and take on board these relatively modest but entirely sensible additional changes to the Bill.

Care Bill [HL]

Lord Best Excerpts

Tuesday 9th July 2013 Lords Chamber

Moved by

[Lord Best]

80: Clause 2, page 3, line 2, at end insert—
“( ) the importance of identifying housing options required to exercise that duty”

[Lord Best]

My Lords, we come now to a group of amendments, five of which are in my name and the names of my noble friends Lady Wilkins and Lady Tyler. These five amendments have the same underlying purpose—namely to give greater prominence to the crucial role that housing can play in preventing and reducing the need for health and social care services. The amendments have been prepared by the Care and Support Alliance, which is composed of more than 70 organisations that support and represent older and disabled people. I am particularly grateful to the National Housing Federation, which has helped bring these amendments together and given excellent briefings to interested Members of your Lordships’ House.

The Bill has been welcomed by those organisations, and they note with approval that the definition of “well-being” in Clause 1 covers “suitability of living accommodation”. Also, in relation to the duty on local authorities to meet needs for care and support, Clause 8 includes reference to such assistance being provided “at home”. However, these passing references to the place where many elderly and disabled people spend almost all their time do not do justice to the significance of housing to enabling people to live independently.

The Bill takes highly significant steps to integrating health and social care services, but downplaying the housing element—the third leg of the stool—will undermine the legislation’s good intentions. The Age UK report, Stop Falling: Start Saving Lives and Money, notes that falls cost the NHS around £4.6 million every day and that around half of the people over the age of 80 suffer a fall each year. It makes clear that it is accidents in the home, or on the icy step outside, that so often lead to hospitalisation. Cold and damp premises are equally likely to be the cause of a deterioration in health. Once in hospital, if the home to which the patient should return is totally unsatisfactory, their discharge will be delayed and/or there will be a swift readmission to hospital when the home fails them. Informal family carers cannot cope with someone’s care needs if they are battling with the inadequacies of a home that has unmanageable stairs or cannot accommodate a wheelchair.

The case has been made for the financial benefits of getting the housing service right. The National Housing Federation’s new report, Providing an Alternative Pathway, for example, shows that housing for someone with dementia in a self-contained flat in an extra-care scheme provided by a housing association can cut the cost of their care by up to 50%, allowing them to live more independently with care and support on-site, rather than in a costly residential care home. Currently, the UK is spending £9.43 billion on housing those with dementia in care homes, so housing alternatives can have a huge impact on health budgets.

Often the ideal housing solution for so many of us as we grow older is a move to a more manageable home with very low heating bills, no stairs or steps, but with high standards, space, light and ventilation. As a wonderful bonus, when an older person downsizes, a much needed family home, probably with a garden, comes on to the market for the next generation. I declare my interest as chair of Hanover Housing Association, which endeavours to build accommodation of this kind, which is in turn likely to be the best place for care and support services to be delivered. The housing provider can supply the back-up, not only through emergency call systems—now much enhanced by new technology—but in personal terms in acting as helper and ally in securing care services. Age-friendly housing developments for older people also protect against loneliness and isolation for the resident through ensuring a sociable, companionable environment.

However, the great majority of people will stay put in their family home. A joined-up care and housing service can make this possible. Sometimes very minor adaptations are all that are needed to extend people’s independence and autonomy. Handrails that are discreetly and strategically placed can prevent falls in the home. Long-armed “D” taps for people with arthritic hands can reduce the occupier’s need for costly help. Introduction to a “handy person” service can get these things fixed. Arrangements to pay for a defunct central heating boiler to be revived can end the misery of choosing between being freezing cold and spending a fortune on an electric bar heater which may well be unsafe. This investment in the home can keep people well.

Home improvement agencies, often called “care and repair” services, can organise access to disabled facilities grants for items like stair lifts or the installation of walk-in showers, making life so much easier for family carers as well as for the person themselves. It is good to note, in the spending review, the transfer of resources from the Department of Health to fund a planned 20% increase in the budgets of disabled facilities grants.

All these measures that prevent the need for more costly care services achieve very rapid payback as well as transforming people’s lives. If a patient cannot be discharged from hospital for a couple of weeks because their home cannot take them back, the NHS will incur costs of well over £5,000—money that could have been so much better spent fixing the home and preventing a series of unnecessary and unwanted hospital stays. Avoiding a move into residential care for a couple of years will save tens of thousands of pounds.

Each of these amendments covers a different clause in the Bill and inserts a housing dimension to the very welcome measures already therein. First, Amendment 80 addresses Clause 2, which focuses on preventing or delaying a person’s need for care. It seeks recognition that housing is a crucial part of a preventive care service.

Secondly, Amendment 81 is particularly significant. It adds housing to Clause 3, covering promotion of integration of care and support with health services. It is interesting to note, in this context, that in Scotland this holistic view of integration is now taken. The relevant Scottish guidance says:

“It will be important that, in bringing … health and social care closer together, partners ensure that housing services (including those provided by housing associations and the third sector, as well as by local authorities) are fully included in the integrated approach to service planning and provision, and that health and social care planning and local housing strategies are mutually supportive”.

So says the Scottish guidance. Sadly, our Health and Social Care Act 2012 does not explicitly reference housing, and a framework for engagement was neglected in that Act’s guidance. This has led to a very patchy involvement with housing by the new health and well-being boards. Some are examplars of engagement with housing providers in a three-way partnership, while others seem blind to the significance of this element in the equation.

Thirdly, Amendment 86 covers Clause 4 and relates to information and advice. Again, this is a very important amendment. The Joint Committee that looked at the Bill strongly recommended that local authorities provide information and advice on the housing options available in their area. However, although the Government have incorporated the need for independent financial advice, the recommendation from the committee to include housing has not been taken up. This amendment, by including housing options in the Bill, should ensure that local authorities provide the requisite information on specialist and adapted housing in their area, on ways for people to get their home adapted, and on the ways in which people can cover the costs of home improvements.

Fourthly, Amendment 87 seeks to improve Clause 5, which is concerned with the diversity and quality of local services. It extends the definition of care and support services to ensure that local authorities include specialist housing, accessible housing and housing-related support in their mix of services.

Finally, Amendment 88 addresses Clause 9, which relates to the assessment of an adult’s needs for care and support. It is intended to make sure that local authorities pick up on whether adaptations to a home are needed or whether a move to more specialist housing would be best. Assessing the housing requirements of the individual is a vital part of the process of seeing what is best for that person and how their lives can be improved. The amendment seeks to make sure that this ingredient in the process is covered as a matter of course.

I hope that the Minister will feel able to take on board the kind of changes to the Bill which these amendments advocate. The report last year from the All-Party Parliamentary Group on Housing and Care for Older People, Living Well at Home, spelt out the case for the three-way integration of health, social care and housing. The White Paper published prior to the Bill promoted the theme of including housing more centrally in the future of social care. The House of Lords Select Committee report, Ready for Ageing?, highlights the housing requirements of older people. The pre-legislative scrutiny committee, so ably chaired by Paul Burstow MP, took this forward with strong recommendations for a higher profile in this Bill for the housing dimension. The 70 organisations in the Care and Support Alliance, which have a real understanding of the needs of older and disabled people, believe passionately that these changes would greatly improve the Bill. I beg to move.

[Baroness Wilkins]

My Lords, I strongly support the amendments which have been so expertly described by the noble Lord, Lord Best, and to which I have added my name, as well as Amendment 87ZC in the name of my noble friend Lord Hunt of Kings Heath.

This is an important group of amendments. In combination, they will help to ensure that housing is at the forefront of decision-makers’ minds when providing for an individual’s care and support needs. The person will be supported in a way which makes them the least dependent on health and social services only if housing solutions are properly taken into account. However, that element is all too often ignored, and dependency is ensured.

I well remember a dispirited social worker who described the effects of a two-year delay in providing an arthritic lady with lever taps. In the mean time, she had to have considerable support to wash and cook and objected strongly when that support was taken away because she was now able to turn on the taps. However, it helped to convince the council to clear their backlog of occupational therapy cases.

It is so often the case that the housing element ensures that a person can maintain their greatest independence and be enabled to live their life to the fullest extent they can. Housing solutions have to focus on the individual—ensuring that the person is at the centre of the services and not the system. There are numerous examples of how, when housing, health and social service professionals work well together, people are able to regain a control over their lives which can all too easily be lost when social or health care are seen as the only options.

--- Later in debate ---

I hope I have reassured the Committee not only that the Government recognise the importance of housing but that the Bill makes it clear that access to suitable housing—including, where necessary, the provision of accommodation—is an integral part of care and support; and that, further, it creates a legal basis for integration and co-operation between care and support and housing more generally. I hope that the noble Lord, Lord Best, is comforted by all that and that he is content for the moment to withdraw his amendment.

[Lord Best]

My Lords, I am deeply grateful to all those who have participated in this debate, particularly the noble Baroness, Lady Wilkins, for coming in so supportively and giving us those really practical examples. It is astonishing that, in the case she mentioned, £50,000 a year was being saved, giving a much better life to Bruce, the tetraplegic she talked about. Big money is being saved in improving people’s lives, absolutely underlining the essence of what we are trying to do here. I am grateful to the noble Lord, Lord Rix, for bringing in the Mencap dimension so fully and reminding us of those old mental institutions, which the noble Baroness, Lady Emerton, was so instrumental in closing, and how housing was seen as the link that really mattered.

I am grateful to the noble Baroness, Lady Jolly, for pointing out how important the Joint Committee thought this to be. I know that members of that committee have not been happy that housing has not appeared in the Bill in the way that they had hoped when they produced their report.

The noble Lord, Lord Campbell-Savours, recognised that we have to find the money from somewhere. Sharing estate agents’ fees is a clever idea. The more likely one, I guess, is the transfer of resources from the NHS, because it is there that the savings are found and the two tie together so well.

The noble Lord, Lord Martin, emphasised the role of housing. He touched on central heating making such a difference to people’s homes, preventing bronchitis and emphysema and so on. When I visited the Care & Repair scheme in Leeds recently, staff told me that one of the most frequent causes of people having to go into hospital and of their homes being found totally inadequate was the fact that a central heating system that was 15 or 20 years old had fallen apart, and they did not have the wherewithal or the knowledge to replace it with a new boiler because that would involve a few thousand pounds. That one adaptation to the home alone would have made a huge difference to their health and well-being.

I am grateful to the noble Baroness, Lady Howarth, for emphasising that putting things in the Bill attracts the attention of the leadership of local authorities to their priority and importance. I am grateful also to the noble Baroness, Lady Wheeler, who emphasised what the Joint Committee on the Bill had said and how, since the previous legislation had gone through, we had seen very patchy take-up, with health and well-being boards and the rest, in recognising across the piece that housing is so important.

The Minister hoped that I would be comforted by the very full exposition that he gave of how there is the implication in so many places in the Bill that housing should be taken on board. I am sure that it is the intent of government that housing should be there; it is just a shame that it is so well hidden from so many of us. Although using the spending review’s £3.8 billion as a ring-fenced sum will require people to be more joined-up, including in relation to disabled facilities grants, and although the legal basis is no doubt in the Bill, it would be helpful if that was more overt and the Bill could make it a little clearer. We may want to return to this matter when we have heard about the compact that the Department of Health is working on, which would be very important if it emphasised housing in a fundamental way. For the moment, I beg leave to withdraw the amendment.

Amendment 80 withdrawn.

Care Bill [HL]

Lord Best Excerpts

Wednesday 3rd July 2013 Lords Chamber

Moved by

[Lord Best]

77B: Before Clause 1, insert the following new Clause—
“Funding
The provisions enshrining the new duties and responsibilities for local authorities in Part 1 shall not come into force unless and until a comprehensive and sustainable solution has been provided by the Secretary of State to address the funding of existing care and support commitments for local authorities and those arising from this legislation.”

[Lord Best]

My Lords, we now come to the beginning of the Bill and the very important Part 1, sensibly postponed until after the Chancellor’s Statement last week on the spending review.

I declare my interest as president of the Local Government Association. The LGA has drafted this amendment and, as with many other Bills, has provided invaluable analysis and briefing for parliamentarians, alongside its direct negotiations with central government on behalf of local councils. Indeed, I commend the LGA’s new publication, Rewiring Public Services, which was launched yesterday and sets out a radical agenda for local services, including social care services.

The provisions in Part 1 have been widely welcomed. They will update and reform the adult social care system. They will support greater integration of health and social care and, on the issue of paying for care, the Bill’s provisions will redefine the relationship between the state and the citizen. Some of these changes will lead to future savings in the cost to the public purse of providing adult social care.

However, achieving later savings means spending more today, and some elements of the Bill mean a shift in the cost of care from the individual to the state. Therefore, before your Lordships’ Committee embarks upon its consideration of the important changes contained in Part 1, it seems important to consider the financial position from which we are starting out.

There is compelling evidence that rising costs of care are leading inexorably towards a crisis in funding for the local authorities which are trying to meet the needs of an ageing population. Before we can assess the practicalities of extra activity and extra spending for social care, it is necessary to be clear how existing care commitments can be paid for, as well as how extra costs arising from the Bill will be funded. Decisions on funding need to be taken before, or at least at the same time as, the policy decisions. Therefore, Amendment 77B—and I am very grateful to the noble Lord, Lord Tope, who has added his name to it—seeks to postpone implementation of Part 1 until the Secretary of State has addressed the crucial issue of how the costs of social care and support will be met in the years ahead.

What we now know from the Chancellor’s Statement last week is that the spending review includes genuinely helpful steps to fund key measures contained in the Bill. Following productive dialogue between central government and the LGA, the plans set out in the spending review make it clear that significant extra funds will be available from the NHS to assist with the costs of local care services. As well as needing reassurance that all extra costs for local authorities resulting from the Bill really will be covered, there remains the greater underlying concern that the financial foundation on which the new position is to be built is not secure. Over the past three years, adult social care budgets have reduced by 20%. In a number of areas, to cope with the funding cuts it has already been necessary for councils to raise the bar before regarding older people as eligible for help from the council. Accordingly, despite growing numbers of older people, fewer people are now being helped because their needs are assessed as moderate, not substantial, even though earlier support can prevent the need for higher costs later.

The Association of Directors of Adult Social Services notes that the bulk of this reduction has been made up by efficiency gains. Many adult services directors believe that they can go a bit further; for example, through better procurement, shifting activity to cheaper settings, subcontracting provision to the private sector, and so on. But the scope for further efficiencies clearly now is much reduced. Demographic pressures, with a 3% growth every year in numbers of older people, mean that savings are predicted to be immediately cancelled out by the cost of meeting increasing demand. The cost of just standing still is estimated at another £400 million a year. Efficiency savings alone cannot keep pace with these budget pressures.

--- Later in debate ---

[Earl Howe]

The details of the payment-by-results system will be worked through. We are working with our partners in the sector including the LGA and NHS England to ensure that the system is designed with a view to incentivising integration. Further details of those arrangements are in course and we will announce them as soon as we can.

The kind of things that we will be looking for are, for example, the results that we have seen in places such as Cheshire West and Chester. The pilots, the whole place community budgets, showed that savings from integration could be substantial if implemented effectively. A business case needs to be presented. In that context, the pilot suggested that, once proposals are fully implemented, the net savings that could be achieved over five years are considerable.

Cheshire West and Chester has made savings of £26 million, with £3.8 million for Greater Manchester, £190 million for the Triborough authorities and £90 million for Essex. These savings are being identified. It gives us confidence to say that there is real potential to save money across the country, as shown by the pilots and other reviews, such as the Audit Commission review. Oxfordshire recently announced that it was nearly doubling the amount of money in its pooled budget for older people. That is a significant move.

I agreed with much of what the noble Baroness, Lady Wall, said. Savings are eminently possible without detracting from quality, by slowing and preventing the development of care needs or the onset of health conditions, or the loss of independence. We hope and believe that preventive care can increase the quality of life for individuals. A proactive stance by local authorities will deliver that. At the same time, preventive care will provide longer-term financial savings to the public purse. For the first time, Clause 2 creates a clear legal duty on local authorities to ensure the provision of preventive services.

I come to the point raised by the noble Lord, Lord Campbell-Savours, about the Dilnot package. I do not view the Dilnot package in the same way that he does. I do not see funding reform as being about protecting people’s inheritances. It is about providing hard-working people with peace of mind about how much they will pay for their care. Deferred payments will ensure that people will not have to sell their homes in their lifetime to pay for care. That will prevent distressing sales of houses and provide everyone with breathing space to make decisions and choices about what happens to their home. In the long term, the scheme is broadly cost-neutral to government, because the deferred payments will be repaid. Everyone will benefit from these reforms, but they will particularly help people with modest wealth who are most at risk in the current system of losing their entire home and savings.

Delivering on these transformational changes to health and care is the only way to secure the long-term sustainability of services, both for the NHS and local authorities. I would be firmly against delaying this —I think we would be heavily criticised if we did. The noble Lord, Lord Bichard, referred to the burgeoning weight of regulation during the past 60 years and one cannot argue with the statistics that he produced. This Bill serves to consolidate more than 60 years of legislation; it will repeal provisions from more than a dozen Acts of Parliament. Reducing the complexity of the statute and rationalising burdens on local authorities are our key aims in this context. I hope that, for the reasons that I have outlined, the noble Lord, Lord Best, will feel sufficiently reassured to be able to withdraw his amendment.

[Lord Best]

My Lords, I am deeply grateful to all noble Lords who have spoken: to the noble Lord, Lord Bichard, for pointing out that we cannot keep loading responsibilities on local authorities and others without willing the means to pay for those things; to the noble Baroness, Lady Howarth, who said that we cannot go on like this; and to the noble Lord, Lord Rix, who explained the position from the Mencap perspective—it could have been that of many other charities which are facing very tough times because local authorities cannot keep up the level of support that they used to have. The noble Lord, Lord Campbell-Savours, produced more impressive statistics, not least in relation to the people with long-term conditions and dementia who are living in the community and need to fund their care needs. The noble Baroness, Lady Campbell, brought us the users’ voice, pointing out that funding cuts have already meant people losing some of the control and choice which had been increasingly expected with use of direct payments and so on.

The noble Lord, Lord Sutherland, pointed out that the culprit is not local government or central government but demography, and that we need to make some choices as a result of those demographic pressures. However, in his view, one of those priorities is clear: it is that we should go ahead with this Bill. The noble Lord, Lord Beecham, also felt that it would be unwise for us to delay things, even though he accepted that cuts mean that social services in Newcastle have returned to the position that they faced in 1973 in terms of the resources available. He pointed that it is local government that has shown itself best able to be more efficient in these difficult times. We need to remember that. The noble Baroness, Lady Wall, pointed out that local authorities should try to make savings wherever they can, and the noble Lord, Lord Beecham, was right that statistics show that local government is doing just that.

I think that it is fair to say that the noble Lord, Lord Bentham, felt that it was necessary to find additional resources, but he thought that those could be found from the underspend in the NHS or the uncollected VAT or some other source. However, he did not want the amendment to delay the good things that the measures bring with them. The noble Earl, Lord Howe, agreed that we need fully to fund the measures—did I say Bentham?

[Noble Lords]

Yes!

[Lord Best]

Oh, not again! I do apologise. How many times has this happened to the noble Lord?

[Lord Beecham]

My Lords, I hope to be of some utility, but I would not claim to be utilitarian.

[Lord Best]

I deeply apologise, and not for the first time, to the noble Lord, Lord Beecham, one of the most distinguished of the vice-chairs and past chair of the LGA.

The noble Earl, Lord Howe, agreed with everybody that we need fully to fund the new measures and to ensure that the funding for existing care services is there. He expressed to us the belief that the new measures will do just that and they herald a sustainable funding arrangement for the future. He noted that the settlement for local authorities is extremely challenging this time round, but that, in terms of social care, the settlement that we are now pointing towards, with jointly commissioned services, the pooling of the £3.8 billion and NHS and local authorities working together, will in his view prove enough to fund a sustainable care service. Only time will tell whether those calculations prove to be accurate rather than too optimistic. In the hope that the noble Earl’s predictions are correct, and recognising that government really are attempting to make serious change in this Bill to the funding system as well as in so many important ways to the care services, I beg leave to withdraw the amendment.

Amendment 77B withdrawn.