Social Care Services

Anne Marie Morris Excerpts

Tuesday 17th May 2011 Westminster Hall

[Alex Cunningham]

It most certainly is. My hon. Friend says that social care accounts for £1 in every £4, and a 16% cut represents a considerable reduction in the amount available to spend on social care.

ADASS also concludes:

“savings on this scale simply cannot be achieved through doing the same things more efficiently or by trimming management costs”.

As for the money that has gone to PCTs, can the Minister tell us, hand on heart, that he has any idea how much of it will be spent on social care this year? Given the revolution unleashed by the Health and Social Care Bill, PCTs have had other issues on their mind as they have sought to protect services during a transition period that will see them abolished. More importantly, this transition period threatens to reverse the progress made on health and social care over the past few decades. I just wonder what guarantees there can be that we will have properly commissioned and funded care once PCTs have gone and have been replaced by consortia that do not have the expertise and understanding of our community’s wider health and social care needs.

Media reports just this weekend outlined the profits that some think can be made from the health and social care system, effectively taking hard cash from the front line. The Prime Minister’s senior adviser, Mark Britnell, told a New York conference attended by the giant private health care providers that dominate in north America that the changes over the next two years will provide a “big opportunity” for the profit-making sector. As I am sure hon. Members will know, no one can make profits without taking cash out of the system. I look forward to hearing what reassurance the Minister can give those who will be hardest hit. What is his guarantee that profiteers will not have their way with the NHS and related social care services?

I know that Ministers get fed up with MPs from the north highlighting the divisions in our country, but the BBC is highlighting them now. In a survey released last week, it identified a new north-south divide, with social care spending this year falling in the north while actually rising in the south, although I will question the value of that so-called rise later. The BBC’s findings reflect the differential impact of the cuts, with councils in the midlands and the north more reliant on central grants and thus hardest hit. The findings may also reflect demographic differences and the effect of falling property values on people’s ability to self-fund.

In the north, spending will fall by 4.7% in the current financial year alone. Then there are deprivation factors to be taken into consideration. Local authorities in the most deprived areas—many are in the north, but they are elsewhere as well—have the worst mortality figures and the highest incidence of long-term ill health, but they are suffering the deepest cuts in spending power. Front-loading the cuts means that huge changes must be brought in quickly, giving little time for consultation with staff and service users over the best way to minimise the impact on front-line services. That said, I would not like anyone to get the impression that things are rosy in the south. The 2.7% increase in spending in the south is about half the rate of inflation and does not keep pace with need. Nor will it be enough to prevent real people from losing real support—support that, in the Chancellor’s words, they depend on.

My main purpose in securing the debate, however, is to consider the human impact of social care cuts, not just to debate dry spending figures.

[Anne Marie Morris (Newton Abbot) (Con)]

I note what the hon. Gentleman says about funding. He briefly mentioned the issue of commissioners and quality, which is clearly as important as funding. Does he share my concern that the changing role of the Care Quality Commission, which will now monitor providers rather than commissioners, will mean that there is a gap and therefore a risk that commissioners will not be held to account and provide good-quality care?

[Alex Cunningham]

Yes, I agree that there is a considerable risk. I should say that I have been much impressed by the role played by local authorities in health scrutiny. I hope that the Minister will answer the hon. Lady’s question directly later.

The successful judicial review against Birmingham city council’s adult social care cuts looks set to be hugely significant. The Minister might be tempted to hide behind a carefully drawn veil of localism, but does he really consider it acceptable that Birmingham should seek to withdraw support from 5,000 people? Many of those people could be in a situation where abuse or neglect have occurred, or will occur, or they could be unable to carry out the majority of their personal care or domestic routines. They will be the real losers in all this.

Does the Minister consider it acceptable that 2,145 elderly and vulnerable people in Lancashire will have all care and support removed, as part of cuts that are the subject of another judicial review? Does he consider it acceptable that desperate families are being forced to go to the High Court to try to prevent devastating damage to their quality of life or that of family members?

In West Sussex, the “Don’t Cut Us Out” campaign has brought people together to campaign against eligibility cuts. If Members visit its website, they can read testimony from Tony, who has limited mobility. He must carry an oxygen cylinder wherever he goes and he is susceptible to blackouts and periods of deep depression. He will lose all the benefits and support currently provided by West Sussex county council. He says:

“My current care package...provides for 13 hours of care support each week and has kept me out of hospital for much of the last two years, saving the Country hundreds of thousands of pounds. Before, I was in hospital for six months at a time, and once discharged was being re-admitted every two weeks or so. I can’t imagine what my life will be like without this support.”

Back in the north, local people, service users and staff have been campaigning to halt the closure of Leeds crisis centre and the threat to mental health day services in Armley and Hunslet. At a packed campaign meeting organised by Unison, a campaigning trade union of which I am proud to be a member, a service user said, “I am saving the council money by using these services; when living in London, where there weren’t these services, I had many hospital admissions; I have had none since living in Leeds.”

Mencap provided me with a graphic example of what the cuts mean for George and his daughter, who are from Rotherham. George’s daughter has profound and multiple learning disabilities. Due to her disability, she is doubly incontinent and requires the use of many disposable items of medical equipment. She lives with her dad, and as part of her care package, the council picks up all body and medical waste from the household. The waste includes faeces, urine, blood and vomit. Mencap says that Rotherham council has gone from collecting the hazardous waste once a week to once every 14 days and has reduced the amount that it picks up by 50%. The council has also stopped providing specialist waste bags for the disposal of the waste, leaving the family to cover the additional cost themselves. That bodily waste now goes into black bin bags mixed with household waste, which are sent to landfill. These stories illustrate the fundamental truth: these cuts are a false economy with devastating human, social and economic costs.

In a recent national survey by a group of charities, including Carers UK and the Alzheimer’s Society, half the respondents said that increased charges for care meant that they could no longer afford essentials such as food and heating, and more than half said that their health had suffered as a result. We must consider the services run by voluntary organisations—dare I say it?, the big society—that offer early help for people who do not necessarily qualify for assessed council support. Day care centres, meals on wheels, support groups and drop-in centres are being cut because they are losing grant funding.

Jackie Dray used to run four support groups called “Elders with Attitude”—I love that name—in Birmingham, but she was told in March that her £30,000 council grant was to be cut altogether. She now runs only one group and is desperately looking for alternative funding. She said:

“They are cutting luncheon clubs or groups like mine that could make a difference between somebody remaining in the community or sinking into clinical depression and residential care. For a small amount of money, you could delay the point at which people have to go into hospital. I see a lot of clinical depression in carers and cared-for alike. People are teetering on the brink. There’s a lot of frustration, worry, lack of sleep.”

Before we can consider the future of social care services, we have to consider the consequences fully.

While we await the Dilnot commission report on long-term funding and the Government’s response to the Law Commission review, the Government are, in effect, already re-engineering the infrastructure of care and support. As services are razed, my fear is that capacity is being lost, services are being withdrawn and staff are being lost—capacity and skills that cannot easily be recreated. The Government are seeking to soften people up and lower their expectations, to get them to accept a return to reliance on family and buying from the open market with their own funds, or a patchwork of precarious charitable provision from a third sector suffering its own cuts and challenges.

I want to turn to the ideal, which I thought all the parties shared, of personalisation in adult social care. I fear that that ideal is being lost. The cuts mean that the policy, which promised much, is fatally undermined. Social workers and care managers tell their union that they are being expected to reassess personal budgets with a view to cutting them. I know that they need to consider value for money for all care packages, but they believe that they are expected to make cuts to get the budgets down.

A forthcoming report on a survey that Unison conducted with Community Care will highlight the fact that the paperwork and bureaucracy associated with personal budgets is excessive and inaccessible for service users. I question the Minister’s decision to prescribe from Whitehall that personal budgets be provided in the form of direct payments. That appears to be at odds with his claim to be a champion of local determination and removes choice from people who wish to have a managed budget. It appears to be linked to the aim of completely withdrawing state provision. Individuals will be expected to navigate the market or take on what many will see as the onerous and stressful responsibility of becoming an employer. I urge him to reconsider the prescription of direct payments, as there is evidence that it will restrict choice, but more importantly, distress some of our most vulnerable people, who already have enough challenges in life.

As we contemplate the future of adult social care services, there can be no under-estimating the scale of the challenges that we face as a society: by 2041, the number of adults with learning disabilities, we are told, will have risen by 21%; the numbers of young people with physical or sensory impairments by 17%; and disabled older people by a massive 108%. We all know that the number of dependent older people is set to increase hugely. The Association of British Insurers says that currently 20% of men and 30% of women will require long-term care at some point. If we add to that the challenges of the increasing number of young adults with complex needs who will need very expensive care packages for decades; the 170,000 people with a learning disability who Mencap tell us live with parents and carers who are already over 70 years old; the growth in the number of people with dementia, which the Alzheimer’s Society says is set to soar by a third to 1 million people by 2025; the costs facing authorities due to alcohol misuse; and the number of people with obesity-related problems, then we can see that the Government’s proposals are destined to fall well short of what is needed.

The director of children, education and social care for Stockton-on-Tees borough council, which serves people in my constituency, says that we have to be mindful of the knock-on effect of the reduction in other funding streams that impact on adults—the independent living fund, the Supporting People programme and affordable housing funding. She tells me that some of the funding streams that have historically been linked with it are being reduced or ceasing, while her department works to maximise people’s independence.

[Alex Cunningham]

That is very much the case. A stream of people have come to our surgeries or to see us in Parliament, and there seem to be so many attacks—left, right and centre—on some of the most vulnerable people in our society. As my hon. Friend says, something needs to be done if we are to arrest this situation.

The director of children, education and social care for Stockton-on-Tees borough council says that the result of the cuts, if we have limited extra care and supported living options, will be a further over-reliance on residential provision. An integrated health and social care facility and extra care scheme in Billingham in my constituency was an important part of my council’s strategy for supporting people, but the Government refused the private finance initiative credits to make it happen. Would the Minister prefer his granny, mother or other elderly relative to be forced into residential care when they could have been supported in their own home or an extra care facility and had the independence that I know most older people want?

Another area of concern is the shortfall in funding to support carers. Yes, I know that the Government allocated a welcome £400 million for carers’ breaks, but other funding managed by PCTs to support adults and their carers is not ring-fenced in any way, and although some flexibility is needed, carers, who are often seen as the poor relation, could end up all the poorer.

The sector skills body estimates that the social care work force needs to double by 2025, yet it is a sector characterised by labour shortages, low pay, poor prospects and a poor image. Some 60% of care workers hold no care qualifications, and only 20% have a national vocational qualification level 2; only 10 % have an NVQ level 3. Before anyone intervenes on that point, I should say that I believe that previous Governments, including our own Labour Government, could have done more to address that issue. However, it is not just Governments’ responsibility; other organisations, including service providers, should play their part in driving up qualification standards and meeting the costs.

Is the provision made by such organisations being properly managed or being left to the market? In Stockton, we have over-provision of residential care places, some of which are under financial pressure, including those owned by Southern Cross, which is seeking £100 million from investors to secure its future. Surely we need some kind of controlled management or strategic planning to get this right and ensure that standards are maintained.

We must look to the future of adult social care. We need immediate action to lay the groundwork for genuine reforms to flourish. The Chancellor said that his cuts would not touch front-line services; he should be prepared to say that he got it wrong. There is an urgent need for a new plan that looks again at the local government settlement and works with local authorities to ensure that front-line services are funded to meet need. Everybody agrees that we must do more to give early help because it prevents dependence and saves money on acute care, and yet those services are first in line for the chop. Will the Minister genuinely and strenuously consider the recommendation of a duty to provide early help for adult services such as that which Professor Munro made for children’s services?

The Minister must reconsider the equation of personalisation with the transaction of receiving direct payment. Personalisation is not about ticking boxes and having the right number of people receive direct payment. Trying to make it work in the context of the cuts requires him to spend time talking to practitioners and service users about what is happening on the ground and what they think the priorities should be. We need to get it right for individuals.

We need an improved and comprehensive work-force strategy covering training, development and qualification standards as a condition of provider registration and a commitment to working towards a living wage for all care workers. We must work with work-force representatives to boost the autonomy and confidence of practitioners. I am sure that the Minister will welcome, as work-force regulators have, Unison’s duty of care handbook for health and social care staff. The handbook aims to promote awareness among workers of their duty of care and other professional duties, and of how to raise concerns about poor practice.

Costs, too, need to be addressed urgently. The Association of British Insurers says that the average cost of care in residential homes in the UK is approaching £25,000 a year, with people in England spending an estimated £420 million a year on private home care. This question was not sensibly debated during the general election. We need cross-party co-operation to reach a long-term sustainable solution to the problem.

[Anne Marie Morris]

The hon. Gentleman raises a question about care homes and fees. Does he agree that one way to solve the problem would be to introduce a standard contract? At the moment, there are great differences in provision; there is no consistency in standards, which means that one person’s care can be very different from another’s.

[Alex Cunningham]

During my time I have visited many care homes, and I have seen many variations in quality and standards. I have seen some places where elderly people were highly motivated and excitedly engaged in activities and others where people were sitting in seats glued to the television—at least, I think that they were glued to the television; they certainly seemed to be in another world. I agree with the hon. Lady that we need a solution of exactly the sort that she outlines.

There is an overwhelming desire to end the postcode lottery for care. It is important that when people move around the country, they should receive the same standard of care without their cases being constantly reassessed. Recommendations made by the Law Commission for national eligibility criteria and carer assessments are a start in plotting a way forward. We must end the cost-shunting and turf wars between health and social care over continuing care assessment and funding. Do the Government still intend to allow the Law Commission to draft a Bill to simplify the legislation, and if not why not?

When Dilnot reports, we need to hear from Ministers a genuine commitment to cross-party engagement on long-term funding. The Minister must realise that a voluntary insurance market, like that described by the Prime Minister’s senior adviser this weekend, will not be acceptable to a public worried about the workings of the discredited financial services sector.

As well as a new funding system, we need to review the quality standards of service regulation, with greater emphasis being placed on the importance of providers having a stable, highly skilled and confident work force. The quality of care is all about the quality of relationships, but for as long as we have a 25% turnover of care staff we are letting down the hardest hit, who deserve much better.

The future of social care and its funding is not a matter only for this generation or this Government. We all have a responsibility. I hope that the Minister accepts that the Government should not go it alone, but should work with everyone involved to find the kind of long-term solution that will help to ease the anxieties of an increasing number of disabled and elderly people.

I end with a question for the Minister. If we are all in this together, why is it that adult social care is the hardest hit? Is it not the case that the most vulnerable are taking a disproportionate hit? I hope that the Minister will accept my points and other constructive points made during this debate, and that he will answer our specific questions. He should reflect on the unfairness of what is going on. He should realise that despite all the statements, funding is not meeting today’s needs and that current plans will not address the increased demands of the future. I hope that he will tell all those who receive adult social care services that he will make changes to current and future plans to ensure that the most vulnerable have a quality of life that most of us take for granted.

--- Later in debate ---

[Catherine McKinnell]

I agree that that is a great concern, which is why the Minister must take on board the deep concerns that are being expressed today. In any event, reforming the law will still not be enough.

I am pleased that, as a result of the Tyne Tees investigation, the Care Quality Commission has agreed to review its reports and to conduct unannounced assessments on the homes in question. However, I am concerned that it appears to have required a television programme to spur the Care Quality Commission into action. By placing their loved ones in residential care, people are putting huge amounts of trust in a service. They rightly expect that the Care Quality Commission is adequately monitoring, regulating and inspecting all care homes on a frequent basis.

[Anne Marie Morris]

The hon. Lady has made some extraordinarily good points, and the Care Quality Commission certainly needs more help to do an effective job. Now that we have an outcome-based set of performance criteria, homes need to be given guidance on how to comply with them. In my meetings with the Care Quality Commission, it says that it no longer gives advice, which means that it is an uphill battle for any home to ensure that it provides the quality of care that is needed and that it complies with the new criteria.

[Catherine McKinnell]

I agree that the Care Quality Commission should take a proactive approach to improving the quality of care in our adult services.

Another worrying statistic is that on-site inspections in care homes have fallen by 70% since the Care Quality Commission was introduced in October 2010. That must worry anyone who lives in a care home or who has a loved one in a care home.

Will the Minister consider the following issues because they are crucial to the future provision of social care services? What further steps can the Government take to ensure a much greater level of protection and safeguarding for vulnerable elderly people in residential care? What measures will he take to ensure that the culture of fear that was spoken about by people participating in the Tyne Tees reports is broken down, so that care workers, relatives and residents feel confident and safe in raising concerns about the standard of care? What steps is he taking to improve the status, pay and training of care home staff, who are doing an incredibly difficult and important job? How will he ensure that the swingeing cuts to local authority budgets over the coming years do not detrimentally impact further on the quality of social care being provided to elderly people, particularly at a time of ever-increasing demand?

--- Later in debate ---

[Mr Anderson]

The privatisation of home care services in this country has been a complete failure and a nightmare. I have represented home care workers for many years and have seen the service deteriorate. We had a dedicated work force who had a set list of clients whom they went to see day in, day out. They built a relationship with that person and their family. When those jobs were contracted out, it was said, “We will send worker A on this day and worker B on that day.” The home care worker lost that direct link with not just the family but the wider team within the authority. That team would work together and take a holistic view and work better for the person concerned. It is clear that services are being contracted out to save money. If we save money, services will not be as good.

It is clear that we will see problems being stored up if we lose public sector capacity in home care services. At the moment, some 31,000 residents are being taken care of by Southern Cross Healthcare. Their homes now hang in the balance as a result of reckless business practices and local commissioning, which has allowed the organisation to become so dominant in the market. Southern Cross and Four Seasons—the big two in residential care—have operated casino-style finances, and both are now teetering on the brink of collapse. A toxic cloud, formed by irresponsible borrowing, weakening demand, council cuts, the slump in care home property values and the collapse of favourable credit facilities, now hangs over the heads of frail elderly people and their families at a time of insecurity and when they need real security.

How has it come to this? How has RBS, a state-owned bank, become the biggest shareholder in Four Seasons in exchange for writing off debts of £300 million? Would taxpayers’ money not be better spent directly on care homes run by democratically accountable councils, rather than being tied up in byzantine financing arrangements?

Across the social care market, research by Community Care suggests that one in five providers expect to go out of business in the next financial year. The regulator describes the home care market as a cottage industry of small, often barely viable providers alongside a few giants such as Care UK, whose chairman kindly provided £21,000 to fund the personal office of the Secretary of State for Health—perhaps that is one reason Care UK is doing so well.

If Southern Cross, Four Seasons or indeed local providers collapse, how will local authorities find new homes for people when they no longer run them? When home care providers default, as they often have and might in future, how will local authorities fill the gap if they have scrapped their own home care teams, which is happening up and down the country?

What about the quality? Care Quality Commission data show that privately provided care services are less likely to be rated “good” or “excellent” and five times more likely to be rated “poor”. I know that the Government do not like targets or standards, but when their own commission is saying such things its message should be listened to. Private providers consistently score lower on a range of indicators of quality and safety. When we look at the employment practices of some providers, we cannot be surprised that home care workers do not stay in their job. They are not paid for their travel time between visits, and they have to provide their own mobile phones and pay for their uniforms. They suffer from underpayments; they often have zero-hour contracts; and they sometimes have to pay towards the cost of administering their own time sheets. No wonder people do not see it as a job for the future or a career that it is worth investing their time and talents in. We need real regulation of employers to stamp out employment practices that have impacted so badly on home care users and, through them, on staff.

Where are we today? We have a Government who want more from staff for less; who want more work by fewer staff, because they are making 500,000 public sector workers unemployed; who want more pension contributions from less pay and for poorer pension provision; and who want people to spend more time at work by making, in particular, women work until they are 66 years old, with less time at home and in retirement.

What did we get last week? The Chancellor has a new red tape initiative. What is he going to do when people are losing their jobs? If there is a chance of redundancies being managed sensibly, what does he talk about? He wants more chances of people being sacked, with less chance of real support by limiting the time to consult. People will have more chance of being made redundant and less legal support to challenge decisions taken by their employer.

The CQC sees a vacuum in regulation and in the checking of safety and quality of care. The CQC’s risk-based approach is resulting in a dramatic drop in inspections. A freedom of information request by Community Care found a 70% drop in CQC site inspections in the past year alone, at a time when more people are in need of care.

[Anne Marie Morris]

I thank the hon. Gentleman for being so generous in giving way. The statistics are interesting, but care homes in my constituency of Newton Abbot complain that more visits are being made. I spoke to the CQC just this week and it said that it was making on-site visits to every home within its purview in the south-west. There might be a regional difference, but in the south-west, where there are a huge number of elderly people, the number of visits is going up, not down.

[Mr Anderson]

I thank the hon. Lady for that. More inspections are good: we want inspections that work; otherwise, we will get into the problems that my hon. Friend the Member for Newcastle upon Tyne North (Catherine McKinnell) mentioned.

Staff and service users fear that there is an over-reliance on provider self-assessment and secondary sources rather than direct inspections. There are fewer indicators and data sources for adult social care providers than there are for NHS providers, yet the methodology is common. Alongside a “lighter touch” approach from the regulator, local authorities are cutting quality assurance departments, which, as Community Care showed, means fewer local checks on the quality and safety of care being provided.

Some of the changes that the unions and workers at the CQC would like to see, which I agree require serious and urgent consideration, include reinstating and strengthening the requirements on the types of incidents and issues that must be reported to the regulator. These should again include medication errors, significant injuries, accident and emergency admissions, safeguarding referrals, matters where staff are subject to disciplinary action or dismissal and unusually high staff turnover. Those are all indicators of things that might be going wrong, but they are not being recorded as they should be. A minimum frequency should be set for how often a service is visited.

I have no doubt that the hon. Member for Newton Abbot (Anne Marie Morris) is correct about the experience in the south-west, but it should be replicated across the country because it would give people greater confidence that things were being done properly. There should be a greater range of tools so that service users and employees can make their concerns known to people who can affect outcomes. We want to encourage people who want to blow the whistle where necessary, and give people whose relatives are in care confidence that, if they make a genuine complaint, the care will not be reduced.

I hope the Minister will look at my points, provide answers on the failures of private adult social care providers and say whether anything can be done to make the CQC more representative. For years, adult social services have been regarded as the Cinderella service, which is a disgrace. People are in care not because they want to be but because they have to be, so I hope we will work together to try to make adult social care something this country can be proud of.