Social Care

Baroness Pitkeathley Excerpts

Thursday 1st December 2016 Lords Chamber

Moved by

[Baroness Pitkeathley]

That this House takes note of the challenges in the current system of social care and of proposals for reviewing it and for longer-term reform of the system.

[Baroness Pitkeathley (Lab)]

My Lords, here we are again. This is not the first time I have led a debate on social care in your Lordships’ House and I have been wont to call those who join me the usual suspects, because we are the relatively small band who bang on about this subject whenever we get the opportunity. There are new faces as well as old ones here today. It is particularly welcome that the noble Baroness, Lady Cavendish, has chosen this debate for her maiden speech, to which we all look forward.

I have to tell your Lordships that it makes pretty depressing reading to go back to the other debates on social care in which many of us have participated, because the problems remain the same and so little progress seems to have been made. If I felt that before all the other debates—in nearly 20 years in your Lordships’ House, I have rather lost count of the number of times I have focused on this—how much more I feel it this time, when endless reports and newspaper articles are telling us all how bad it is. Your Lordships will be all too familiar with some of the headlines of recent weeks. One said that,

“social care is at a tipping point”,

another that it was “Slow, patchy, cruel” and that social care funding is “not fit for purpose”. Others said that the bed-blocking crisis hit a new high and that local authorities,

“join NHS chiefs in call for extra … funds”.

It may surprise your Lordships to know that I have managed to find some comfort in these terrible analyses, because perhaps they show that at long last there is agreement across all areas about what the problems are. That will be evident in the briefings which your Lordships have received for this debate. It is not as though we have not agreed before, but perhaps not so strongly and not across all areas. When even the chief executive of the NHS, not to mention the chair of the Health Select Committee, and two former Secretaries of State say that if there is any extra money it should be put into social care, maybe we are at last ready to address the issues.

Am I being too hopeful? Perhaps. Certainly, the announcements we were hoping for in the Autumn Statement provided no comfort by their total lack of appearance or even mention. I bow to no one in my desire to have better broadband in rural Herefordshire but, really, can we get our priorities straight? How the Chancellor could ignore the pleas from all sides is beyond me. His decision has been met with incredulity and dismay and called shameful. Nevertheless, I am determined to spend less time today on the problems of social care, which are well known to your Lordships anyway, and more on what the possible options are.

Let me summarise the problems and leave others to elaborate. There is a shortfall in social care funding of about £2.5 billion between what is available and what is required. Four out of five councils do not have enough provision, especially for care at home, and at least 1 million people are going without the care that they desperately need. Much more stress is falling on family carers, who increasingly find it difficult to cope. The results of these shortfalls are all too apparent: too many people end up in acute and very expensive hospital care in hospitals which are already bursting at the seams, even before winter pressures begin to bite.

The situation is bad for everyone. It is bad for councils, which will face legal challenges if they are unable to meet the obligations placed on them by the very welcome Care Act; it is bad for the NHS, as hospitals fill with people who could and should be treated at home; it is bad for care homes that increasingly find it difficult to balance the books, with the resulting threats to the quality of care which recent TV programmes have illustrated; it is bad for family carers. In short, it is bad for anyone who cannot afford to pay for their own care. Even if you are a self-funder, it is bad for you because you have to contribute to underfunded local authority places if you are in a care home. So much for the so-called society “which works for everyone”.

I could go on with endless examples of the bad but I will not. I turn instead to offer options, in the hope that the culture in which we operate is finally changing enough to encourage bold and courageous action. They say that humans and cultures never change unless we are forced to do so. If that is the case, we are forced to do this now before the whole system is not just at tipping point and in crisis, but in danger of breaking down completely. I should say here that I always worry about the danger of too much criticism sapping the morale of the dedicated staff who work in social care and do their best. They are usually paid at the very lowest levels. We owe it to them as much as to the frail, old and disabled to think boldly.

We must first tackle the different methods of funding health and social care, which have been so difficult to overcome and such a barrier to the co-ordination and integration of health and care services. In 1948 when the system was established, men died on average at the age of 66, one year after retirement, and women at about 68. There was no need for the type and range of care we now need. It did not matter so much that while health was free at the point of delivery social care was always means-tested, because you were not going to need very much social care. Social care has been paying the penalty ever since for those decisions, which at the time they were made were perfectly logical. What we need now is a decision of the level and quality that our forebears made then in relation to the NHS. But this time it must be about reshaping health and social care around today’s needs, not those of the population of post-war Britain.

Various attempts have been made and we all remember them: the royal commission, the Wanless review, the Dilnot review, the King’s Fund commission on the future of health and social care and the Barker commission—but no government response has been sufficient. It is evident that what is really needed is a long-term, cross-party approach which takes an open and honest look at the system and, above all, is open and honest with current and potential care recipients about what they can expect.

I think we are now at a crossroads and can make one of two decisions. We can go on as we are, muddling along, trying to do more with less, managing demand by just not meeting it. That is how we are managing demand: we are just not meeting it. I remind your Lordships that, of the more than 1 million people who it is estimated are not receiving care, most have already been assessed as having high-level needs, because helping those with moderate needs is already a thing of the past in most areas. We can keep promoting independence—that is always a good thing—we can keep trying to get individuals to manage their own care better and, above all, we can keep trying to integrate the budgets for health and social care. There are some excellent examples of integrated care at local level which, no doubt, noble Lords will illustrate, but the overall picture is patchy and still too cautious and too hedged about with suspicion and lack of willingness to give up power over budgets, still less to transfer it to other professionals. A single pooled budget for the health and social care needs of a whole population would enable NHS and social care providers to agree the very best use of the public pound and to focus on services which reduce the need for long-term care.

I am sorry to go down memory lane, but I have been talking about this, as have many other people, for almost 40 years—it is probably over 40 years, in fact. My first book was published in 1978. It was about hospital discharge for older people. Funnily enough, it showed that proper co-ordinated care can happen only if there is a single budget in the control of those who provide the services, free from political control and including the contribution of the private and voluntary sectors too.

If we are going to go on with the current system, if we are going to go on trying to muddle along, then I must make a plea for honesty. No Government—and I include my Government in that—have ever made it clear to the public that responsibility for paying for care and for arranging it rests with individuals and their families and that public funding is available only for those with the least money and the highest needs. Most people are aware that NHS care is generally free at the point of use, but their understanding about social care is far less clear, and people therefore have inappropriate expectations. If I had a pound for every carer who has said to me, “My mum has paid taxes all her life, and I can’t understand why her house has to be sold or all her savings used to pay for her care”, I would be a millionaire. That carer is a perfect example of a person who is just about managing, caring for her mother and probably teenage children too, trying to balance paid work with caring responsibilities and so on.

As we are not transparent, no one ever prepares or plans for care, and they have to scrabble to arrange and pay for it at a time when they are anyway distressed by the very need for it. If they are not prepared to reform the system, the Government must surely be prepared to promote clearer public understanding of how the system works and what people can expect and, more importantly, what they cannot. People plan ahead for pensions, and it is possible they could similarly plan ahead for care, but only if they know they have to.

However, it will not surprise noble Lords to know that this sticking-plaster solution is not my preferred option. I believe we must embark on long-term reform of the system because this problem is not going to go away; it is only going to get worse. All international evidence shows that spending on health and social care rises inexorably as the population grows and ages. The question is not whether these costs will arise, but how they will be met. Will they be met by the public purse or by private individuals? We can talk for ever about achieving more with less and delivering better value, but that will never release resources of the scale required to meet the widening funding gap.

Every independent review of the past 20 years has recommended that in future funding of social care, as well as healthcare, should come from public, not private, finance. The needs of individuals cannot be divided up neatly into health or social care needs, as all those of us who over many years have tried to fathom the difference between a health bath and a social care bath have long acknowledged, and now is the time for us as a society to acknowledge that the funding cannot be neatly divided either.

We must embark on a frank and open debate about how to fund health and social care on a sustainable basis into the future and remind everyone that such a debate cannot be settled in a single Parliament, so we need to secure cross-party consensus on shared principles to guide that reform. We have enough research and excellent material to enable us to do so; we just need the will to do it. We know all the questions about social care, so let us not embark on any more questions about what social care needs. What we need now is answers.

To those who say that this is not the time to do this with public finances in such disarray and with so many other problems, which we have just been hearing about in the previous debate, I remind your Lordships that our forebears tackled reform in the middle of a world war when the country was pretty well bankrupt and not the fifth-richest nation on earth, which we keep being reminded that we are. The Wanless review called for this debate 10 years ago. It has never been more necessary, and it is now even more urgent. I beg to move.

--- Later in debate ---

[Baroness Pitkeathley]

My Lords, we have had an excellent debate and I thank all noble Lords who have taken part, especially the noble Baroness, Lady Cavendish, for her thoughtful speech which makes us eager to hear more from her. The topics covered today have been as wide-ranging as the issue itself but there has been agreement about the crisis which exists, if not yet on how to address it.

I did not of course expect the Minister to announce from the Dispatch Box the great public debate that I have called for today. Many others have called today for such a debate and it is of course way above his pay grade—but that does not mean that I resile one iota from the calls for that debate. We must have it; it is inevitable and it would be better to have it sooner than later—before the system really does collapse, as many people have warned us it will.

The Minister has had many suggestions and, with his usual courtesy and honesty, has certainly addressed some of them. I welcome his focus on the strategy and I certainly acknowledge the progress made, as he reminded us, with some STPs. However, a couple of examples that I have had remind us that the STPs should not be about just health and social care but should include carers and the voluntary sector. It is important to bear that point in mind as we go forward with the STPs.

The emphasis has been on the interdependence of the health and social care services, as well as on the needs of users, carers and care staff. I get the impression that the time is right, and I think that the Minister has confirmed this. The people at the top—even, dare I say it, at No. 10—have realised that something must be done. If you have a philosophy which says that the Government must work for all and that you must help people who are “just about managing”, or even the “not managing at all” as the noble Lord, Lord Warner, reminded us, I hardly think that you can avoid addressing this issue. If that is the case and there is agreement that something must be done, I hope that this debate can be required reading. Readers will find calls for more resources but I do not want that to frighten them off, because they will also find in this debate a wealth of practical and deliverable suggestions on how to address these issues. So although I am a bit depressed, I am not totally depressed. Like the Minister, I am not without hope and I certainly hope that by the next time the usual suspects meet here to discuss this, we will have made some more progress. I beg to move.

Motion agreed.