Care Bill [Lords]

Bill Esterson Excerpts

Monday 16th December 2013 Commons Chamber

[Mr Dorrell]

I shall come on to that point, but to react directly to the hon. Lady’s point, surely it is much better to intervene before the patient arrives in hospital in the first place, preventing the avoidable episode of care. The hon. Lady talks about discharge, and she is, of course, quite right, but how much better is it to prevent the case from arising in the first place, which is what clause 2 is about?

[Bill Esterson (Sefton Central) (Lab)]

I think that is precisely the point my hon. Friend the Member for Bridgend (Mrs Moon) was making. The money simply is not there in local government. When 20% of the adult services budget has been lost, the services are not there and the care managers are not there to do the assessment to decide whether to keep people at home or to help them get out of hospital. The service back in the community, after people have come out of hospital, is not there either. Does the right hon. Gentleman accept that that money has to go back in?

[Mr Dorrell]

Of course I accept that if we have more money, we can do more, but I do not think that that exempts us, particularly given the public finances we inherited in 2010, from the obligation to see how we can get more for the £125 billion of taxpayers’ money that is already committed to health and social care in England.

That brings me to clause 3. The only way to deliver person-centred care and early intervention to prevent avoidable cases, is to reinvent care on a much more integrated model between the national health service and the social care authorities. That is why there is the obligation in clause 3 to consider integrating health and care. In that way we will not think of the NHS as one bureaucracy and social care as another, but instead think of it, as Mike Farrar said when he was at the NHS Confederation, as a care system that provides medical support when necessary, rather than as a medical system that provides care support when it has got the money—that is how not to do it.

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[Meg Munn]

My hon. Friend is absolutely right. I managed care services when, not the previous Government but the one before that, brought in a health and social care Act. Within the first six months, we found that every single person who ended up in residential care did so because of carer breakdown, as the carer was not getting support. That is why this support is such an important part of what we should deliver.

Care services must be personalised: they have to be about choice, as well as need. If we are to make such personalisation a reality, we need further integration of our health and social care services. The duty on local authorities under clause 3 to promote the integration of care and support with health services does not go far enough in that respect. Indeed, a recent survey of health and wellbeing boards found that most local authorities have not identified integrated care as a priority. Clearly, we must do more to drive forward the development of integrated care. Without such an approach, we will return to the days that I remember well, when there were fruitless arguments about whether a service such as bathing was required on social or health grounds.

The integration of health and social care services is crucial to ensure that we provide carers with sufficient support. As a patron of Sheffield Young Carers, I feel privileged to have seen at first hand the selfless role that even very young carers undertake in our communities, and they should be valued.

As has been said by the right hon. Member for Banbury (Sir Tony Baldry) and my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley), the Bill places a duty on local authorities to have regard to the importance of identifying carers, but that is not good enough. Some 80% of carers have contact with a health care professional, and it makes absolutely no sense to leave the NHS out of the duty to identify carers.

That matter is especially worrying as regards young carers, who quite often need a lot of support. The Children and Families Bill will strengthen young carers’ rights by providing that when a child is identified as a young carer, the needs of everyone in the family should be considered. That of course presupposes that young carers will be identified in the first place. If we do not place a corresponding duty to identify carers on health authorities, we risk young carers falling through the gaps, and we cannot continue to leave them without support.

My remarks would be somewhat lacking if I did not refer to the funding or, perhaps more accurately, the lack of funding that underpins our social care system. The proposals outlined in the Bill primarily concern redistributing the costs of care, and they will not bring any extra funding into the system.

[Bill Esterson]

My hon. Friend is making an absolutely crucial point. Does she agree that unless investment in social care is made now, it will end up costing far more in the cost of the NHS, as well as that of social care? It is the lack of ambition, as well as the lack of finance, that is really disappointing in what the Government are introducing in the Bill.

[Meg Munn]

I agree. The demand for services is now greater than ever. Our social care system is being cut to the point of breaking. As has already been discussed, should the proposed health funding reallocation for clinical commissioning groups be implemented, the situation will only get worse. South Yorkshire is due to lose £150 million by April 2014. That is staggering given that, under the proposals, other parts of the UK that already have better health outcomes and longer life expectancy will receive an increase in funding. This Bill seeks only to ration scarce resources; without a completely different approach, we will fail to meet proven need.

As a former social worker, I welcome clauses 42 to 47, which introduce a duty on local authorities to make inquiries when they suspect that an adult is at risk of or is experiencing abuse or neglect. Yet no duty is placed on care providers to report suspected abuse or neglect to the local authority. The Government contend that the present guidance is sufficient, but I disagree. In the light of Winterbourne View and Mid Staffordshire, we cannot afford to have such gaps in protection.

A recent Care Quality Commission report stated that our accident and emergency departments see 500,000 elderly victims of neglect. I am therefore far from convinced that enough has been done to address the issue. Where victims of abuse are imprisoned in their own homes by a perpetrator who denies access to adult safeguarding staff, there are no current legal means by which access can be achieved. An amendment was tabled by the noble Baroness Greengross in the other place to enable a social worker to apply for a court order to access an adult at risk. Between now and the Committee stage, will the Government reflect on that matter and introduce something to address that gap?

The Bill is an opportunity for much-needed reform of our health and social care system, but in its current form it does not make the changes that we need. For that reason, I fully support my right hon. Friend the Leader of the Opposition’s reasoned amendment.

I apologise, Madam Deputy Speaker, that I will have to leave very shortly to read in a carol service.

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[Bill Esterson (Sefton Central) (Lab)]

The hon. Member for South Swindon (Mr Buckland) speaks with great passion and knowledge in support of children with autism. He made an incredibly important point when he asked who cares for vulnerable children once the parents have gone. Indeed, who cares for all those we care for once we are gone? That is a powerful and important point.

I agree with the hon. Gentleman that this debate is about the principle of the Bill. He talked about the need for action, which is why the Bill is welcome. We have an opportunity to improve services for many people, but Labour Members feel that the Bill should be more ambitious, which is why the reasoned amendment is so important, and it is what the reasoned amendment is saying. I also agree with him about the need to integrate what happens under the Children and Families Bill with what happens under this Bill. The crossover he mentioned between children’s service and adult services as children grow up is important. The Children and Families Bill and this Bill create significant new responsibilities for the NHS and local government, and the big question for the Government is about where the resources will come from to deliver them. I was a local councillor for more than 15 years under both previous Governments and it was a familiar story for local councils to be given new responsibilities without necessarily always being given the resources to deliver them. That is an important point about this crucial Bill.

The hon. Member for Bradford East (Mr Ward) mentioned the need for free social care at the end of life. That was an important point, but at what stage should social care be free? What do we mean by end of life? What criteria should we set? How much earlier than the end of a life should that care come? How do we fund free social care and how do we fund social care at all? That is one of the big concerns and that is why the reasoned amendment mentions our concerns about where the cap has been set.

My right hon. Friend the Member for Stirling (Mrs McGuire) mentioned the concern that the needs of disabled people may have been overlooked. The London School of Economics cites the fact that 97,000 fewer disabled people have been in receipt of social care since 2008—the figure for older people is 250,000. The LSE cites £2.8 billion as the figure required for councils to set eligibility at moderate, in the context of an overall budget spend for health and social care of £120 billion. The fact that it would take £2.8 billion to set the criteria at moderate speaks volumes about what could be done if we got this right.

My hon. Friend the Member for Lewisham East (Heidi Alexander) mentioned her family and I am going to talk about my family now. My dad cares for my mum. Let me describe my mum’s experience this year, because it is the experience of many older people and their families. In the early part of the year, she was being cared for by my dad and she gradually declined until she was rushed into hospital. I think it happened because no health professionals or social care professionals were keeping a close enough eye on her. She ended up in hospital where, happily, she received very good care. Her wish was met and she was able to go home, and the health service provided a hospital bed that she could use there.

Once she got home, the lack of service in the community became a problem again. There was not the rehab, the physio or the support to enable her to return to some kind of active life. Now, many months later, it is too late—that will not happen. My mum rarely gets out of bed any more. For many people, such an experience is all too familiar. It happens because of how social care and health have been allowed to operate over the years, with no proper integration and without people in the two services talking to each other. My parents receive a care package now, with carers coming in. My mum’s social care needs are met but the lack of proper support has meant that things are not as they should be. I do not think that my mum’s case is the worst, by any means, but it is indicative of where things are missing.

The Government have made a proposal and they have talked a lot about integration between health and social care. I remember looking at integrated health and social care teams many years ago as a local councillor and there was success then. There has been more success recently and there are good examples of health and social care professionals working together, but cuts to social care, in particular, mean that the money simply is not there any more.

I cited the figures earlier. In Sefton, we have seen a 40% cut in local government funding. The care managers are simply not there any more. They are not there, as Members have said, to help people in the community stay in their own homes; they are not there to help people who have gone into hospital go home again. Those situations are combining to leave a crisis in A and E—we will have that debate on Wednesday, but that is what has been allowed to develop. I am afraid that the reorganisation of the NHS during the first years of this Government, with clinical commissioning groups being created, meant that administrators and managers in the health service were concentrating on setting up new structures and not on ensuring that health services were delivered properly. These things do not happen by accident. When £3 billion is spent on reorganisation and not on patient care, that is the sort of situation we end up with. The question is what should we do. We have a proposal for a £72,000 cap on care, but my hon. Friend the Member for Lewisham East described the sum that her nan had to pay, which was £130,000. For many people, the £72,000 cap will be no help, and other Members have given the details that show that.

There are a number of ways of funding social care, one of which is to have a cap. However, let me return to the comments made by the hon. Member for Bradford East. If we are considering free social care at the end of life, or, as I said, a lot earlier than that, perhaps the time has come for Members to debate free social care as part of a health and social care service that is free at the point of delivery and at the point of need, like that which my right hon. Friend the Member for Leigh (Andy Burnham) has mentioned before. Perhaps the time has come to say that that is the ambition that we, as Members of Parliament, should have.

Tinkering at the edges will not solve the problem. The debate we must have—and it must be a cross-party debate—is about how to pay for such a service. As people get older, that is what will be needed. Sooner or later, we as legislators will have to deliver exactly that service. Anything short of that will not solve the problems; things will only get worse. I put it to Members from all parties that that is what is needed. We have made a start with the Bill and tonight’s debate, but we will need to move down the route of free health and social care and of whole-person care. That is the only way we can solve the challenge of an ageing population.

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[Dr Wollaston]

Absolutely. I welcome the fact that Torbay will be part of one of the integrated care pilots, and particularly that focus on mental health, as my hon. Friend says.

Services in Torbay have been transformed through the use of care co-ordinators, so that only one phone call is necessary. There has been transformational work in sharing information and records and in rapid response to a crisis and putting prevention in place. The challenge that Torbay now faces is financial. Unfortunately, the elastic can stretch only so far before it snaps. Torbay’s funding is set to fall from £71.2 million this financial year to £63.6 million in 2014-15. Those cuts are in addition to the demographic challenges, the challenging situation in relation to children’s services, and the fact that we know that across the country 2015 is set to be a crunch year for NHS funding.

I welcome the £3.8 billion transfer for better care. We heard in the draft Bill Committee and in the Select Committee how such joint funding arrangements are the best driver to integration. A formula for integration cannot be dictated. What works for central London or central Manchester will be very different from what works in south Devon and in rural areas, but the fund will force people to work better together in a way that fits their area. That is very welcome.

[Bill Esterson]

Would the hon. Lady advocate a single service, and has she any thoughts on how that would operate? I am interested to hear her views.

[Dr Wollaston]

Indeed. It operates very well already in Torbay, but it cannot be dictated centrally. We need to get the hurdles out of the way, allow people to work together locally and facilitate that. We heard on the draft Bill Committee that joint funding streams were the best way to move that forward.

Unfortunately, in Torbay in the crunch year 2015 we will see the funding drop below 90% of projected expenditure. At that point, rather than driving further integration, it will cause systems to start to fall apart because people need to protect their own silos. That is a real danger. As the Bill proceeds to Committee, I hope we look very carefully at the effect of the funding gap and make sure that we are not setting a system up to fail. One of the problems with the Bill is that it sets up many new statutory responsibilities. Councils will have to fund care accounts, which will undoubtedly be complex, bureaucratic and subject to challenge. Councils will have responsibilities for carers’ assessments. There will be increasing numbers of eligible people as the thresholds and caps change. We will see safeguarding adults boards, more rights to information and advocacy, and for many, deferred payments, if they have not already been making those.

Once we create these additional statutory responsibilities, there will be less money to go around for the very things that are at heart of the well-being and prevention principle. That is what concerns me. Would it not be a tragedy if we set up carers’ assessments but there was no funding left for services to respond to needs? Voluntary organisations in my community can function incredibly efficiently on very little money. They do not need to be fully funded, but they need some funding. If that money dries up, I worry about how we will move forward with a genuine well-being and prevention principle.

I want the Bill to succeed. In the remaining minutes I shall touch on those aspects that I think are, sadly, still missing, which were recommended by the draft Bill Committee. One is how we calculate care costs according to their actual cost, not the cost to the council. For a person living in their own accommodation, it sometimes costs a great deal more to access support than it would cost a council to provide it. We need to look at that again.

There is a small but important area relating to powers of entry in exceptional circumstances for those who are subject to abuse in their own home. It would be wrong for us to ignore that possibility. Although the overwhelming majority of carers of course do a wonderful job in challenging circumstances, there are occasions, sadly, when people can be at risk from those who love them. Very often that is as a result of the intensely challenging circumstances that carers face. We need to reserve a power of entry in exceptional circumstances where there are very serious concerns about individuals who may be vulnerable and unable to communicate easily.

Another issue is free social care at the end of life. We know that 73% of people would like to be able to die at home. In my experience working as a GP in rural areas, where that broke down for most people was as a result of a lack of social care, and the challenge of caring for somebody right at the end of their life, when they may, for example, be doubly incontinent. Until people are in that situation, they may not understand how incredibly demanding it is to have to be with someone 24 hours a day, trying to stay awake and provide the intensive support they need. Allowing everybody to access free social care in those terrible final days would be a very important step forward.

Finally, the duty of candour we have introduced for foundation trusts is welcome, but I think that it should be extended to social care.