Adult Social Care

Baroness Laing of Elderslie Excerpts

Wednesday 8th March 2023 Commons Chamber

[Mr Betts]

The hon. Gentleman makes a good point, and he has been through some of those discussions on the Select Committee—I think the County Councils Network also made that point strongly to us—so he is absolutely right. I was not going to go too much into the long-term reforms of local government funding, but as a Committee we have said that there is a real challenge with the reforms of both council tax funding and business rates, and we have produced reports on that. There is not a clear linkage between how much money a council might get in from business or non-domestic rates and how much demand for social care is going up. Demand for social care is going up that much faster and the tax base needs to be adapted to recognise that, so his point is an important one.

To some extent, that demand is being met by tightening the rules on exemptions. More and more people who would have got social care in the past do not get it now. Age UK says it is 1.5 million—an estimate, but probably not an unreasonable one. There is also less prevention work going on, which means that people who have small needs to help them live in their homes do not get those needs addressed until they become serious needs. Then they end up in hospital, which is much more expensive and a much worse outcome for the people concerned. It results in more pressure on the NHS, more cost and a less good service.

On the other hand, there is the pay and conditions for care staff. People doing the same job in care get less money than people in the NHS. That is true of nurses, for example, where we can make direct comparisons. We know that up to half of care staff tend to leave within a year, and many are on zero-hours contracts. There have been repeated requests for a long-term workforce plan. There has rightly been a request for a long-term plan for the health workforce, but we need one for the social care workforce as well. I think that the Chancellor, the right hon. Member for South West Surrey (Jeremy Hunt), when he chaired the Health and Social Care Committee, argued that case very strongly, and quite rightly.

There is a question of pay: these are skilled people with a real commitment that should be recognised, and not at a minimum pay level. There should be a system with proper career progression and training, so that people can realise the benefits of their skills and commitments. There is evidence that the care market is broken, that many care providers have gone out of business or struggled over the years and that the level of fees in some areas probably does not reflect their costs.

Then, of course, we have the issue of people having to give up their homes to pay for their care costs. It is a complete lottery. If in the end someone finishes the last years of their life with dementia, much of the value of their home will go to pay for their care. If they finish their life by having a heart attack and dying, they do not pay anything towards their care. That is an unfair system and it needs to be addressed. The Dilnot reforms have been around for some time. They have been nearly started and then not started, and nearly started again and not started; I will refer in a couple of minutes to how we might take things forward.

How might we change things to improve them, then? This debate is not just about making complaints; it is about providing solutions. I accept that, and that is what the Select Committee is trying to do. One suggested solution is, “Well, just amalgamate it—let’s have one big service. Put it all in the NHS and it’ll all be all right.” I think most would say that the NHS has enough challenges at present without taking on another great challenge on top. What we do not need is another mass reorganisation affecting both health and social care, the cost of which would probably be a lot more than the cost of doing things any other way.

We should also remember that most people receiving care receive it not in a hospital or even in a care home, but in their own homes. The link that councils can make between their home service, providing adaptations and the like, and care, is key in that regard. The other thing I would say is that we cannot carry on relying on short-term fixes, with one-off grants here, one-off grants there, and a council tax system that is regressive and not fit for purpose, let alone for long-term funding of social care—or, as the hon. Member for Harrow East (Bob Blackman) said a few minutes ago, business rates, which bear little relation to demand for social care either.

I go back to the 2018 joint report with the Health and Social Care Committee, in which we said two things. We did a lot of work with the focus group on this question and spent a lot of time on weekends away in a hotel in Birmingham. What people said was, “If we knew the money was going to social care, we would happily pay more.” That is what happens in Germany and Japan, two countries that we looked at. We said, “Let’s have a social care premium.” Immediately, it might be said that that is not dissimilar to the Government’s proposed increase in national insurance rates. The difference was that, at the time, we said that we had to target any payments. There will be different ways of doing this, I accept, but there has to be a way of raising extra money for social care that neither comes from the current local government system, nor takes care out of local government.

We said that there should be a social care premium as a percentage of income, but that we would raise the bottom level so that the poorest people would not pay. We would increase the top level in the way that national insurance does not, so that people on the highest incomes would continue to pay, and we would include unearned income and higher-level private pensions, but we would also exclude the under-40s, as they do in Japan. We felt that people under 40 were probably getting the worst of the deal after the financial crash in terms of the impact on their finances. That is how we thought we could raise the funds, and it was agreed by the 22 members of the two Select Committees as a way forward.

What is sometimes missed, and what we also suggested, is that we have to deal with the issue of people’s homes being sold. I have to say to the Government that their arrangements to try to implement Dilnot are complicated and unfair. People may not pay until their assets reach a minimum level, but—and I have never heard a Minister address this point—the Government cap the amount that people pay in such a way that people with lower value houses pay a bigger percentage of their homes than people with the highest value houses.

Someone who has a home worth half a million pounds pays a much smaller percentage than someone who has a home worth £100,000. That is not fair, so our Select Committee said that a percentage should just be taken from everyone’s estate. Then, the people with the most would pay the most, and the measure would not be confined to people who need care. That removes the unfairness of people with dementia paying all or most of the value of their home while those who do not have dementia paying nothing. With a small amount of inheritance tax, or another way of assessing people’s estates, we could raise a lot of money and deal absolutely with the problem of people having to give up most of their home to pay for their care costs. That is certainly worth a look.

We need to find a long-term solution to the problem. It is not going to go away, is it? The number of elderly people will continue to grow; the number of people with learning disabilities will continue, quite rightly, to require more from our services. Councils said that the funding gap was £7 billion last year, but they have also said—the Health and Social Care Committee has addressed this, and other important think-tanks have confirmed it—that if we are to deal with the combination of problems, including the immediate funding gap, the need to address eligibility criteria and bring more people back into the social care system, the challenge to local government finance, and the need for a long-term workforce plan, the gap is probably about £14 billion. That is a big sum of money, and we cannot find it in the existing local government finance system, which cannot cope as it is.

If we carry on as we are, and demand keeps increasing with no improvements to eligibility or workforce pay, there will be a consistent further increase in the pressures on other local government services. There will be bigger cuts to libraries, buses, planning, street cleaning and so on. The public, in the end, will simply not stand for that. I say to the Minister: please, let us just have a bit of long-term thinking and recognise that this is a serious problem that will not go away. Local government funding, as it exists at present, cannot take the strain any longer. We need an alternative source of revenue, we need to keep social care linked in to the rest of local government services, and we need, of course, to develop better contacts with the health service. Money to deal with the problem of people sat in hospital beds when they need to be in social care is welcome, but all that is short-term thinking.

I say to the Minister—and, to be non-partisan, to the Labour Front Benchers—where is our plan for long-term care? Where is our recognition of the funding needs? How will we bring about change? Could we, as the Joint Committee said, just possibly get a bit of cross-party thinking on this for the future? Whatever solution we come up with, we need one that will work for the long term, not just for half a Parliament or for one Parliament.

[Madam Deputy Speaker (Dame Eleanor Laing)]

I call Damian Green.

--- Later in debate ---

[Barbara Keeley (Worsley and Eccles South) (Lab)]

I was not going to speak, but I have been drawn by some of the speeches that I have heard to add some comments, particularly on autistic people and people with learning disabilities and their care. One of the worst aspects of the chronic underfunding of adult social care is that it has led to a reliance on inappropriate in-patient care for autistic people and people with learning disabilities, 2,000 of whom are in that situation. The Government seem chronically unable to get that number down; there have been all kinds of targets to reduce it, but it has not happened.

That care is often expensive and far from home. The hon. Member for North Shropshire (Helen Morgan) told us about people in a care home far from their homes, but when the care is in in-patient units, it is often unsuitable. We know from scandals at units such as the Edenfield Centre, most recently, and Winterbourne View—there have been 10 years of scandals in those in-patient units—that they are frequently found to use restraint and seclusion as a punishment.

There have been inquiries and reports into the level of social care funding, such as that chaired by my hon. Friend the Member for Sheffield South East (Mr Betts), who made an excellent speech. The Health and Social Care Committee, of which I was a member, also looked into the issue and made recommendations. The squeeze on local authority funding means that local authorities feel that they have to put the bill on to the NHS—it becomes easier for a local authority to let the NHS pick up the bill for an autistic person or a person with learning disabilities.

Those placements can cost hundreds of thousands of pounds a year—up to £1 million. In one case that we have spent a lot of time talking about in the House, the NHS was funding a placement that cost £1 million a year. Clearly that makes no sense, because the money could go into housing or care for that person, but there does not seem to be any way to passport the money from the NHS, which is shelling it out every year, to the local authorities that would need it if they were to house and provide care for those people.

However, we had a solution years ago. When people were moved from long-term mental health institutions into the community, a dowry went with them from the NHS to the local authority. When I was the vice-chair of social services as a councillor, if we picked up somebody who had been in a long-term mental health institution to move them to the local authority, they came with a dowry that might be as much as £1 million. If a local authority were to buy a property or pay for care for a number of years, that system would work.

I urge the Minister to look at the recommendations made by the Health and Social Care Committee when we looked at this, but also to take account of what the hon. Member for North Shropshire said about how we cannot leave this in an unsatisfactory and precarious situation. It is good that some solution was found in the case she mentioned, but too often people end up in in-patient care and then will be there for the rest of their lives. There are people in these institutions who have been there 10, 20, 25 or 30 years, and it is tragic, because once someone has spent that long in an institution, it is very difficult to find a way back to the community. I wanted to mention that because it has been raised in the debate.

I want to mention one other thing. The right hon. Member for Ashford (Damian Green) and the hon. Member for North Devon (Selaine Saxby) talked about support and recognition for carers, and they are right to do so. We should all think about how we support unpaid carers. However, I want to say that I think the thing that is missing is that we do not have a proper national carers strategy. The last national carers strategy we had in this country was under the last Labour Government, and it came out in 2008. That would solve the problem, which my hon. Friend the Member for Sheffield South East talked about, of there being no respite care breaks for carers. That national carers strategy had a commitment of £255 million specifically to support carers, including £150 million for respite care breaks. We now find that there is no money we can identify or point to that is specifically for respite care breaks. Given the squeeze on local authority funding, it just does not happen.

What this Government have had is a carers action plan, which is a weak document. The last one, which covered 2018 to 2020, had no funding commitments and was very short of ambition. I know that carers organisations very much campaign for us to go back to having a national carers strategy, which in the case of the Labour Government had the commitment of the Prime Minister and each of the Secretaries of State responsible for services used by carers. I think the key thing, as we have heard in this debate—I really stress this point—is that we have to go back to having some money that is kept separately for respite care breaks for carers, otherwise they will be pushed and pushed, and they will not get the support they need.

I just wanted to speak on those two points, Madam Deputy Speaker, and I join everyone else in saying what a pleasure it is to see you back in your place.

[Madam Deputy Speaker (Dame Eleanor Laing)]

Thank you. I call the shadow Minister.