Adult Social Care

John Pugh Excerpts

Thursday 8th March 2012 Commons Chamber

[Chris Skidmore (Kingswood) (Con)]

I start, like others, by congratulating my hon. Friend the Member for Truro and Falmouth (Sarah Newton) on securing this debate, bringing out the urgent need to tackle the issue of the future of social care, and ensuring that we face up to the responsibilities of looking after the elderly of today and tomorrow. We have heard humble messages from the Minister and the shadow Secretary of State about their willingness to work together. The spirit of cross-party agreement is encouraging.

As the right hon. Member for Leigh (Andy Burnham) said, these issues go right back to Beveridge in 1942, when the average life expectancy was 69 and social care was not an issue to be considered within the realms of the state. The right hon. Gentleman mentioned the “sixth giant”, and he is right that we need to revisit Beveridge for the 21st century and perhaps to look again at what Beveridge considered to be most important—the contributory principle. The contributory principle for social care will be all-important when we look at how to deliver social care reform.

As we know, reform is desperately needed. The arguments over the funding of our social care system are well practised, but let us rehearse some of the statistics, which are becoming more familiar with every debate we hold. The number of those aged over 85 will double by 2030, and during the course of this Parliament alone, more than 1.4 million people will turn 65—one in 10 of whom will have a long-term care need that will cost more than £100,000. We should also make it clear that this problem is not unique to the UK. Germany and Japan have recently taken radical action to reform their systems. However, the UK has a specific problem that makes finding a solution to the ever-growing problem of social care particularly difficult: most people simply do not understand the system. They do not understand that social care and the associated costs of getting older are not free, as the Minister stated, and nor have they ever been.

That point was made in the Dilnot report, and it cannot be stressed enough. I wish to highlight two of Dilnot’s recommendations. First, he states:

“To encourage people to plan ahead for their later life we recommend that the Government invests in an awareness campaign.”

Secondly:

“The Government should develop a major new information and advice strategy to help when care needs arise.”

The acknowledgement that more needs to be done to inform the public is welcome. In reality, until one is forced to interact with the system, there is a serious lack of information compounded by an assessment procedure that is often unrealistically complicated. For many elderly people, part of the shock that comes from being forced to sell their house to pay for care is the unexpected nature of that situation. In some respects, we are facing a problem of responsibility and of planning ahead. Although people are now accustomed to the idea of preparing for their old age with regard to pension provision, there remains an aversion to preparing for the eventuality of future frailty and ill health. Few of us wish to admit that we will grow old and frail and need help and support, before it is too late.

The solution to the funding crisis brought on by an ageing population will inevitably require individuals to pay more, and from an earlier age. Whatever we do to change the current system, it is absolutely essential that a much clearer picture of the relationship between contribution and entitlement—precisely as Beveridge set out—is at the heart of that.

Reform requires realism. Even if the Dilnot proposals are implemented in their entirety, they will not provide the full solution. Whatever cap on care costs is set, domiciliary care costs and annual living costs are not taken into account. A new system that is able to lever more private funding into the system will ensure that we can provide the best deal for the elderly, but it will require an understanding that we need to grow an insurance market to maturity that is then sustainable in the longer term. That will not happen overnight. This is a process that will take between 10 and 20 years.

The current Government have taken the first important steps to reforming the system. As hundreds of billions of pounds are being talked about in respect of the current euro crisis, it is easy to forget that the Government’s decision to give an additional £2 billion a year to social care in the 2010 comprehensive spending review was the greatest ever increase in social care funding, and will lead to a vast increase in resources. We are investing more than ever before in carers and respite care, recognising the huge contribution that they make to our country, selfless in their service to their partners, parents, families and relatives.

In addition, a greater focus on personalisation and individual budgets, combined with an increased use of resources such as tele-health, will put more control over care into the hands of individuals, ultimately allowing new providers to provide more tailored services, thereby driving down costs at the same time as improving quality. Placing the person at the heart of their care has the potential to transform social care services, which for too long have been led by inefficient monopolies.

The Prime Minister’s recent call for greater integration of health and social care is equally welcome. I am a member of the Health Committee, and we called for that in our recent report. If we fail to address the social care problem, the NHS will end up picking up the tab. Every unplanned hospital bed admission for the elderly is a mark of the failure of social care to prevent that from happening in the first place. We know that if we can reduce demand for hospital beds by just 10%, that could free up £1 billion that could then be redirected into community-based care services. We must recognise that hospital is not always the best place for care to take place and redirect resources to reflect that.

In preparing for the Committee’s social care report, we visited Torbay, and I was particularly struck by the experience of integrated care there. Torbay’s primary care trust and adult social services have been combined into Torbay Care Trust, following which five integrated health and social care teams were established. They seek to be proactive in managing patients and to work in partnership with GPs. In Torbay, a team was also introduced that was specifically charged with monitoring patients in hospital and discharging patients where there is pressure on beds—again, the team is working closely with clinical professionals. That has helped to cut out unnecessary lengthy hospital stays and delayed transfers of care. As a result, Torbay now has the lowest use of hospital bed days in the south-west region, as well as the best performance on the length of stay. The chief executive of the NHS, Sir David Nicholson, has said:

“I have seen the future and the future is Torbay”.

He did so because it is the elderly who will benefit most from integrated care. Complex long-term conditions complicated by age can be properly managed only with a collaborative approach.

[John Pugh (Southport) (LD)]

Torbay has, for some time, been a model of good practice and the fact that this good practice has not spread much further than the confines of Torbay is something of an enigma. Would the hon. Gentleman care to comment on that?

[Chris Skidmore]

Torbay was one of the sites for the pilots set up in alliance with Kaiser Permanente, which came over in 2003. Interestingly, it is instructive that one of the problems the NHS faces as an institution is that, although it creates fantastic pilots and the NHS innovation centre is working hard on rolling them out across a wider area, that process encounters significant delays. Good models of care should be spread out far more widely and far faster.

What most elderly people want from their health care system is simplicity. They do not want to be moved around constantly from pillar to post, waiting for specialists to see them; they do not want to see a host of different medical professionals, each of whom is unfamiliar with their case; and they do not want to languish in hospital beds when they could be more comfortable at home. The most important change must be a cultural one. There may have been a tendency in the past for health care to be reactive, responding to medical crises as they arise, but the future must be very different. To paraphrase John F. Kennedy, we do these things not because they are easy but because they are hard. We know that we face a challenge that will define the landscape of health and care for the decades to come—it is a challenge that all in this House cannot be willing to postpone.

--- Later in debate ---

[John Pugh (Southport) (LD)]

I congratulate the hon. Member for Truro and Falmouth (Sarah Newton) on starting this debate. I shall be relatively brief because I sense that this is just the beginning of a debate that we will have throughout this Parliament and probably beyond. The whole issue represents a huge financial challenge to Government and a demographic challenge to the country and it will not go away. I suspect that many of the bad stories we have heard about poor care will, if anything, multiply over the years to come as finances are stretched further.

There are obvious things that the Government can do and that they mean to do, such as developing the public health agenda as well as ensuring that healthy old age is a possibility and that more healthy ageing takes place. I think that the Government are serious in their intent. Obviously, as has been suggested by many hon. Members, they can also join up health and social care a little better than they are at the moment. We want care to be integrated more and costs—and people—to be shunted around rather less. I cannot always follow how the Health and Social Care Bill advances that aim, because, after all, we will have a new set of commissioners with limited experience in interacting with local authorities and we will necessarily lose some established commissioners and some established arrangements will collapse. That will create a difficulty, albeit a temporary one; we will have it for a little while yet.

As I tried to point out in my intervention on the hon. Member for Kingswood (Chris Skidmore), there is no obvious mechanism for spreading good practice. How many times have we said that Torbay is an exemplar but then pointed to very few places that have followed that example? There is a real issue with how we spread good practice. I accept that the Bill gives the commissioners the right mandate to integrate social care and health care, but I question whether they will have the right capacity. I listened to the Minister, who put faith in the health and wellbeing boards being able to join things together or to force people to act together who might otherwise not do so, but the big issue staring us all in the face is the cost of care, followed by the quality of care.

In some respects, quality of care is the easier fix. We could have effective regulation and the Care Quality Commission could do a lot better and be less overloaded, but I suspect that it will not be short of work given some of the things it is asked to do by the Bill. Let me take this opportunity to pay tribute to the Minister, who has done a great deal in his time in Parliament to emphasise the need to treat people in care properly. In particular, he has campaigned for people to be respected in old age and for the elders—I think that is the word he used; it is a very nice word—to be defended. In terms of improving the quality of care, he is alive to the need to ensure there is portability so that, when someone goes from one place to another, the care does not decline but remains at a constant and expected standard. There is also a need, which we all recognise—again, the Minister has this well within his remit—to provide a proper legal framework in which people can understand their entitlements and secure them.

Then we come to funding, which is the big issue. I am relatively familiar with this issue because I have experience of being in a local authority with a large demographic bulge towards the top end that has had some difficulty with past Governments over this. Local authorities usually argue that they can provide only what they can—that provision is subject to whatever resources they have—and they try to ration what they deliver according to what they have in the kitty. They cannot always do what people feel they should, so they prefer to do what they can, but Governments are often quite explicit in telling them that regardless of what they have they need to deliver on the entitlements that people expect. I am very familiar with this because when I was the leader of a local authority, when Lord Boateng was in Richmond house, I was once summoned to be roundly told off because my local authority had just lost a celebrated case against Help the Aged. In that case, this problem was precisely the issue: we knew what we could justifiably afford but it was far less than what we needed to deliver what people expected. The previous Labour Government laid down in no uncertain terms that regardless of what we had got, we had to provide the service that was expected.

That tension between local authorities and central Government has always been there and is not going to go away. I accept the point that the Minister made—if we have an outcomes framework and greater transparency, it will be more obvious to people than it is now exactly what is going on and what quality of service is being delivered by individual local authorities—but at the heart of this issue is the local authority settlement. One can say many things about the local authority settlement, but one thing it is not is transparent. It is something that people argue over time and again. My borough has always found its resources severely stretched because we have a high percentage of elderly people and we have never felt that any Government have given us a fair deal in that respect. So the debate goes on, and in some ways it is going to become more critical because at some of the local authorities that have had to make quite severe cuts, including mine, the costs of adult care are going to swamp their budget completely. They are going to have to give up delivering other services in order to fund adult care. That is despite Government top-ups, which are welcome.

There is also the phenomenon of some sheltered housing providers, which have been affected by the refocusing of Supporting People budgets, giving up providing services that people expect as part and parcel of sheltered housing. There are also the local authorities being driven to be more efficient and switching providers but in the process completely hacking off the people who want continuous provision and do not see the case for doing that.

We need a solution to what is a huge financial problem. The solution needs to be affordable, sustainable, fair and, obviously, cross-party. I think we all regret what happened at the last general election, when the cross-party consensus broke down for political reasons. That is where Dilnot comes in. The Dilnot solution seems to be viable: it allows for individual responsibility but also caps costs. That deals with the two big problems I have always come across with this issue. From time to time, I get constituents saying to me how unfairly they are being treated when other people, who have blown all their money before retirement on cruises or whatever, seem to get provision—the free-rider problem. Dilnot recognised that and endeavoured to deal with it. The report also deals with the other, probably larger, problem that people fear that the cost of care will run away with their entire income and they will end up destitute. I personally know people who genuinely hope to die before the money runs out, and that is an unfortunate end to one’s time on this earth.

If Dilnot or something like it is to work, insurance companies will have to develop the right products, as other hon. Members have emphasised. If one has discussions with insurance companies, one will find that they are of varied minds and that some of the products that Dilnot expects that they will offer are not the ones that they would ideally wish to provide or that they think they should provide, so there will be quite a debate there.

Another problem with Dilnot, which I think we can all see, is that in so far as it caps the overall costs, it presumably represents some sort of bail-out for the fabulously wealthy. People might see fairness in that, but they do not see that it should necessarily be the Government’s first priority in the current circumstances.

Then, lingering behind everything, the Treasury is simply worrying what it is all going to cost at the end of the day and wants some financial certainty, for quite good reasons. It is difficult for anyone to provide that, so all this is going to provide a rich menu for a future debate, and we are grateful to the hon. Member for Truro and Falmouth for initiating it.

--- Later in debate ---

[Laura Sandys (South Thanet) (Con)]

It is a great pleasure to follow my hon. Friend the Member for Congleton (Fiona Bruce).

My hon. Friend the Member for Truro and Falmouth (Sarah Newton) has been very important in instigating this debate about future policy on long-term care and ensuring that other such discussions are going on around the House. If it is the case that we come into Parliament because of certain issues, then reviewing and reforming long-term care would be one of the reasons that I find myself in this place. I am not sure that anything is more important for Government, Opposition and this House to resolve, and I give a huge amount of support to the cross-party debate that is going on.

However, we must realise that, unlike in other parts of NHS reform, there is not one person in the country who does not have a view on this subject and does not understand what long-term care means to them. They will look at it, and present it, through the prism of their parents or elderly relatives, and in their heart they will be thinking, “That is what my future will look like.” The shadow Secretary of State said that this debate needs to go beyond this House and to engage the public. I welcome that comment. As my hon. Friend the Member for Kingswood (Chris Skidmore) said, this is about a contract. We are entering into a discussion that will end up as a settlement between the country—the hon. Member for Luton North (Kelvin Hopkins) thinks that a little more funding might be needed—and the public, whose responsibility meets that of the state halfway, or perhaps more.

The public know that the system is broken. Its funding has been squeezed and there has been very little reform or innovation—other than in Torbay, which as we all know is the place to move to as one gets older. When people talk about care packages, it sometimes seems as though the patient is the package and it is hard to understand where the care kicks in. I believe that Dilnot has produced something useful and important, but perhaps it is a little pre-emptive. Until we can be explicit about what this care looks like and feels like, and what people’s experiences of it will be, it is difficult to talk to people about how we expect them to pay for it. I do not believe that the public are prepared to fund the current system, so we must first look at changing it.

I have been a carer myself. I cared for my father when he had a stroke when I was 17, and I saw my mother age by 15 years over a five-year period of caring for him. I have seen it first hand, and I understand some of the key issues that people face. I have also worked professionally in the areas of incontinence—not a charming subject, but one that is exceptionally important in this respect— epilepsy and motor neurone disease, so I have seen this from the end user’s perspective.

What could the new system look like? I believe that the system should be re-engineered around the principle of early intervention. The deceleration of the impact of ageing could be achieved by co-ordinating non-clinical services to keep people fitter and out of the care system. The things that social care delivers must change; it needs a total refit. I believe that that could be guided by four key principles. The first is about keeping the new old young. The second is about keeping people out of care, rather than talking about funding them in care. The third is about caring for carers; we need a whole stream of wraparound policy to support those people who are making that ultimate sacrifice—well, not the ultimate sacrifice, but a significant one. The fourth is about the need for top-quality care for those who do end up in residential care.

I hope that we will be able to keep the new old young. Members will be thrilled to hear that most of us have already started the process of ageing. Everything that we do now will have an impact on us in our 60s and 70s, and beyond. Why are we not introducing, through our GPs, human MOTs to look at any challenges to mobility? Owing to distributing far too many leaflets, both my arches have collapsed and I now have insoles in my shoes. That could have become a major problem as I got older. Why are we not looking at people in their 40s and 50s and taking steps to intervene and decelerate the ageing process?

[John Pugh]

Does the hon. Lady not recognise that delivering leaflets is one of the finest ways of keeping the old young?

[Laura Sandys]

I totally agree.

The acceleration of ageing starts to happen before we get old, and we must look at the public health opportunities to engage with and pre-empt some of the issues that we might face as we get older. That leads me on to keeping people out of care. The three biggest reasons for people going into care are dementia, incontinence and accidents, such as falls. Are we looking at those three factors in enough detail? This morning, on the radio, we heard about a drug that could help people to stay more able despite their dementia, and I hope that it will become more widely available.

I said earlier that I had worked in the area of incontinence. It is one of the most easily managed conditions, so why is it not properly supported? Why are so many people referring their family members to residential care for that reason, when the condition can be addressed easily and extremely cheaply? We are not addressing the condition, and we need to look at it in a lot more detail to ensure that more people can keep their relatives at home. I also mentioned falls. Why do we wait until someone breaks their pelvis before going into their house to see whether they have a handrail, whether their lights are working or whether the ramp is in the right place? None of this is rocket science, folks. It is perfectly straightforward, and I do not understand why such interventions are not being made much earlier.

We have a system that is broken, but we are not doing the necessary pre-emptive work. Instead, the system rewards acute services. It finds installing handrails or wet-rooms less thrilling than ambulances and broken hips. That makes no financial sense, and no human sense. The public know where the system is going wrong, and they can see that earlier intervention would make a difference to their loved ones. Many people have spoken about carers today, and we need to do as much as possible for them. They are at the heart of keeping people out of the care sector.

If we re-engineer our care system, making prevention and pre-emption the gold standard, we must look at a re-engineered funding mechanism, too. I believe that there is a policy framework that is a little like the green deal: for those who support people out of care, there is a bonus and an incentive, rather than the current financial model that rewards hospitalisation and pays far too little for those in home support.

I welcome the comments of hon. Members about how little care workers in homes are paid. My word, if we look at the value we get from that particular care intervention in comparison with extreme nurses in hospitals, we should start to understand that we have a very unbalanced system.

In conclusion, if we have a vision for decent and dignified care, the public will enter into a contract with the Government. They might even do so more than the Government think; they might even pay more than we are currently asking them to contribute. However, they will do that only if they see a re-engineered system that places the foremost priority on delivering care—quality care—that they can trust, rely on and understand.