Social Care

Lord O'Shaughnessy Excerpts

Thursday 7th December 2017 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Lord O'Shaughnessy) (Con)]

My Lords, with the permission of the House, I shall now repeat a Statement on social care made in another place by my honourable friend the Parliamentary Under-Secretary of State with responsibility for care and mental health. The Statement is as follows:

“This Oral Statement is the Government’s response to the recent Opposition Day debate on social care on Wednesday 25 October. Since that debate, the Government have announced further plans for the Green Paper on care and support for older people on 16 November. This Oral Statement reiterates the substance of that announcement while providing further detail to the House in some specific areas.

An ageing society means that we need to reach a longer-term sustainable settlement for social care. This is why the Government have committed to publishing a Green Paper by summer 2018, setting out our proposals for reform. An inter-ministerial group is overseeing this work. It builds on the additional £2 billion over the next three years that we have already provided to meet social care needs. In developing the Green Paper, it is right that we take the time needed to debate the many complex issues and listen to the perspectives of experts and care users, building consensus around reforms that can succeed. This is why we are starting a process of initial engagement over the coming months through which the Government will work with experts, stakeholders and users to shape the long-term reforms that will be proposed in the Green Paper.

The Government have asked a range of independent experts in this area to provide their views, including the leads of the two most recent reviews on social care, Andrew Dilnot and Kate Barker. We are also engaging closely with key stakeholders, along with people who use services and their carers. The Government will be hosting a number of round tables to hear a range of perspectives from those representing different constituencies, including carers, service recipients and providers, health services, financial services providers, local government and working age adults. Once the Green Paper is published, it will be subject to a full public consultation.

The Government also recognise that there is broad agreement across Parliament that reform of social care is a priority and look forward to working with parliamentarians to hear a range of views. We have already written to the chairs of the relevant all-party parliamentary groups to invite them to meet with us to discuss their priorities and perspectives for reform.

The Prime Minister has been clear that the consultation will include proposals to place a limit on the care costs that individuals face. To allow for a fuller engagement and development of the approach, with reforms to the care system and the way it is paid for considered in the round, we will not be taking forward the previous Government’s plans to implement a cap on care costs in 2020. Further details on the Government’s plans will be set out after we have consulted on the options.

The Green Paper will focus primarily on the reform of care for older people, but will consider elements of the adult care system that are common to all recipients of social care. We are committed to ensuring that people with disabilities and complex conditions are able to live healthy, independent lives and to participate fully in society.

Many of the issues and questions about the sustainability of the care system will be relevant to adults of all ages. To ensure that issues specific to working age adults with care needs alone are considered in their own right, the Government have committed to taking forward a parallel programme of work on working age social care which is being led jointly by the Department of Health and the Department for Communities and Local Government. This work will also be overseen by the inter-ministerial group to ensure close alignment with the Green Paper.

Carers are vital partners in the health and social care system. It would not make sense to pursue strategic issues related to carers in isolation from the wider work on the future of social care. They will therefore be a key part of this Green Paper. A sustainable settlement for social care will not be possible without focusing on how our society supports carers. I am committed to making sure that the issues raised with us through the call for evidence on carers in 2016 are central to any proposals for the wider social care system. Alongside this, we must continue to work to improve the experience of carers today. The Government remain fully committed to supporting carers to provide care as they would wish and to do so in a way that supports their own health and well-being, employment and life chances.

Ahead of the Green Paper’s publication, the Department of Health will also publish an action plan for carers in the new year, setting out priorities for a cross-government programme of work to support carers over the next two years. In the short and medium term, we are taking important steps to ensure that we have a stable adult social care sector. We are promoting quality care across the system and supporting the wider networks and services that keep people living independently for longer.

It is important to recognise that quality across the adult social care sector remains good overall. The October 2017 State of Care report found that 80% of adult social care settings had been rated as good or outstanding. However, the Care Quality Commission also underlined that there are substantial variations in the quality of care, depending on where people live. The Department of Health is working with the adult social care sector to implement “Quality Matters”—a shared commitment to take action to achieve high-quality, person-centred adult social care. Through our programme of sector-led improvement, we are supporting councils to make savings and improve services by promoting good practices, including new approaches.

Looking beyond social care provision, it is important to highlight the broader support and services that help people to live independently. This means that well-adapted, specialised housing is becoming increasingly important. The disabled facilities grant is a means-tested grant to help meet the cost of adapting a property for the needs of a person with a disability or support need. The autumn 2017 Budget provided an additional £42 million for the rest of the 2017-18 financial year, taking funding for this year to £473 million.

Getting social care right means a better system that everyone can have confidence in, where people understand their responsibilities, can prepare for the future, and know that the care they receive will be of a high standard and help them maintain their independence and well-being. The Government want to take the time to consult and build consensus on a long-term, sustainable settlement for the future, which includes looking at the quality of care being delivered, the funding of the system and how it will be paid for in the round”.

[Baroness Wheeler (Lab)]

I thank the Minister for reading out the Statement in response to the October Labour Opposition debate on the social care funding crisis.

We are told that the Statement builds on the extra £2 billion over the next three years provided by the Government to “meet social care needs”. However, for the record, the Minister will know that independent think tanks such as the Nuffield Trust and the King’s Fund, care providers across the social care sector, voluntary organisations such as Age UK, and organisations representing the staff who deliver the services have all shown clearly the inadequacy of this sum to meet existing and rising demand and to address the funding crisis. Government cuts to local authority budgets have meant cuts to adult social care funding since 2010, which are set to reach £6.3 billion by March 2018. That is the scale of the funding gap that needs to be addressed, and we know that social care did not get even a mention in the Budget. Can the Minister explain to the House why such a key issue was left out?

On the Green Paper and the Government’s preparations for yet another round of consultation, the Minister will accept that this stop/start Green Paper has been a very long time coming, particularly when viewed in the light of the agreed Care Act provisions that were first promised for full implementation in 2016. On 16 November, the Minister told the House that a group of independent experts, including Andrew Dilnot and Kate Barker, would support government engagement with stakeholders. Today’s Statement says that these two are among a range of experts who will “provide their views”. An inter-ministerial group has also been set up. What role will these key experts—who have widespread respect and authority among key stakeholders —play in overseeing the review and consultation? Will they be involved at the heart of the review or will they just feed their views to Ministers?

The Minister will know that it is particularly upsetting for those of us who were involved in the painstaking work on the Care Act to be lectured again about how complex the issues are and on the need to “build consensus around reforms”. That consensus was part of the Care Act and the Government chose not to go ahead with it. We know, too, that they consulted on their proposed care “floor” during the general election; it was roundly rejected by the electorate, causing huge despair and consternation among the millions of disabled people and their carers struggling to cope. Meanwhile, many people are still faced with the catastrophic and rising costs of paying for care.

I mention carers specifically. The Minister is right to acknowledge that they are vital partners in the health and social care system, but the reality is that they have now been waiting nearly two years for the national carers strategy to be updated, refreshed or called to action, with promised deadlines being set back time after time. Last summer, carers were finally told that the strategy would be morphed into the end-of-the-year Green Paper. It was not a satisfactory situation, but carers organisations put huge effort and time into consulting with carers across the country to meet the deadline—only to then receive the announcement of the delay of the Green Paper to summer 2018.

Katy Styles, a carer and campaigner for the Motor Neurone Disease Association, contributed to that consultation and hoped that her voice would be heard. She said:

“Not publishing the National Carers Strategy has made me extremely angry. It sends a message that carers’ lives are unimportant. It sends a message that Government thinks we can carry on as we are. It sends a message that my own time is of little worth”.


We now have the promise of an action plan in the new year. Does the Minister acknowledge that he now has to be straight and play fair with carers and provide them with a date for the action plan? Can he be more specific about the scope and funding that will be allocated to the action plan?

Finally, Age UK estimates that there are 1.2 million people currently living with unmet care needs and that almost a quarter of all adult social care services receive the poorest safety rating from the Care Quality Commission. Can the Minister tell the House how the Statement will help people going without essential daily care, such as help with washing, dressing and toileting, to receive a better quality of care?

[Lord O'Shaughnessy]

I thank the noble Baroness for her response and her questions; I will deal with them in order.

First, she asked about funding. She is quite right to point out the £2 billion of extra funding that was announced in the March Budget; of course, we have had two Budgets this year, so extra funding was included in a Budget this year. I should also point out that that was the latest tranche of additional funding, which totals over £9 billion over three years, taking into account the additional funding announced in recent financial Statements. The precise purpose of the funding is to address the fact that we have a growing and ageing population. The number of people requiring care packages is rising, and often the complexity of those packages is becoming more acute—hence the need for more funding, as we all recognise.

Experts will be fully engaged in the Green Paper, providing advice to Ministers and supporting engagement. There is no point in having such an august group and not drawing on their expertise. I do not think that there is any contradiction in the way that I have described their role. We would not want to involve those people—and they would not want to be involved—if they were not going to be listened to.

On carers, I acknowledge the delay in the carers strategy and I understand that that must be frustrating for those who have invested so much time in it. I have two things to say in response. First, it is right that the position of carers is considered in the round, with care costs. Secondly, that is why the action plan is important: it provides a staging post between now and the intention to introduce fully fledged policy proposals in due course. I am afraid that I do not have a specific date or a funding package for that, but I will write to the noble Baroness with as much detail as I can find and place a copy in the Library.

[Baroness Jolly (LD)]

My Lords, I too thank the Minister for repeating the Statement. I declare my interest as chairman of a learning disability charity, providing services to around 2,000 adults in England.

On the long-awaited Green Paper, I welcome the Government involving independent respected experts in the field, including Andrew Dilnot, Kate Barker and Caroline Abrahams. However, we are sorry that the Green Paper will not have any element of care for working-age adults when published.

I want to raise a few issues that were mentioned by the Minister in the other place in her answers to MPs. She called for all party groups to be involved and said that there could be no change without consensus. That is exactly what I wanted to hear and it makes sense. The Minister knows our views on this.

On carers, in a debate earlier this week the noble Baroness, Lady Pitkeathley, talked about the worth of carers being equivalent to the NHS budget. I also praise carers and I am delighted that they will be involved in this review, but I am somewhat disappointed, along with the noble Baroness, Lady Wheeler. They went through quite a lot of consultation for the carers strategy and there is a certain amount of irritation that they might have to revisit all this work. If they have caring responsibilities, it is not always easy for them to get to a central place. I hope some mechanism can be found to ensure that that is captured, but also to see whether anything should be changed.

The Minister also agreed that health and social care cannot be considered independent of each other—another area of agreement. Will the Government consider introducing a statutory, independent budget monitoring agency for health and care similar to the Office for Budget Responsibility? This would report every three years on how much money the system needs to deliver safe and sustainable treatment of care. It could even be the first stage in the integration of health and care.

With the delay of the Green Paper, it is unthinkable that the Government are now leaving the social care sector in this state of uncertainty. They have completely failed to address the critical crisis in social care and now there are more than a million vulnerable older people without the support they need. With a funding gap, as we heard just now, of at least £2 billion by 2020, I wonder how much worse things will have to get before the Government will act. To put that in a more balanced way, does the Minister have any sense, whatever the outcomes may be from the Green Paper, of when we might want to see some of those becoming reality? Local authorities will also tell you that they are desperate for a solution. I echo what I said before: how long does the Minister reckon we will have to wait to see something change?

[Lord O'Shaughnessy]

Again, I thank the noble Baroness for those questions. I will try to deal with them in order. As I set out in the repeat of the Statement, there will be a parallel programme for working age adults. It is important to note that that feeds into the same inter-ministerial group. I emphasise that in terms of its profile in the overall work programme. It is of course separate from social care for older people, but it is a parallel programme.

The noble Baroness is quite right about the need to build consensus. We all know how much we need sustainable reform in this sector. Governments of all hues have tried it. We really do need to get there now. I cannot give her timings at this point of course, but it is becoming urgent as our population changes.

I completely agree with the noble Baroness on carers. I pay tribute to those carers of all ages, including young ones, who take on extraordinary responsibilities and dedicate their lives to caring for others. It is an amazing thing to do. I recognise her frustrations at the delay. I hope contributing to the Green Paper should not involve much additional work, although inevitably there will need to be some updating. As I said, I will write to noble Lords to give more details about the carers action plan, which is intended to be a bridge between now and the consequences of the Green Paper and the options it lays out.

Finally, we do not agree, as the noble Baroness knows, that there is a need for such a body on health and social care. She is of course right about integration. That is why metro mayors, such as the one in Manchester, are taking on these combined responsibilities. It is why integration is built into the better care fund. This is a direction we need to push down to provide proper, holistic, wraparound care for older people.

[Baroness Finlay of Llandaff (CB)]

My Lords, I declare my interests as vice-president of Hospice UK and my role with the Royal College of Emergency Medicine. I will ask the Minister three short questions. Will the voluntary sector be closely involved, given that there is a £1 billion contribution to care from hospices and the voluntary sector, which looked after 212,000 patients last year, providing health and social care that otherwise would have fallen to statutory funders? Secondly, given that falls are the major cause of deterioration in the health of older people, and the lack of social care in preventing falls and in being able to take people out of hospital afterwards, will the Minister assure me that this will look at the flow through hospitals and the requirements of social care provision in an integrated way? Thirdly, while the Minister has mentioned young carers, will he specifically provide assurance that this will also look at child carers, some of whom might be at primary school age? They are often forgotten when people look at the burden on carers because they are, in a way, invisible apart from in the school sector.

[Lord O'Shaughnessy]

I can absolutely provide that reassurance on the voluntary sector. The noble Baroness is quite right to highlight the vital role it plays—it is essential and critical to this sector. On falls, she will know just how important reducing falls is. The disabled facilities grant is increasing. It is not a well-known bit of government spending and not talked about much, but it amounts to about half a billion pounds a year. It can have a really big impact by keeping people in their homes for up to four years longer, reducing falls by 40%. It is something we have had the opportunity to discuss in this House recently. It is critical. She is quite right to focus on the frontier between health and social care and making sure that it flows and works well.

On child carers, I will write with more details about what the action plan covers, but clearly we will make sure that it looks at all carers, because a carer could be of almost any age. As she pointed out, it includes very young children as well as people in their 80s and 90s. A true carers approach would encompass all of them.

[Baroness Verma (Con)]

My Lords, I thank my noble friend for the Statement. I refer to my registered interests. I will ask my noble friend about two issues. The first is respite care, which seems too often to be missed, particularly when there are reduced services. Services have been cut back for many service users. When family members have to manage the burden we need to have some discussions on extra respite support. Secondly—I am a broken record on this—we need seriously to look at the value we put on paying care workers a proper return on the work they do, given the extra responsibilities being put on them all the time.

[Lord O'Shaughnessy]

I am grateful to my noble friend for raising both those points. She is quite right about respite care. Local authorities have a duty to provide it, but I also note that there is pressure on the system. Indeed, the issue of one particular respite home, Nascot Lawn, has been raised. It is something I am interested in and I am looking at it. I will take that point away. We are trying to look at the care service in the round, so respite care must be part of that.

My noble friend is right about paying care workers properly. We have increased the national minimum wage, now moving on to the national living wage, precisely to provide a proper recompense for people who work in that sector and, critically, to start to provide a proper career structure so that people can move on, add to their skills and progress while staying in the caring profession.

[Lord Bradley (Lab)]

My Lords, I was pleased to be a member of the Select Committee on the Long-Term Sustainability of the NHS, the title of which was extended to include social care. The consultation seems to be constructed to continue the siloing of social care away from the broader care system between the NHS and social care. Will the Minister confirm that the whole relationship and integration of the NHS and social care will be included in the consultation? Will he confirm when the Government will respond to our Select Committee report, which was published last April?

[Lord O'Shaughnessy]

I thank the noble Lord for raising that point. I apologise again for the lateness of our response to the Lords committee. What I hope is now the final version is with me for approval, and I hope it will be provided very soon.

On the Green Paper, we all want more integration between health and social care. We know that is important for the people who are increasingly using those services who are in older age, have comorbidities and are moving in and out of different settings of the time. Social care is paid for on a different basis from the NHS. That is critical. We have to get a sustainable financial basis on which we distribute social care while thinking about how it interacts with the health service. The Green Paper is trying to crack a nut that, frankly, has eluded Governments for the last 20 years.

[Baroness Brinton (LD)]

My Lords, I am grateful to the Minister for referring to Nascot Lawn. I was not going to raise it today because that is about care for severely disabled children under 18, but I want to pick up on my noble friend’s point about adult care for people with disabilities and long-term conditions. As we know, their care needs are very different from end-of-life needs. Both the current social care system and the Dilnot proposals were focused on end-of-life care, so I welcome the parallel work stream, but will it operate to exactly the same timescale and report back?

I have a further question on housing. Your Lordships’ House will remember that the recommendations of the Lords Select Committee on the Equality Act 2010 and Disability included a whole chapter on housing. It is not just about the disabled facilities grant, which is important; it is also about Building Regulations ensuring that enough of our homes are built so that, as people age and their needs change, houses can be adapted easily if need be. Will that recommendation be forwarded to the group to look at?

[Lord O'Shaughnessy]

Once again, I thank the noble Baroness for raising this issue and I am pleased that she supports the parallel work stream. I will come back to her with details on the timing—I am afraid that I do not have those with me today—but I stress the importance given to it and the fact that it is reporting to the inter-ministerial group is significant.

The noble Baroness’s question on housing goes slightly beyond my remit. I know that building regs have changed over time to encourage more homes to be built, but I will have to come back to her with more details on that point.

[Lord Ramsbotham (CB)]

My Lords, sadly, the fastest-growing part of the prison population is the elderly. The lack of provision for them is one of the disgraces in the current prison system. Has the Minister considered, as part of the carers strategy, whether prisoners might be employed and trained as carers for the elderly, because that might transform the situation?

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[Lord O'Shaughnessy]

That is a novel suggestion. We usually talk about young people going off the rails, but I did not realise that that was true of the prison population. I have not heard such a proposal. I shall certainly take it back to my colleague, the Parliamentary Under-Secretary of State for Community Health, who is leading the carers strategy, so that we can look at whether it might be possible.

[Baroness Altmann (Con)]

My Lords, in the context of our demographics, with the current baby-boomer generation foreseeably entering the age at which they will need care in the next 10 to 15 years, no money has been set aside, either at public sector or at the private sector level, to cope with the rising costs of care. Councils have increasingly rationed care so that they exclude preventive expenditure to help people avoid extreme need. Whatever happens with this review, does my noble friend agree that families will need money set aside if they are going to pay for care? There is no automatic provision. There is a state pension; there are huge incentives for private pension provision, but there is nothing to build up money that would pay for care. Will my noble friend comment on the urgency of helping families understand the importance of, for example, using some of their ISAs as an allocated fund for future care? People in their 60s and 70s have ISAs and pensions. Perhaps we might allow tax-free pension withdrawals for care, so that, at some point soon, we help families put money into a fund that can last into their 80s and 90s and be there for care—in case it is needed—or perhaps be passed on to the next generation, thus starting an ethic of saving for care as well as pensions.

[Lord O'Shaughnessy]

As ever, my noble friend makes excellent and wise suggestions, which I am grateful for. She highlights an important point, which is that social care is a co-funded service for most people. Most people make a contribution to their social care and the state will often make a contribution, too. Therefore, vehicles that allow people to save up in advance, whether through pensions, ISAs or the other means that my noble friend has suggested, are an excellent idea. I am sure that they will be part of considering the financial sustainability and build on products that are already in the market, whether equity release or deferred payments, so that people can go into their old age with confidence that, whatever their care needs, they will be able to afford them.

[Lord Howarth of Newport (Lab)]

My Lords, I think I heard the Minister mention in the Statement that his ministerial colleague had written to chairs of relevant all-party parliamentary groups to invite their participation in preparatory work in the department leading up to the publication of the Green Paper. Does he think there may have been an oversight here, because, as co-chair of the All-Party Parliamentary Group on Arts, Health and Wellbeing, I have received no such letter? I know that the Minister has seen the report of the APPG entitled, Creative Health: The Arts for Health and Wellbeing, and was kind enough to speak warmly of it in the House last week. Will he and his colleagues in the department study the substantial evidence presented in that report that engagement with the arts can confer considerable benefits in the field of social care in terms both of quality of life for people receiving care and their carers, whether family members or professional carers, and of value for money? Will he investigate the possibility of the APPG on Arts, Health and Wellbeing being involved in the process that he has mentioned?

[Lord O'Shaughnessy]

I will certainly be happy to do that. I absolutely endorse the ultimate finding of that report about the valuable contribution that the arts have to make. I shall investigate whether a letter has perhaps gone astray.

[Lord Elystan-Morgan (CB)]

Have Her Majesty’s Government given any thought to a far-off, divine event, by which I mean the total merger of the services aspect of social services with the NHS, thus cancelling out a great deal of imperial rivalry between the two bodies? At a personal level, such rivalry often means a whole platoon of people beating a path to a patient’s door, unco-ordinated with each other and duplicating each other’s services.

[Lord O'Shaughnessy]

I think that everyone in this House endorses the idea that health and social care should be better integrated. That statement is easy to make but difficult to achieve, as I think we would all agree, not least because the funding bases are very different. The NHS is taxpayer funded and free at the point of use; social care is funded on a different basis. That is one of the factors, as well as the bodies responsible for commissioning and so on. A practical way forward is to seek integration at a local level. That is happening now, for example, in Greater Manchester, which has powers over both services and is looking to integrate, and it lies at the heart of NHS England’s five-year forward view, which is about bringing services together in 44 areas, known as STP areas, to provide that level of integration. Patients do not want to have to flit through different bodies all the time. They want a sense that there is one service looking after them throughout their needs.

[Lord Trefgarne (Con)]

My Lords, perhaps I may underline the words of the noble Lord, Lord Ramsbotham, a few moments ago about the care for very elderly prisoners in our system. I have heard some shocking stories of failures in that regard. I hope that my noble friend can make some inquiries.

[Lord O'Shaughnessy]

Yes, I will certainly do so.

[Baroness Donaghy (Lab)]

My Lords, in the absence of my noble friend Lady Pitkeathley and the noble Lord, Lord Warner, I feel a sense of responsibility for seeking an assurance that all the evidence and issues that have been submitted to the various reports, not least Dilnot and the carers reports, will be put together as part of the consideration and that we will not reinvent the wheel. This is a well-trodden path; some of us are quite disappointed that we have got only to Green Paper stage. As my noble friend Lady Pitkeathley said only on Monday, we know what the problem is and what the answers are, so why cannot we just get on with it? Can we have an assurance that all that work will not be wasted?

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[Lord O'Shaughnessy]

I am happy to provide that assurance. Inevitably, there is economic modelling that will need to be updated from previous reviews. It is the reason that, in particular, Dame Kate Barker and Sir Andrew Dilnot have been invited to play a role as well as others, as I am sure the noble Baroness knows. We do not want to have to reinvent the wheel and we know what we want to achieve. The difficulty is that, as Governments have found throughout the years, it is easier to say that than to do it. We all want to get through that process and hopefully achieve it this time.

[Baroness Uddin (Non-Afl)]

My Lords, in the light of all the previous comments I want to raise a couple of issues. I welcome having another look at social care in general and the fact that the Minister says that the Government are looking at integrated care. That is not the experience of men, women and children on the ground; I declare an interest in that I have a son with autism but I receive no service, so I do not really need to declare that. I think an awful lot of parents are like me and my husband: their families manage it themselves. The level of support for social care for adults with autism or a learning disability has been decimated over the last 10 years in various ways. How will this new approach to social care ensure that there is some reverse, so that there is dignity and honour for those individuals who go through the social care process and system?

Does the Minister agree that it is really important to ensure that there will be some reparation, almost, for the loss of services in the past so that adults, particularly those with a learning disability and autism, have access to services such as simply going to the library? My noble friend Lord Howarth mentioned the arts earlier but there is also music, as was pointed out earlier in the Chamber. There is a variety of ways in which social care is now more innovative, and that access should be available to service receivers in all parts.

My final point is about the communities that do not automatically understand the new approach or the latest fads and reports. They do not follow the system. How will we ensure that all kinds of communities understand that there is an approach to integrated social care, and that they will not be left behind simply because they do not understand the system or are not au fait with it, or if they are not politically correct and shouting the loudest?

[Lord O'Shaughnessy]

The noble Baroness put it beautifully in saying that the people we are talking about, who are on the receiving end of care, need to be treated with dignity and honour. I wholeheartedly agree with her.

I will separate integrated care into older people and working-age adults, as the noble Baroness did. On older people—and on health and care in general—I encourage her again to look at the five-year forward view and the plan for integration. In the recent Budget, we funded more than £200 million of capital programmes to help move a handful of local areas to what are called accountable care systems. That is where you look at the health of a population, which is quite an important step forward towards integrated care. I agree with her that that is not necessarily the everyday experience.

On disabled working-age adults, we may talk about the ageing and growing population but I believe that they are the fastest-growing group of care users. There is of course excellent work going on at the local authority level; I had the privilege many years ago to chair a special school in Wandsworth and saw the fantastic work it did with a peripatetic autism service there. But I know that there is huge variation, which is why the parallel programme of work that I talked about is so important.

Finally, the noble Baroness talked about hard-to-reach communities, and I could not agree more on that. One of the ways of reaching them is to engage with those who give voice to those communities. I would be delighted to discuss that with her, to make sure that we are listening to every voice we can as we move ahead.

[Baroness Tonge (Non-Afl)]

My Lords, way back in the early 1980s when I was working as a community doctor, I was also chair of social services in my borough. The main topic of conversation and angst then was how to combine health and social care budgets so that patients could receive proper care. How many more decades do we have to wait for this country to get its act together and do something about it? Other countries in Europe have good social care; why cannot we?

[Lord O'Shaughnessy]

First, I think we do have good social care in this country. That was the CQC’s finding, and it is important for us to recognise that we are building from a position of strength. Secondly, I agree with the noble Baroness on her point about integration. It has taken too long and that is what we are all focused on doing. I hope that she will join in this process so that we can build a true consensus as we move ahead.