Care Bill [HL]

Lord Sutherland of Houndwood Excerpts

Tuesday 21st May 2013 Lords Chamber

[Lord Sutherland of Houndwood]

My Lords, it is, of course, a pleasure to follow my colleague, the noble Lord, Lord Warner, whose experience contributed so much to the outcome of the Dilnot review, and who has regularly drawn the attention of this House to the importance of its conclusions. I also thank the noble Baroness, Lady Barker, for her kind remarks. Suffice it to say that I remain one of the usual suspects and will continue in that gang for the foreseeable future.

The context of this Bill has a history. The post-war creation of the modern welfare state as we know it was momentous, and many of us have benefited from that for most of our lives. The two Bs, Beveridge and Bevan, gave us two structures. The first is the National Health Service, which in principle offers healthcare free at the point of delivery, and the second offers other benefits that cannot be defined as healthcare, including care services deemed to fall outside healthcare. These are not free at point of delivery but are subject to two constraints. The first is means-testing and the second is that responsibility for delivering these benefits lies currently with local authorities, and so is not currently in national service as is the National Health Service. This Bill goes some way, but not the whole way, towards changing that situation, and I will come back to that. It contributes to a redefining, but I agree with the noble Lord, Lord Warner, that the role and the difference between healthcare and social care still remains unclear.

The second and last relevant point of difference from when the national services—the health service and the local authority care service—were set up is the growing demographic change in our country and in every country. Demographic shifts have created a completely new situation which, whether we like it or not, will have an impact on how and where we spend money. We simply live in a different world. For 50 years, we got away with trimming at the edges, changing bits here and there in relation to health and social care spending. That can no longer be the case. It is clear, at last, that something must be done. This Bill does something, and it is very welcome. That is the strength of the Bill. However, it is, at best, a good start, for many of the reasons that have been given already. Its strength is that a peg has now been put in the ground, and there is a commitment to having a national strategy and policy that we have simply avoided because of the huge fissure that runs between health services and social care services. That is part of the world in which we live and it has very significant consequences.

The fundamental recommendation of the Dilnot report, that a cap be put on the cost of care for any individual, has been accepted. All credit is due, for this is at last an acceptance by the Government, including, therefore, the Treasury, that the risks involved in the frailties of old age, like those involved in cancer, stroke and diabetes, should be shared across the whole community. I hope that that principle has been established in the Bill before us.

Of course, the fears of the Treasury, which are always there, are already being realised. Inevitably, a chorus of voices points out that there is less to this than meets the eye. The Bill does not commit the resources that we all know are necessary if you are to duplicate the quality in social care services that we have in the National Health Service. As we have heard, Dilnot’s proposal included the possibility that a cap might be as low as £25,000. In the event, it is eventually £72,000, with the possibility of deferred payment. Again, as we have heard from the noble Lord, Lord Bichard, local authorities are vigorously pointing out that there is already a shortfall in funds made available before account is taken of this new proposal. They estimate that the current round of cuts to the adult care budget amounts to £2.68 billion—or 20% of previous provision—and that is before the provisions of this Act are dealt with. At the same time, as has also been mentioned, care home owners often subsidise local authority-sponsored residents from the charges made to those who are self-financing. That cannot be right. There should be a single charge, and a single cost that applies to everyone. However, the rich—or the moderately rich—are subsidising others. That is the position in which they have been put.

Of course, we all know that we are now in the worst financial crisis in living memory. Account has to be taken of that—and I put it to you that account has already been taken of it. What that does—and the noble and learned Lord, Lord MacKay of Clashfern, made this point very fairly—is to raise expectations, in the way in which this Bill is being canvassed, which will come home to roost. People who have legitimate hopes that their old age will be comparatively secure will be disappointed.

Equally important in the Bill is an implicit bet—and that is the best of it, as far as I can see—that the principle of a cap on care costs will stimulate a strong insurance market to cover pre-cap and possibly post-cap costs. We shall see, but there is no guarantee about that. Of course, conversations have been held, but my previous experience on the royal commission was that those providing insurance products were not interested. We shall see if a cap makes all the difference. Let us hope that it does.

The Government, while being commended on a good start, or indeed on facing up to demographic change, must accept, however, that as we stabilise our economy—and the expectation and hope is that we will do that—a reordering of priorities will be the only rational response to the empirical realities of the huge demographic change. We must accept, as a Government and as a Parliament, that these priorities will have to be looked at. The world out there is different. The facts and the shape of the population are different. If there is no more money, priorities have to move around a bit. That is the reality, or we will be having desperate scenes in the houses, streets and care homes of our country.

One change which cannot and should not wait until then is the need to ensure that the huge sums already being spent on care, social care and even more so on healthcare—the noble Baroness, Lady Greengross, referred to this—are spent in the most efficient and effective way, and to maximum standards of the quality of care.

In two successive parliamentary Sessions we have had two relevant major Bills. The first, now an Act, was, despite its Title, almost wholly concerned with healthcare. It is called the Health and Social Care Act but there is not much social care in it. This second Bill, as its Title says, has to do with care. However, there is the rub. Why were these two not one Act? There is a legal, financial, and administrative fissure in our society that runs through our attitude to the provision of care. We simply cannot continue like this. It is at government and at professional level. Doctors and social workers are the best of friends in the pub, but you should hear them when they talk about each other when it comes to money. There is a fissure there.

On the royal commission, we reran the hoary old joke about the difference between a health bath and a social bath. You had to divide them up in those days to decide which fund provided the money to provide the bath. Both the commission and the Dilnot report firmly made it plain that bringing together health and social care provision and, ultimately, budgets, is essential if we are to maximise value for money in this massive and increasing spend—and it will not go down.

There are some good pilots taking place. I would find it very helpful if the Minister could tell us what the outcome of the pilots would be. What process is there for taking account of the evidence of what they provide in terms of shared facilities, budgets and provision? The message is very clear: combining budgets provides better administration, improves the effectiveness of spend and, importantly, has a huge potential vastly to improve the quality of care.

I would like quickly and briefly to make two points that have come up in the debate about the assessment and evaluation of what is going on. The first is that there is provision, rightly, to deal with what I can refer to only as the Southern Cross problem. We cannot have major providers going bust on us. That is right—but I wonder whether it is right to ask the Care Quality Commission, whose expertise is in a wholly different field, to take responsibility for this. Is there not even a group within the department of health economists, or economists, who know about running big businesses—they are essentially property businesses—and can give a proper health reading? Those responsible for assessing the quality of care are not those people. Yes, they will employ others. But if it is to be a kingdom within a kingdom, why not charge reasonably well paid civil servants with doing that?

Lastly, although it is not mentioned in the Bill, the Minister made mention of a new inspector. I simply ask whether we can have some information about the context in which such an inspectorate will work. It is canvassed as being like Ofsted, which is of course a great reassurance to those of us who were involved in setting up that body. However, it does not seem at all like Ofsted. Does this new inspectorate have a statutory basis? Is it independent of Ministers? We have had a row within recent weeks about who can close down a unit within a hospital—for example, for the heart surgery of children. Where are the lines of accountability? What is the new inspector responsible for? The chief inspector of schools is accountable to Parliament, not to Ministers. That gives it an independence and certainty about being taken seriously that will not necessarily be the case for an inspector within the employ of the department. So there is a lot of room for clarifying the provision there, but I am sure that we will come back to that in Committee.