§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Lennox-Boyd.]
§ 12.6 am
§ Mr. William McKelvey (Kilmarnock and Loudoun)
I much appreciate this opportunity to bring to the attention of the House and the Minister the importance of the subject for debate tonight. While I agree that many elderly people are living contented and satisfied lives in residential and nursing homes, we have evidence that many others are spending years in drab and boring hospital institutions that offer little prospect for privacy and dignity in advancing years.
Many elderly people become confused and upset when they are uprooted to other types of houses or hospitals as their infirmity advances. The proposal we are debating tonight is that all elderly people in care and in accommodation in Scotland should be subject to some form of registration, and that such registration should cover all providers of care for the elderly, including local authorities, health boards, owners of private homes, and voluntary organisations.
I am aware that a system of sorts operates in England and Wales, but the legislation underpinning it is merely a consolidation of various practices and legal obligations that have grown with time. That system contains numerous pitfalls that I hope we might escape in Scotland. We have a golden opportunity to learn from those mistakes, so that we can and will create a legislative framework that will take us into the 21st century, with a clear vision of our obligations to the growing numbers of elderly in our communities and our ability to meet them.
Registration should be a means of demanding that universal standards apply to all settings in which the elderly live permanently. It must include regular inspections to ensure that standards are maintained, as is outlined in paragraph 6 of the Griffiths report and in paragraph 30 of the Wagner report.
I suggest that the registration body should have to be made up of experts in health, housing and social services, perhaps also including a representative from a national organisation such as Age Concern, which does such magnificent work on behalf of the elderly. I earnestly believe that such a body should have a degree of autonomy, with experts seconded from such major organisations. A multi-disciplinary body such as this is more likely to be able to take enforcement action which a single authority might find itself reluctant to take because of the consequent responsibility for homelessness which the most extreme action may require.
Demographic trends show a significant and advancing increase in the number of people over the age of 75, and an even greater increase in the number who—thankfully—are living beyond the age of 85. The latter are more likely to be physically and/or mentally frail. They are more likely to be single or widowed, and hence to live alone. They are also more likely, as the records show, to have poor housing and a low income. They are thus more likely to need proper residential care.
The task is a large one, and it is growing extremely fast. Indeed, outwith my constituency, in Ayrshire alone, the increase in homes for the elderly is already quite stunning. 963 In 1980 there were just 200 places; now there are 1,400. Registration is therefore essential to ensure universal and adequate conditions.
The registration must have as its purpose the requirement to meet basic human needs. The need for food, shelter, warmth, personal space, autonomy and identity are, as I am sure most hon. Members will agree, fundamental, and are not diminished with advancing age. Indeed, the reverse is the case.
§ Mr. George Foulkes (Carrick, Cumnock and Doon Valley)
Will my hon. Friend confirm that, when he and I and other Ayrshire Members met the Ayrshire and Arran health board, the officers of that board also confirmed their concern about the increase in the number of places for the elderly, and the difficulty of registration in Ayrshire; and that they support the plea that he is putting forward tonight?
§ Mr. McKelvey
I shall underline that shortly by reading a brief paragraph from a communication that I received from the authority.
Old people should reasonably expect the same standards of accommodation as younger or fit people in their own homes. Indeed, as their universe is often limited to their own surroundings, I feel that it is more important for them to expect and receive a higher standard of accommodation and care. It would be a mistake, however, to believe that the elderly fall neatly into set categories requiring less or more care. We are dealing with human beings, not cans of beans. These people cannot be shuttled about in the system as they grow more frail and elderly—or, indeed, become less profitable. That, I feel, should be uppermost in our minds. I consider it unnecessary and, indeed, cruel to shunt elderly people around because of lack of nursing provision. Often such nursing care may take only a short time to perform, and it is less often in any sense intensive.
If a residential home becomes overburdened with frail and elderly people at the extreme end of dependency, the level of nursing care for that home should be increased correspondingly. That raises two important issues which I am sure have already been brought to the Minister's attention: the assessment of need for nursing care, and the knotty problem of finance. Age Concern has researched all those issues thoroughly, and has come to the sensible conclusion that full health and social assessment should be undertaken before any elderly person enters any type of residential care, and should continue at regular intervals thereafter—that is most important—for each resident. In that way, the owners or authorities concerned are able to assess requirements, and detect any deterioration or indeed improvement in condition, and are able to plan resources accordingly.
Assessment takes place in some areas of residential care, particularly in local authority and health board homes and hospitals. Some private nursing homes, to their credit, have also undertaken this form of assessment. The problem is that it is piecemeal and that, when it takes place, some things, particularly social considerations, may be completely ignored or overlooked. That is why I suggest that a multi-disciplinary body, much like that previously suggested for registration, should be set up to assess all potential and permanent residents in all types of 964 accommodation. Such a body could consist of health workers, social workers and housing experts and include an advocate to speak on the residents' behalf.
Nursing care costs money—everyone knows that—and it is likely that fees will increase as the need for nursing care increases beyond a certain point. That must be made clear to residents or their representatives on entering residential accommodation, and the means to do that should be an initial contract with the resident and any subsidising authority. Such a contract is essential to ensuring that residents are not unduly worried by rising fees that are not agreed by the subsidising authority.
This problem has already caused considerable concern to residents and their families in my constituency. A lady came to see me who was concerned about the care for her mother in a residential home. She had been gazumped. Two months before the new prices were to be announced by the DHSS, the owners of the home demanded another £10 a week—or else. They even went so far as to suggest that the £9.25 that the person received on behalf of her mother—she was on social security and got £34—should be handed over to the home to help to pay. I am glad to say that, following my intervention, the matter was conveniently dropped. The lady is now staying in the home and will receive the additional benefits.
This subject has been debated in Ayrshire in a lively way, and I shall refer to some of the organisations that have contacted me about it. The Ayrshire and Arran health board—
§ Mr. John McAllion (Dundee, East)
Just before my hon. Friend mentions the agencies that have supported him, may I draw his attention—he may not know of it—to the early-day motion tabled in my name and those of other of my hon. Friends, which will appear for the first time on the Order Paper tomorrow? It reflects the case of Age Concern Scotland for charge in this respect, and has attracted the support of 107 hon. Members.
§ Mr. McKelvey
That is splendid news. I am sure that the Minister will have noticed it and will forward it to the relevant Minister for consideration.
The Ayrshire and Arran health board has said that nursing homes are identifying and meeting the need. That is correct. It also states:Popular areas like Ayrshire attract many many residents from other parts of Scotland which in turn can create—and will create—demands on the National Health Service in Ayrshire for which the Board is not presently funded. It also creates real problems in relation to nurse recruitment and retention for both the public and private sectors.There has already been an increase from 200 to 1,400 beds.
David Watts, a local practitioner on the Ayrshire and Arran local medical committee, has seen for himself the difficulties and unfair load placed on the backs of general practitioners because of the rapid growth in the number of homes in Ayrshire. He states:Nursing homes require nurses and there s a finite pool of nurses in Ayrshire. At present the Health Board employs about 1,900 registered nurses and the nursing homes, who are always advertising for staff, employ 190. If uncontrolled growth is allowed to continue we will experience a nursing crisis.The second area of concern relates to the impact of private nursing homes on the workload of general practice. No account is taken of the ability of local general practitioners 1.o cope with the extra workload and the consequence is that homes open and discover the local doctors are reluctant to accept the residents onto their lists of patients because they feel unable to cope with the increased demand.
965 I have received a letter from Martin Kuhn, who is a nurse in a geriatric hospital at the sharp end of the problem. None of us envies his working conditions and his job requires the utmost devotion. He has brought to my attention the fact that at its annual conference the Royal College of Nursing will debate the following motion:That this meeting of the Royal College of Nursing congress requests council to urge the Government to establish a national, trained inspectorate to monitor standards of nursng care in all private nursing and residential homes in the United Kingdom.The largest nursing union in this country is concerned about the growing problem mentioned in that motion.
Those who devote all their time to the care of the elderly in the National Health Service know that the elderly and frail are being shunted down to them as they become less profitable to private hospitals. That does not lead to an atmosphere that is conducive to good working practices.
Age Concern Scotland—in its document "The Case for Change"—says that the distinction between residential care homes and nursing homes providing long-term care should be abandoned as they are no longer useful or appropriate to today's standards. They have written to the Minister along those lines and are still awaiting a reply. I am indebted to Mary Marshall of Age Concern Scotland for her work, which she brings to the attention of hon. Members.
I have received many letters from Elizabeth Reid of Kilmarnock, who works on behalf of carers. I ask the Minister to reflect on the fact that last year the Public Accounts Committee said that the Government spent £450 million on private residential care. That is a large sum of money and much profit has been made by those who run private residential homes. Elizabeth Reid says that many people would prefer to keep their elderly relatives at home. She thinks—I am sure that this will happen—that all carers should write to their Members of Parliament asking the Government to change the law so that invalid care allowance is made a free benefit and so that carers are not pressed further into the poverty trap. If half that £450 million were to be transferred to carers, untouched by benefit subtractions, the Government might improve the fate of our elderly and frail people who, despite being happy in residential homes, would prefer to stay at home if they were not a burden to the rest of the family.
I thank everybody who has written to me about this subject. The matters raised by Age Concern Scotland and the Griffiths report provide us with the criteria to meet the needs of the growing number of elderly people in Scotland. My earnest hope is that their proposals can be transformed into legislation sooner rather than later. I feel that we owe our elderly people the right to live a proper and dignified life in their latter years.
§ The Parliamentary Under-Secretary of State for Scotland (Mr. Michael Forsyth)
I congratulate the hon. Member for Kilmarnock and Loudon (Mr. McKelvey) on his success in the ballot and his concern in raising this important subject. I join him in paying tribute to the work of Age Concern. Perhaps I could reassure him that I did reply to Miss Marshall on 12 February in response to the booklet and advised her that it would not be possible for us to offer views on the recommendations until we had had 966 a chance to consider the recommendations arising from the review by Lady Wagner into the future of residential care and Sir Roy Griffiths's report on care in the community.
Scottish local authorities currently provide around 60 per cent. of all residential places for elderly persons and other adult groups, comprising some 11,000 places, while the voluntary sector provides around 6,000 places and the private sector approximately 2,400. This is a rather different picture from that which exists in England and Wales where places are divided fairly evenly between the independent and statutory sectors and over two thirds of the independent places are provided by the private sector. Because of the larger private sector, the total number of homes, and places in homes, is considerably greater in England and Wales in relative terms.
Long-stay nursing homes are provided mainly by the private sector. In 1979 there were 77 registered nursing homes containing 2,612 beds. By 1987 the number of homes had increased to 164 with 5,063 beds. Of those, about 700 beds were in establishments offering acute hospital facilities. The major growth however is in the long-stay sector. While information setting out the position at March 1988 is not yet to hand, signs are that the increase has continued.
The number of homes and the total number of places available in residential homes has risen relatively slowly in the past 10 years or so. But the fact is that we have in Scotland a higher proportion of elderly persons in long-term hospital care than in England and Wales and considerable unmet demands for residential care as witnessed by the weight of pending applications.
I am in no doubt that a considerably enlarged residential care sector is desirable in Scotland, not necessarily in the traditional mould of residential homes, though accommodation of this kind is recognised as having a continuing and important role in the care of the elderly. One aspect of this need is the high proportion of elderly, mentally handicapped and mentally ill persons, who are inappropriately placed in long-stay hospital accommodation.
The current Scottish position in this regard suggests not merely ineffective use of resources on relatively expensive hospital care but a failure to meet the likely needs and preferences of the persons concerned in many cases. There are, for example, currently twice as many occupied beds in geriatric hospitals in Scotland as in England, and the figures for patients in mental illness and the psychiatric hospitals are not very different. Even with the new emphasis on domiciliary care, there is a real risk of a greater imbalance between hospital and community as the size of the very elderly population continues to rise.
Local authorities cannot realistically plead for more resources when they are not making the best use of the opportunities that are available, at very little cost to themselves, through the private sector. There is evidence now that some at least are beginning to grasp the opportunities available. I see no inherent contradiction between the encouragement of the private sector and proper control of standards. There are indeed plenty of examples of better, more responsive, services resulting in this way for elderly persons and others in need of care in a residential setting.
In this sphere as in so many others, competition between the public and the private sectors can lead to 967 greater choice for the individual consumer and enable the local authority to spread its own resources for care in the community more widely.
I would not wish to dwell solely on the potential contribution of the private sector. Indeed, I pay tribute to the voluntary sector which has served Scotland so well for many years and remains, meanwhile at least, the principal source of independently provided accommodation.
It is our view that a well-regulated independent sector has an important and significant role to play in the provision of residential care. Such provision is an important part of the Government's strategy of care in the community for the more vulnerable members of society, including the physically and mentally disabled and particularly the frail elderly whose numbers are growing steadily and will continue to grow.
Under the Social Work (Scotland) Act 1968 and the Nursing Homes Registration (Scotland) Act 1938, responsibility for the control and monitoring of independent residential care and nursing homes rests with the local authority and health board respectively. Registration is not concerned purely with physical standards. It is also about residents experiencing a good quality of life and enabling them to maintain as much personal independence and dignity as possible. Sound local authority practice and procedures relating to the registration and inspection of establishments are crucial if acceptable standards of care are to be maintained.
The 1968 Act requires that residential establishments whose sole or main object is the provision of social work care require to be registered with the local authority. These arrangements apply to all client groups, including children. Authorities can refuse or cancel registration if they consider the person operating the establishment or person employed as a manager is not a "fit person", if the building, its fitments or staffing are not fit for the purposes intended, or if the conduct of the establishment is not deemed to be, or likely to be, such as to provide the services required. Persons who are aggrieved by refusal or cancellation of registration may appeal to an independent tribunal. In the 20 years since these provisions have been in force we have had only one such appeal in Scotland, and that did not relate to standards of care.
Local authorities have a duty under the 1968 Act to inspect establishments which they have registered and have appropriate powers of entry.
§ Mr. McKelvey
I ask the Minister to consider two points. First, I am not surprised that there are not a great number of complaints about the system, because those who use it are often bullied and are too frightened to complain. If they did, they would be put out on the streets.
Secondly, the Minister has not responded to my suggestion that there ought to be a multi-disciplinary body. Both Griffiths and Wagner have concluded that that ought to be the means whereby residential homes are monitored.
§ Mr. Forsyth
If the hon. Gentleman has evidence of the kind of practice that he has just described, I should like to see it. We are still considering the Griffiths report recommendations. We shall also consider very carefully the arguments that the hon. Gentleman has put to us. The evidence that is available to the Scottish Office shows that the standards of care are good, in the main, and that the 968 local authorities have powers that they can use, but it seems that it has been unnecessary to use them to maintain standards of care.
Local authorities have a duty under the 1968 Act to inspect establishments that they have registered, and they have powers of entry.
§ Mr. McKelvey
One of the problems that local authorities face is that if they close an institution all that they do is to put the inhabitants out into the street and the community has to take care of them. Therefore, they are very reluctant to use such an extreme measure.
§ Mr. Forsyth
If the hon. Gentleman has evidence of homes that local authorities wish to close because of inadequate standards but are not doing so. I should like to see it. He is saying that they are not using their powers because they would be unable to provide alternative accommodation. I said earlier that we wish to encourage the wider provision of accommodation in the private sector to meet these demands.
The provisions that I have described were strengthened during the last Parliament by a measure introduced on the Government's behalf by my former hon. Friend the Member for Banff and Buchan which became the Registered Establishments (Scotland) Act 1987. It is relevant to the debate that I remind the House of the provisions of that Act. It enables local authorities to charge fees for the registration and subsequent monitoring and inspection of establishments, as has been done in England and Wales since 1985.
The Act extends authorities' powers to impose any reasonable conditions of registration, subject to the opportunity given to the home owner to appeal to the tribunal. That enhances authorities' control over establishments registrable with them to a greater degree than is available in the south. Here we meet the point which the hon. Gentleman made about elderly people having to move from one home to another. The Act also introduces the concept of joint registration of establishments, providing both residential and nursing care in contrast to the existing legislation which neither explicitly permits nor forbids this practice.
The measure as a whole was welcomed by the statutory, voluntary and private sectors alike. We are on the point of issuing a consultation paper outlining our proposals on the level of fees which local authorities will be allowed to charge for registrations.
The hon. Gentleman is legitimately concerned about the arrangements for regulating standards in both residential care homes and nursing homes. The first essential, I believe, is that homes of both kinds suitable in location, design, construction, furnishing and equipment should be operated by persons who are suitable for the task, have proper training and experience and have sufficient, carefully chosen and suitably trained staff at their command.
As I have said, responsibility for the registration and inspection of voluntary and private homes rests with local authorities. Authorities are accountable for the actions they take in the exercise of these responsibilities, and may in the last resort have to defend their decision to refuse or withdraw registration before an appeal tribunal. In that situation they must be free to exercise their discretion, and detailed prescription by the Secretary of State regarding the exercise of their functions could not be justified.
969 In exercising the discretion available to them, local authorities will need to have particular regard to the physical and care standards in their own homes. It would clearly be unacceptable to have different standards in the independent and statutory sectors. The duty of care that they owe to their own residents is, if anything, greater than that they can discharge in regard to those in the care of others.
970 I trust that the hon. Member is satisfied with the assurance I have given regarding the regulation of standards in private and voluntary residential care in nursing homes in Scotland, and the measures currently taken to secure the best interests of residents in care. If the hon. Member—
§ The motion having been made after Ten o'clock on Wednesday evening, and the debate having continued for half an hour, MR. DEPUTY SPEAKER adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at twenty-three minutes to One o'clock.