§ Ms. Dawn Primarolo (Bristol, South)This debate is about community care. Although the Government have continually promised reports and proposals on this subject, because of problems with the policy towards it, there were no proposals in the Queen's Speech to legislate on the problems in the community care scheme, despite the publication of the Griffiths report earlier this year.
I want to record some of the criticisms of the scheme made by some of the carers and organisations involved in the problems faced by people. I also want to discuss the Griffiths report's proposals and the fundamental problems of the community care scheme.
The Audit Commission review, published in December 1986, laid out the principles of community care, with which we would not disagree. It went on to describe the policies of successive Governments—but what has actually happened has been quite different. The Audit Commission made a series of proposals. The first concerned short-term funding to avoid the long-term waste of two systems that work inadequately and struggle to survive in parallel. The second related to how the social security system links with the community care policy. The review was concerned to ensure that there were no "perverse incentives" involved in encouraging residential, rather than community, care or provision for people to make a profit—I add, out of someone else's need. Thirdly, the Audit Commission recommended a more rational organisational structure for community care policy.
I want to deal with the transition from long-stay hospitals of mentally or physically handicapped people, and with those who have remained in the community with their families. What services are provided for them?
In July 1987, I received representations from the Avon group of societies for the mentally handicapped. It expressed its worry about the development of a two-tier system of caring for people in the community. I contacted my county council, which explained—this seems to be a common pattern across the country—that the policy and plans are quite well developed for services for people who are leaving hospital. Finance is not always available, but the employment plans are beginning to be put in place. It went on to say that there is no Government money to provide comparable services for people who have always lived in the community. That includes the cost of respite care, residential care and day provision which runs into many millions of pounds.
In my constituency surgeries—many others will have experienced this—it is especially distressing to hear the stories of women, who tend to be the carers in our society, explaining the difficulties with their children who have reached the age of 19. There is no provision for their care in the community. The Down's Syndrome Association stressed that point. It said that the money available is directed to the transfer of patients from long-term hospitals and to speeding the closure of such hospitals. Yet 52 per cent. of the mentally handicapped already live at home in the community, and not enough services are being provided for them.
I do not say that people should stay in long-term hospitals. But if we are to have a community care policy, it must be exactly that. The Avon Mental Handicap Action Group wrote to me saying that the closure of 134 long-stay hospitals was going well, but that the same could not be said of the integration of the former patients into the community. That was not to say that the community had rejected those people, but that the intensive support, care and encouragement which they need is not being provided.
Another letter from the Down's Syndrome Association said:
More and more parents are discovering that there is nothing at all on offer for their mentally handicapped sons and daughters as they leave school, and no adequate respite-care to make life endurable. Also as the subnormality hospitals close, there is no long-term care to replace it for the severely handicapped already living at home. Such a crisis-orientated service adds to the already intolerable burden that these parents have to bear. The most severely handicapped and multiply handicapped people are the worst-served. As they grow into large adults, their parents are becoming older and less able to cope.Many families who are incredibly devoted to their members must put up with inadequate services which lead to frustration, demoralisation and—in some people's lives—panic and fear about what will happen to their children.The National Schizophrenia Fellowship was so worried that earlier this year it launched a nationwide campaign, making the point that the transfer of people into the community without sufficient: support services was causing greater pain, more anguish, more suicides, more sick people, more people ending up in prison and more people sleeping rough on the streets.
I received a letter from a parent making representations on behalf of her 14-year-old son, who suffers from Down's syndrome. She said:
In March this year a group of parents of mentally handicapped young adults formed the Avon Mental Handicap Action Group. We are extremely worried about our `adult' children's future. Avon County Council is in a desperate situation—we are told by all three parties"—Avon county council is run by a Tory-SL,D administration—that there are no resources to provide the residential and respite care so desperately needed for mentally handicapped adults living in the community and no resources to provide the extra day-care facilities".The distress that this situation is causing aged parents who are still caring for their children is beyond belief. That mother, as a younger parent, believes that her child has a right to a life of his own and she can see no hope for enriching his life in the future if those facilities are not provided.
After reviewing the services available, the Bristol community health council concluded in its 1987 annual report that, although it strongly supported—as I and the Labour party do—the principles that underpin community care, sadly, the reality is very different.
I want to remind the House that 3.25 million women in Britain are unpaid carers. A carer is someone who looks after a friend or relative who has a physical or mental disability or is ill or impaired by infirmity. Most carers are women. Without their help, the health and social services simply could not cope, but what about the health needs of the carers themselves? Caring can sometimes be a lifelong responsibility and can take a tremendous toll of the carer's life. Carers are six times more likely to suffer a breakdown in mental health and many carers are themselves elderly with failing health. To leave them struggling in the community is simply unforgivable.
Shelter compiled an extensive report on Bristol outlining the problems that people who are discharged 135 from hospital face in trying to find housing in the city. The problem cannot be shrugged off by saying that it is the fault of an inadequate housing authority. There is already a serious housing problem in Bristol and those people, who may have been in hospital for a long time, are tossed out into the world and are not receiving the support that they need.
Let me quote two cases. The first is a couple who are both ex-patients from a mental hospital and have been brought out into the community. Their income dropped substantially as a result of the housing benefit changes and they find it difficult to cope financially even at the best of times—who does not find it difficult on social security?—but they now find themselves living in fear of building up debts.
Another couple said to me:
We find it very difficult to manage our money having spent a lot of our lives in hospital. We have just about managed to pay off all our bills until this year and we simply do not know how we shall cope.The income of another ex-patient, who lives in a house as a lodger, dropped from £49 a week to £41.70 a week as a result of housing benefit changes. He should pay £40 a week for board and lodging, but his landlady, out of the goodness of her heart, gave him back pocket money to help him get by. She has taken on the responsibility of a carer and is saving the state work, although such a demand should not be made of such a person.
Three people discharged from hospital in 1976 ran up enormous electricity bills in my constituency. I received details of the case from the Bristol Society of the Mentally Handicapped which pointed out how those people had been deserted by every agency simply because there was no clear line of responsibility as to who was the care manager.
In June, I wrote to the Under-Secretary of State asking him specific questions about proposals for improving care in the community. I was told that the Griffiths report had undertaken a review of community care policy and that when the proposals were available—they were actually published on 16 March—they would be considered jointly with the recommendations from the committee on residential care and proposals would be brought forward in due course.
How long is "due course"? We have had a Queen's Speech. Where are the proposals? The Griffiths report proposed that a Minister should be responsible for these matters. It also stressed the changes in the responsibilities of social services. It made recommendations about resources and about the role of the National Health Service. It recognised the carers, their unpaid role and their need to be supported. When all that information is available, why are there no proposals?
I have many criticisms of the Griffiths report. The philosophy behind community care was not properly investigated, and there are some errors. The balance between the public and private sectors must be examined. There is no place for the profit motive in the care and health of people in our community. That is not stated clearly in the Griffiths report.
People are being transferred from mental hospitals and long-stay hospitals without the necessary service developments in the area health authorities to support those people in the community. The whole emphasis of the strategy so far has been on the shift of responsibility from 136 the National Health Service to local authorities. However, that strategy is cruelly undermined by the Government, who continue to batter local authority finance around the head so that the authorities do not have the money to make the necessary provision.
The central problem is, who has the responsibility of the community care manager? That responsibility falls between two stools. For example, a constituent of mine was resident in a private residential home which closed because the owners decided that they did not want to run it any longer. My constituent was found a place in another residence and was transferred. However, none of his belongings were transferred and were left packed up in the other home. No arrangements were made to transfer his social security, so he had no money. His social worker was away on holiday. I am not decrying social workers for taking holidays and in this case I understand that the co-ordination failed.
The problem in the private sector is that private sector residential provision comes and goes all the time. There are lots of reasons for that, but what happens to the residents in those circumstances? Who is responsible for ensuring that they are adequately provided for and transferred to new accommodation?
We must also consider the training of staff in community care. There is no central personnel policy. We must not simply transfer people; we must transfer the staff as well. As that has not been done, staff morale in hospitals has been undermined. Staff feel insecure and unhappy about their futures. There has been no central strategy about retraining or recognition of qualifications. The transfer of staff has been piecemeal and unco-ordinated in many respects. Managers are becoming reluctant to provide funds for building fabrics because they know that those buildings will not exist for long and there is also a real problem with the declining standards of care in long-term hospitals.
The Government have made no provision for those problems. They have done even worse: underpinning the whole community care policy is a social security system that is cruelly cutting people's income. Under that policy, the Government are automatically transferring people from hospitals to live in poverty on social security benefits without the support they need.
I conclude by quoting from "A better Life—A Charter for You to Sign and Support", produced by MIND. It sums up the state of the current community care policy admirably:
Mental health services in Britain are underfunded, inadequately staffed, dominated by huge, crumbling institutions, hamstrung by outmoded ideas with no consensus for the future. The state of decline which brings crisis to mental health care brings personal tragedy to many thousands of people with mental illness. Trapped in Victorian institutions, 40 to a ward, with no privacy, no choice, no power, and no way out. Or"—the alternative as it exists now—living on the breadline in a dingy bedsit with no friends, no support, no job, and no home. The choice is stark.That is not choice. We need to know when the Government will bring forward proposals for enhancing and supporting the community care policy. The tragedy is finding itself in the lives of hundreds of thousands of people all over the country. It is appalling that, while the Government claim to be targeting those in greatest need, they make no progress in community care.
§ Mr. Andrew Rowe (Mid-Kent)The House owes a considerable debt to the hon. Member for Bristol, South (Ms. Primarolo) for raising this centrally important issue. I found myself sympathising with a number of her points, but she was less than charitable to a Government who have, among other things, overseen the largest single attempt to alleviate the extraordinary conditions suffered by the large number of people who have been institutionalized unnecessarily—and, by modern standards, often wholly improperly—in hospitals for the mentally ill throughout the country.
It is often said in my constituency that the Government's programme of what is inelegantly called decanting the mentally handicapped from institutions into the community has been little thought through and leaves many of them uncared for. That may be the case in some authorities, but it is not in mine.
After one of the hospitals for the mentally handicapped in my constituency was half-emptied, it was thought that it would be nice if a number of its former patients, having lived in the community for some time, could return to visit friends remaining in the hospital. Thus, the former patients were gathered up from their foster homes, and so on, in the community and taken to their old hospital. When they arrived, only one of their number was prepared to leave the bus, because the others were terrified of being returned to what had in fact been an extremely well run, cheerful and hospitable institution. Nevertheless, so much did the former patients prefer being members of the community that they did not want to leave the bus.
Their attitude is something for which the Government can and should rightly take credit. However, I share the hon. Lady's anxiety that sometimes those who come with a dowry, as it were, from the National Health Service receive preferential treatment over the large number of others looked after at home by courageous people who are close to, or even beyond, breaking point, struggling with difficulties over which they have no control.
It is a complex issue, and I sympathise with the Government in not having yet made their proposals. However, I have less sympathy with them for having refused a formal debate on the Griffiths report before publication of the White Paper. I pressed for one but was rebuffed again and again. To me it is a sensible way of letting the House express its views before the White Paper is published. Nevertheless it is a complex issue, and I should like briefly to refer to one or two key issues within it.
The first is the question of choice. It is probable that scarcely a family in the country will, in the foreseeable future, have direct contact with at least one of its members who requires community care in one form or another. In that respect community care is unlike many other issues that we debate. Among that vast number is an increasing proportion who are accustomed to making choices because they have had the opportunity to do so all their lives.
I remember addressing a meeting of the British Association of Social Workers two years ago. The room divided neatly into two halves: one half vilified me for suggesting that people should be entitled to choose to go into private care if they wished, while the other half felt that it was a perfectly natural expression of the lifestyle that such people had enjoyed throughout their lives. I 138 expect that if I addressed the same audience now the proportions would have changed dramatically, and that most social workers now accept that it is perfectly reasonable for someone who can afford it to choose private care.
The fact remains, however, that either at the time of making their choice or soon afterwards, such people are extremely vulnerable. It is crucial that, whether they are in private or public care, they should be able to rely on standards being guaranteed. That means a common system of inspection of all kinds of residential and community provision, and I hope that the Government will bring forward clear proposals for a standardised system of inspection of community care, foster and residential homes.
I do not agree with the implication of the hon. Member for Bristol, South that private care is more haphazard, by its very nature, than public care. There are as many horror stories of haphazard and poor-quality care in the public as in the private sector.
I strongly believe that part of the definition of choice is that it be informed choice. It is important for those in need of community care to have someone to speak for them if they feel uncertain or indeed incapable of speaking for themselves. I was proud to be one of the sponsors of the Disabled Persons (Services, Consultation and Representation) Act 1986, whose principal architect, the hon. Member for Monklands, West (Mr. Clarke), is sitting on the Opposition Front Bench tonight. I believe that the part of the Act that deals with advocacy is very important. I am not suggesting an army of people to second-guess the professionals. I am suggesting that those who are not able to speak for themselves are entitled to expect someone to speak for them who can be trusted to do it properly.
Then there is the question of prevention. One of the bizarre features—to use the words of the Audit Commission report, the "perverse incentives" which operate in the sphere of dependency—is the fact that for the lack of a couple of hours' respite care during a week people may be precipitated into enormously expensive and inappropriate care far earlier than they need be. I am sure that the Minister is aware of the large number of households in which carers are themselves in danger of breaking down completely. If they are allowed to break down through lack of respite, two people will be thrown into total dependency at colossal expense when a relatively small expenditure could have avoided it.
To return to a matter that I have raised here before and about which I feel passionately, may we please persuade those who design and build our houses to build in from the beginning a substantial proportion of those features that make it possible for people to remain independent for far longer than is possible today? It is absurd for builders to suggest that first-time buyers would be put off buying a house because the lintel on every door was 1½ in wider than the lintel on standard doors or because there was a ramp instead of steps. A ramp is every bit as beneficial to the mother who has to cope with a push chair or the middle-aged woman who has to cope with a heavy shopping basket on wheels as it is to somebody in a wheelchair.
I understand that such items cost about £1,000 to install when a house is built but that they cost up to £20,000 if they have to be installed as adaptations. Consequently, those who need specially adapted homes are inevitably placed in a ghetto. No matter how humane the local 139 authority or housing association may be, they become "ghettoised" and put together because that is the only way in which their needs can be met. That is an absurdity to which all of us ought to turn our attention.
The key question, which was raised by the Griffiths report and the hon. Member for Bristol, South, is, who is responsible for the community care service as a whole? I believe that considerable advances have been made in many local authority social services departments, including the Kent social services department. Aided by some good district health authorities that have made it perfectly clear that they are not prepared to release patients until the social services department is willing to receive them, we are working out a partnership of which we can be proud. It seems to me perfectly sound to suggest that good local authority social services departments have been rightly nominated by Griffiths as those who should be responsible for community care.
If the Government believe that another body ought to be responsible for community care, it would be perfectly reasonable for hon. Members to debate that question, but I utter a word of warning. To a civil servant—I used to be one—sitting at a desk working out theoretical patterns of responsible administration, the idea of involving the family practitioner committee, because general practitioners have such an enormous part to play in the day-to-day care of many vulnerable people, seems to be enormously attractive, but I suggest that it may prove to be the ingredient that makes the responsibility for community care fall to pieces. Many general practitioners do not want to be directly responsible for the total care in the community of many vulnerable people. They do not believe that they have been trained for it and they do not necessarily feel that they are equipped to provide such care. The way in which they are remunerated means that, on the whole, there will always be an incentive to offload the most difficult and the most severely burdensome of their patients, for reasons that I fully understand and that are in no way deplorable.
There is a marked difference between the way in which medically trained personnel think about people's problems and the way in which people who have been trained as social workers think about people's problems.
Although I know that many general practitioners and hospital consultants will bite my head off for saying it, on the whole, medical care is more authoritative, and in many cases reinforces the sense that the patient is dependent upon the advice and authority of the doctor. Good social work makes a real attempt to preserve for as long as possible the equality of authority between the client and the social worker. That is a crude way of putting it, and I realise that it will read badly tomorrow, but we should be very wary of turning community care into too much of a medical model.
It is perfectly clear that, with their long history, their long training and their long habit of controlling the institutions and organisations in which they work, if members of the medical profession are given part of the responsibility it will not be long before they hold all the responsibility. I believe that they would be less willing to use social work techniques and rather too anxious to use nursing techniques, and that would not be to the long-term benefit of people needing community care.
140 The issues are extremely difficult. They are issues of which I know my hon. and learned Friend the Minister is fully seized. There has seldom been a managerial report on such a sensitive subject that has been welcomed by such an enormous variety of professional organisations. In that welcome there is a clear message to the Government—"For goodness' sake, let us make up our minds as soon as we can about how best to look after the most vulnerable people in the community." I believe that the programme which the Government have put into such courageous effect in so many parts of the country of unloading people from institutions into the community has called into being a wide variety of responses, many of which are of high quality and are functioning extremely well. More than anything else, the best examples which operate in Britain should be generalised as quickly as possible for the benefit of those vulnerable people.
§ 12.7 am
§ Mr. David Hinchliffe (Wakefield)The Audit Commission's report in 1986 said that
community care policy is in some disarray".At that time that was an understatement, and the position has certainly worsened since 1986. The present shambles has been deliberately planned and constructed as part of the process of pushing Britain towards a private welfare system.The crux of the matter is that, as my hon. Friend the Member for Bristol, South (Ms. Primarolo) pointed out, while local authority domiciliary care has been hammered by Government cuts, private residential care has been given open-ended public subsidy to the tune of £1 billion in the current year in income support to people in private care. That is the Association of Directors of Social Services figure, with which I am sure the Minister is familiar.
I wish to refer specifically to the care of the elderly about whom I am deeply concerned. Having worked in social work for more than 20 years, my general feeling as a social worker and as a politician on the local council was that institutional care for elderly people was the last resort, the final refuge or the final means of caring for an individual. Under the system introduced by the present Government, it is frequently the first port of call. The encouraging trend away from institutional care that has developed over many years has been completely reversed and the institution has been re-invented by the Government. The institutional care model offers the Government the easiest route towards the establishment of a free-market welfare system. So far, free marketeers have not really found a way of making domiciliary care pay. Care vouchers may enable that to come about. At present, the money is made in the residential sector.
The present system is geared towards pushing elderly people into residential care, whether they need it or not. A 60-year-old woman or 65-year-old man may retire and qualify for a pension but they may be as fit or fitter than many hon. Members in the Chamber. However, they could go to the Department of Social Security, having obtained admission to a private home, and ask for income support to cover the fees. I challenge the Minister to deny that the DSS may pay that money. It is in the interests of the institution's proprietors to have a fit person of 60 or 65 in their care because they can make more money by having independent people in their home.
I am concerned that that system exists. I can give as an example a neighbour of mine. A lady in her early 80s lived 141 with her sister until her sister died. The family wanted to ensure that the house in which they were living was sold. The old lady, who could have coped on her own, was shunted off into private care 15 or 20 miles from where she had lived all her life. That is wrong. There was an incentive to put her into institutional care. She could have remained independent in the community. The system did not pay for the care she could have had in the home environment but paid to put her into an institution.
I know of a recent case involving—I am sure that the woman will not mind me mentioning her name—a Mrs. Palmer. I served on the local council with her husband many moons ago. In her old age she became dependent on her family. Unfortunately, her only daughter lived in the midlands. She had to travel to Yorkshire virtually every weekend to care for her mother. They could not obtain any support from the system for the work involved in caring for her in the community. When she went into hospital she was told that she required permanent institutional care. The lady's daughter came to see me. She had struggled without the benefits that she should have had when she was helping her mother to be independent, but she found that once institutional care was mentioned the benefits flowed. Therefore, that woman can go into institutional care without any problem.
The system works the wrong way round. There are huge inbuilt incentives to persuade individuals to give up their independence and move into institutions. The Government have attacked local authorities' ability to offer services geared to keeping elderly people in their own homes.
The Audit Commission said that the current system of redistribution of rate support grant acts as a deterrent to the expansion of community-based services. The current funding policies clearly discriminate in favour of private residential care at the expense of crucial areas of public domiciliary services.
The present system constitutes an irresponsible misuse of public resources. In the Wakefield district council area the number of people over 85 years of age will increase by 41 per cent. between 1981 and 1991. However, there will be no commensurate increase in the funding of the National Health Service or the social services to cover that huge change of demand on the local services. David Lane, the director of Wakefield social services, told me today that if Wakefield received its share of the £1 billion worth of subsidies being pumped into the private sector this year, it would have, by a simple division of population, an additional £6.6 million to keep people in the community and not shunt them into institutional care, frequently against their wishes.
The system results in an uneven and unfair distribution of public funds. About £20 million or £30 million is given to the east Sussex area to subsidise private residential care. It must be borne in mind that subsidies ease the housing and social services burdens of local authorities and reduce their expenditure. That £20 million or £30 million should be compared with the £2 million that Wakefield gains under this exercise. There is clearly a discrepancy in the way in which various amounts are pumped into local economies. There are also differences in the numbers of people in private care. Over a year ago, New Society stated that as many as seven times as many private nursing beds existed in the south-west as in the northern region.
The most worrying aspect is what is happening to elderly people. Domiciliary care is not only a cheaper 142 option but in most cases infinitely better for the individual. I know from my experience as a social worker that elderly people live longer when they are supported in their communities by friends and neighbours rather than being moved 20, 30 or 40 miles into a private institution.
The system rewards those in the private sector who pursue the worst policies, have the largest institutions and use economies of scale by packing in more and more residents. I visited a home, which fortunately was threatened with closure, where there were seven people in one room, including somebody sleeping under the fireplace. The system rewards those who skimp on staffing and pay the lowest wages. In that regard, the private sector should be considered in detail. I know of a 17-year-old girl who is receiving —1 an hour but is left in complete charge of a private home, which is irresponsible. We must consider these facts when corn paring the two sectors.
I am not so ideologically blind as to say that there is no such thing as a good private residential home, but I agree with my hon. Friend the Member for Bristol, South that profit should not be made out of care. Small private homes offer good homely care, but are penalised by the funding system. As a matter of urgency, the Government must consider that problem.
Just as private health care ignores the chronically sick, the private care sector does not want to know those who are incontinent, confused or multiply handicapped. If those people get into a private home, they will rapidly find themselves being moved into local authority part III accommodation. I am aware of this only too well because over a year ago my mother ended up in local authority part III accommodation. I felt sorry for her and the staff because of the day-to-day problems that they faced. As a consequence of the development of private care, local authority part III accommodation is being used as a dumping ground for those who the private sector does not want to know.
The Government want to break the dominant position of local authorities on community care, which has been clear since they took office. In their first Budget they slashed 9 per cent. from personal social services at the same time as they started shunting money into private residential care. When they wanted to break the dominant position of local authorities, the Griffiths report came along and presented them with some difficulties. That is why the Government have difficulty in responding to what Griffiths said. That gentleman, who is a great friend of the Prime Minister and has done everything so well in the National Health Service and caused all the problems that many of us have to face at local level, has come up with a solution that simply is not acceptable to the Government. It means that local authorities have a fundamental role to play in the future monitoring and provision of care.
Local authorities now face many problems. They find it impossible to develop long-term plans when they are faced with the completely uncontrolled expansion of the private sector. They cannot plan for future services when they do not know how many private homes will be in the independent sector. The Government want the complete privatisation of social care. They want to see an end to the collective, public sector provision of social care.
§ Mr. Bob Cryer (Bradford, South)Does my hon. Friend accept that a clique of Right-wing extremists are in control in Bradford? Bradford is being used as a test bed by the Tory central office. The Tory party—the law and 143 order party—is in the process of selling 15 old people's homes. Although the decision is subject to judicial review and Mr. Speaker has said that we should approach a debate on the matter with caution, the Bradford Tories have shown no such respect for the law courts and have gone ahead and discussed the matter in detail in committees. That bears out my hon. Friend's point.
§ Mr. HinchliffeMy hon. Friend has made a valid point. Of all the things that have happened in Bradford, the most unacceptable, lowest point that has been reached by the new group in control is in respect of its proposals relating to the elderly. The Bradford Tories are not the first to make that proposal. Other Tory authorities have done so, but they have not gone as far as the Bradford Tories appear to be going.
The Government are actively encouraging an increasing number of large business concerns to move into the private sector. I hope that the Minister is listening, because I shall refer to an official of whom he is probably aware. An organisation called Premier Care was launched a couple of weeks ago. It is funded by—this is an example of the extent to which businesses get involved in private sector caring—Fulton Prebon Sterling Ltd., reputed to be the third largest money broking firm in the world. It is interesting that one of the directors is a Mr. Maurice Phillips, who, until earlier this year, was the deputy chief inspector of the DHSS's social services inspectorate.
The purpose of Premier Care is to set up a privatised system of registration and inspection. I cannot envisage someone who has been at such a senior level within the DHSS putting his money into a company such as that without knowing that the Government are thinking of having a privatised system not just of care but of registering, monitoring and inspecting. I should like to hear the Minister's response to that point. I can see him shuffling in his seat. I have probably spoken for too long, so I shall finish with one or two points.
I remind the Minister, who is new to his job, that about 20 years ago—around the time when I started in welfare work—the Seebohm report addressed the problem of divided responsibility for policy, resources and coordination in social services, and came up with the existing provision of local authority service, the generic departments that we have grown to know and, some of us, to love. The Seebohm report said:
The more fragmented the responsibility for the provision of personal social services, the more pronounced these problems become.The Government have deliberately fragmented the provision of services for the elderly to pave the way for private welfare; it is not accidental. In consequence, they are presiding over a scandalous misuse of huge amounts of public resources which could be directed to people who need to be supported in the community, rather than being used to support those who do not need to be in residential care.It all comes down to the fact that the Government are sacrificing the interests of elderly people on the altar of their free market ideology. It is a disgrace that there was nothing in the Queen's Speech on Griffiths or community care, and it is appalling that it has taken so long to produce any response. I want to hear some answers tonight.
§ Mr. Peter Thurnham (Bolton, North-East)I congratulate the hon. Member for Bristol, South (Ms. Primarolo) on her position in the ballot; I have tried to achieve a position as high as she has in the ballot on a number of occasions. I have only managed 13th today and I doubt whether we shall get that far, so I am glad to have the opportunity to join in this interesting debate. I look forward to the reply that my hon. and learned Friend the Minister will make. In doing so, I pay tribute to the former Parliamentary Under-Secretary, who helped me several times with matters related to care in the community. I look forward to receiving continuing help from my colleagues in the Department.
The hon. Member for Bristol, South referred to respite care, and highlighted the central question of who has responsibility. My hon. Friend the Member for Mid-Kent (Mr. Rowe) discussed exactly how well care is provided in the public sector and again asked how responsibility should be determined.
The hon. Member for Wakefield (Mr. Hinchliffe) started well by pointing out the anomalies in care for the elderly, and the fact that the Audit Commission has highlighted some of the perverse incentives. He obviously has experience of work in these matters. However, I was sorry to hear the way in which he developed his argument. He is basically a monopolist. He believes that there should be a monopoly of care and that, as long as the monopolist is provided with a super-abundance of resources, everything will be all right, but my constituents, and members of the recently formed Bolton handicap action group, which I helped to set up, are very dissatisfied at having to depend on a monopoly for their services.
The difficulty with the Griffiths report is that Mr. Griffiths obviously spent too much time talking to the providers, and too little time to the consumers of the services. We need a structure that pays more attention to the needs of those who use the services. The hon. Member for Bristol, South highlighted those points very clearly. Griffiths simply does not pay enough attention to the contribution that the voluntary sector can make. We know from the Audit Commission report that the value placed on care provided by the informal section is about £6,000 million. We need a structure that will harness that enormous contribution, help it to grow and make it fit with the system as a whole.
Unfortunately, there is not time tonight to cover all the work done by the voluntary groups. I shall merely mention some of the points put to me by some of the leading voluntary groups such as MENCAP, the Royal Society for Mentally Handicapped Children and Adults, the Spastics Society, RADAR—the Royal Society for Disability and Rehabilitation—and MIND, as well as the British Agencies for Adoption and Fostering. I shall mention too some of the outstanding contributions made by some of my constituents. One of the people who I would like my hon. and learned Friend the Minister to meet if he has an opportunity to come to my constituency is Mrs. Gibson of Legendre street. Although a single parent—a widow—Mrs. Gibson has adopted one of the most severely handicapped children from the Elizabeth Ashmore home in Bolton. The child is almost wholly paralysed, yet she has been able to take the child into her home and care for the 145 child in an extraordinary and welcome way. She is a widow, as her husband, who was a haemophiliac, died of AIDS, so she has already had a tragedy in her life.
I should like my hon. and learned Friend to meet Mrs. Cummings of Hough Fold way who has a 20-year-old son, David, who is profoundly handicapped. She faces all the difficulties, which have been mentioned already, of what happens when a child reaches the age of 19 and all the provision of care and education suddenly stops. An ordinary child may well be able to care for himself, but a profoundly handicapped child cannot. Parents may well be growing older and, as the physical size of the child and his demands become greater, the burden of caring becomes greater.
In reflecting on how Griffiths might have considered the problems differently and reached different conclusions, I think that he underestimated the voluntary sector. On page 26 he states:
this should allow the social services authority to hold the not-for-profit body to account for the proper use of public funds.Why should the not-for-profit voluntary bodies not hold the social services authority to account for the proper use of public funds? That way it might be interesting to see exactly how much money is available and exactly how well it is being used to provide care. As Mrs. Cummings said to me when I saw her last only last week:Only when local health and social services can be directed by a body with legally binding powers to provide services will proper care of the handicapped become a reality.I pay tribute to the hon. Member for Monklands, West (Mr. Clarke) for introducing his Bill which is now the Disabled Persons (Services, Consultation and Representation) Act 1986. It is directed at putting a statutory duty on whichever body is to have responsibility to provide these services, not on the basis of discretion, but generally. That is what carers seek.
How should that be done? That is the question that the Government must address. There is no question but that it must be done. Only last week my right hon. Friend the Secretary of State said:
Everyone agrees that there is a serious problem",and:few people think that the status quo is highly satisfactory."—[Official Report, 13 December 1988; Vol. 143 c. 771.]There are calls for the 1986 Act to be implemented, calls for the Griffiths report to be implemented and calls for more funds. But I suggest that we could pay some regard to the suggestions of the Department of Employment. I refer the House to the White Paper "Employment for the 1990s" and what it says about training and enterprise councils.Enterprise councils are to be formed locally and two thirds of their composition should come from the private sector. They will help to direct a budget of £3,000 million. Each council will have a budget of about £25 million. Therefore, if a local care in the community council were formed in each area, was responsible for administering a budget and consisted predominantly of people from the voluntary sector, they would decide how the money was to be spent. They would hold to account the social services department and the health authority on exactly how they provide care. They would be responsible for harnessing the enormous resources of the voluntary sector to provide care in the form in which it is wanted.
I recommend that the Government should seriously consider setting up local care for the community councils, 146 two thirds of whose members should be representatives from voluntary groups and one third officials from local and health authorities, family practitioner committees, the Departments of Health Social Security and any other relevant official bodies. The chairman of such a council should be an independent person. That council should then bid for the power to direct spending. It should have a life of, say, three years, after which it would have to bid again to have the power to continue. If it could not administer its functions properly, another body could be formed which could bid to do the job. Such a council could take over the powers currently exercised by the joint planning committees, which are made up of local and health authorities.
I do not suppose that such a proposal would be welcomed by official bodies, whose powers would be weakened, but I believe that it would much better serve the interests of the disabled and their hard-pressed carers than the monopoly institutions which presently have that job, and which the Griffiths report calls on to provide the care in a future structure. The Government have been right to hesitate before leaping to take on the Griffiths proposals. That doubt is shared by individual carers, who do not want to be in the hands of any such monopoly. They would rather have the services directed by people with experience of using the voluntary sector rather than just bureaucrats.
The subject of community care has been on everyone's lips for some time—in fact, it goes back 30 years—but to many people its implications are largely unknown. Most people have just a vague idea of the large mental hospitals closing down. For years, community care has been little more than political rhetoric and idealistic policies and has had nothing to do with the realities of ignorance and the neglect of the handicapped and their carers in our society.
The majority of mentally handicapped children and adults have always lived in our society until their parents could no longer cope. Some 70 per cent. of mentally handicapped adults live with their families. That voluntary care, which has been valued at —6,000 million by the Audit Commission, must be increasing year by year. It is clear that the parents are the backbone and the basis of community care. Support for them must be the main task of community care. That support should consist of the provision of respite and day care centres which can properly cater for their requirements.
Community care should mean an end of the need to choose between care by the family and care by the state. Et is scandalous that the only way in which a profoundly handicapped person can receive a dowry is by going into an institution for at least six months. That should not be the only way in which a person can gain entry into a neighbourhood network scheme.
When compared with mentally handicapped adults, mentally handicapped children are relatively well catered for, which is simply because all children must receive full-time education. However, when they reach the age of 19, they are suddenly forgotten. It is as though, like normal children, they are considered sufficiently prepared for the outside world and have no need for further care.
I would like to raise the points made to me by the voluntary groups when we have a full debate on community care. I am sure that all the hon. Members who have spoken would like the opportunity of a full debate on 147 this subject. I hope that I can put some of those points in letters to the Minister, if I have not sufficient time to raise them now.
One of the things that worries parents greatly is how to make provision for their children which is not a substitute for state benefits. If someone wins the pools, he does not lose his pension, but if a disabled person receives an inheritance he immediately loses his entitlement to some of his benefits. That is unfair and I hope that that is also addressed by the Government.
Mary Holland of MENCAP has said:
how we respond to the needs of people who for too long have been denied their rightful place in the community—who for too long have been 'out of sight and out of mind'—will show our true worth as a 'civilised society' approaching the 21st Century.Our challenge is to find the right structure in which we can harness both the resources of the public sector—at central and local government level—and the enormous resources that can be made available on a voluntary basis.
§ Mr. Tom Clarke (Monklands, West)I warmly congratulate my hon. Friend the Member for Bristol, South (Ms. Primarolo) not only on her success in the ballot for the debate, but on introducing the debate with an outstanding speech that was comprehensive and sincere. It helped the House to identify the many problems associated with community care.
Had my hon. Friend the Member for Halifax (Mrs. Mahon) been successful in participating in the debate, she would have said a great deal about social security, lodging allowances and so on. That underlines how crucial it is to have a full-scale debate on community care, preferably in Government time. It is a great pity that tonight's debate has underlined the fact that no such full-scale debate has taken place.
I also wish to congratulate my hon. Friend the Member for Wakefield (Mr. Hinchliffe) who spoke with considerable authority, as one might expect, given his experience in social services. I know that the House listened carefully to many of the points that he made. The hon. Members for Mid-Kent (Mr. Rowe) and for Bolton, North-East (Mr. Thurnham) gave outstanding support to the Disabled Persons (Services, Consultation and Representation) Act 1986. I am particularly grateful that they mentioned that Act in their speeches tonight.
As my hon. Friends have said, we are not without information, research, advice and opinion on this matter. Hon. Members have mentioned the Griffiths report. When the Minister replies, I hope that he will be more forthcoming about that report. Time after time, we have asked his right hon. Friends, including the Prime Minister, to tell us what they think of that report. It was published in March and it is extremely thoughtful.
Months before, when we asked questions about personal social services and community care, we were told that we should wait for the Griffiths report. We did so patiently, but now we are asked to be even more patient in awaiting the Government's response to it. I hope that the Minister will seize the opportunity tonight to tell us precisely what the Government will do about Sir Roy Griffiths' views. Virtually everyone who has spoken tonight has asked for such a response.
148 We have also heard mention of the 1985 report of the Social Services Select Committee, which contained 101 recommendations, and of the Audit Commission report. My hon. Friend the Member for Wakefield rightly reminded us that that report talked of community care being in disarray. All of our concerns about community care find some refuge in almost every section of the Disabled Persons (Services, Consultation and Representation) Act and I am grateful for the references made to it tonight.
The hon. Member for Mid-Kent spoke about advocacy. As he knows, that is in the Act. The hon. Member for Bolton, North-East spoke about consumers. If ever an Act attempted to reflect the views of consumers and to give them a say in service provision, this was it: its very title uses the word "consultation". Two and a half years on, it is extremely distressing to find that only a modest attempt has been made to implement that Act. Sections 1, 2, 3, 7 and 11—some would say these constitute the meat of the provisions for community care—have still not been implemented by the Government. We are entitled to ask, why not? At the time of the Act's passage, there was a great deal of support for it in both Houses. There still is, but millions of people with disabilities and their carers still wait for its full implementation.
As Christmas approaches, we should think about the problems of community care, if only because 90 per cent. of these people—the elderly, the mentally handicapped and the mentally ill—live in the community. Government funding does not reflect that proportion: quite the reverse. It concentrates on residential care or on the NHS. We certainly want proper funding for the NHS, but on the basis of a clearly identified strategy for community care, which recognises that people are entitled to enjoy independence in the community, properly supported by occupational therapy, the home help service and so on. People should not be driven as a matter of necessity, rather than of choice, into residential care, which may not be in their interests.
How can we ignore, particularly at this time of year, the housing crisis in this country? Housing investment has been cut in real terms by 60 per cent. under this Government. Council house starts are at an all-time low. Housing subsidies have been eroded. The consequences of this have been brought to our attention repeatedly, not least in Scotland by Mr. Laurie Naumann, the director of the Scottish Council for the Single Homeless. His document, called "The First Four Weeks", deals with unemployed homeless young people who know all about lost income support and YTS jobs that do not exist.
We condemn the Government's approach because it offers no clear strategy for community care or for evolving a relationship between the providers and consumers of care.
The Government talk of cost-effectiveness. There is not much evidence even of that, as was clear from the Griffiths and Audit Commission reports. The revolving door syndrome can be seen especially in the discharging of patients from long-stay psychiatric hospitals. There is nothing efficient about that. Section 7 of the 1986 Act makes it possible at least to deal with people who have been in psychiatric hospitals for six months or more. Many of them are sent out into community care that does not exist. Many find themselves in prison, or in places entirely unsuited to their needs. 149 The Government's policy of running down hospital provision and closing wards and of not providing sufficient bridging funding is not a substitute for proper community care. In many ways, it weakens the concept of community care, as the Opposition understand it. The tragedy is that the Government are not even attempting to identify the problems nationally. Several times I have tabled questions to the former Minister, the hon. Member for Derbyshire, South (Mrs. Currie), and in reply after reply it appears that central information does not exist. There is no incentive for people to provide local plans.
I realise that time is running short and I am anxious to accommodate the Minister, so I end on this note. The Opposition's attitude to proper provision of community care represents a challenge to poverty, homelessness and neglect. For that reason, we cannot place all our faith in the free market. How can we, when in New York it has produced 30,000 former psychiatric patients on the streets? How can we do that, when we know of the problems that exist in London and in many other parts of Britain? We believe in a policy of mutuality of concern for service provision; in insisting on the rights of the consumer; and in a community care priority that is crying out to be met.
§ The Minister for Health (Mr. David MellorI am glad to follow the courteous speech of the hon. Member for Monklands, West (Mr. Clarke). I too would have liked the House to have had the opportunity of having a longer debate on community care. It is an important issue to which hon. Members on both sides of the House have something to contribute. Although I do not determine the business of the House, I dare say that if the will is there on both Front Benches, it should be possible to have a longer time in which to discuss the matter.
§ Mrs. Alice Mahon (Halifax)rose—
§ Mr. MellorI am genuinely sorry that time was not available for every hon. Member who wished to speak. I could not reasonably have been expected to take any less time than the nine minutes with which I have been left. One or two others might, with advantage, have compressed their remarks a little. If the hon. Lady has a point to make, I shall be happy to accept an intervention in my speech.
§ Mr. John Battle (Leeds, West)rose—
§ Mr. MellorThe same goes for the hon. Gentleman. If they would allow me to get into my stride for a minute or two, I should be happy to give way to them. People who stay up until 1 am are entitled to have their say.
I have noted the points made in the debate. Some common threads ran through the speeches with which I had no difficulty agreeing, but honesty compels me to say that I cannot fully endorse some comments by Opposition Members. As I shall show, there has been a formidable underestimate of the additional resources that have flowed into community care during the past decade.
As one of those who find a good deal of the argument in Sir Roy Griffiths' report most compelling, it saddens me that those who are troubled about the emphasis that he places on local authority provision base their objections on the fact that some local authorities cannot recognise that the proper provision of community care must be a fair balance between the individual carers—about whom the 150 hon. Member for Bristol, South (Ms. Primarolo) had some important words to say—and local authority provision. In my constituency, I have always worked closely with my local social services department, and I know the good work that is done in the country. But we should not forget the voluntary and private sectors.
The attacks on the private sector by the hon. Lady and by the hon. Member for Wakefield (Mr. Hinchliffe) were unconvincing and redolent of another age, but they provide good ammunition for those who say that the voluntary and private sectors would not get a fair judgment if Sir Roy Griffiths' analysis were followed. I am reluctant to arrive at that conclusion, but it behoves all of us to take off our ideological blinkers, look at the situation in the round and recognise that good community care will be a balanced contribution from a range of sources.
§ Mrs. MahonMy point concerns hostel charges and the change from board and lodging to housing benefit which could mean a 30 per cent. cut in provision. Will the Minister give us a sign of future funding arrangements and a guarantee that we shall not see a cut in funding to the valuable hostel services, particularly women's refuges?
§ Mr. MellorI am glad that the hon. Lady has registered that point, which largely concerns the Department of Social Security. I shall ensure that she receives a full answer either from me or from my colleague at the Department of Social Security.
It is clear that there has been a dramatic increase in community care resources. For instance, when the National Audit Office considered the period 1976–77 to 1984–85, it indicated that there had been an 18 per cent. real terms increase in expenditure on services for the elderly, the mentally ill, the mentally handicapped and the physically disabled. The personal social services provision or 1989–90, which has just been established, has been set at £3.3 billion. That is over 10 per cent. more than was provided in the 1988–89 settlement and so allows for considerable growth, even discounting inflation. Between 1983–84 and 1987–88, local authorities, which have always had a crucial role to play, increased their expenditure by more than 20 per cent. in real terms.
We must be careful not to underestimate the extent of the additional provision that we have seen in practical terms. Many of us are concerned about mental handicap because few of us do not feel touched by those problems. The hospital population fell by about 15,000 between 1976 and 1986, but the number of day care and residential places in the community rose by over 50 per cent. more than that. There were over 26,000 additional places, which is a sign of the growth in provision that we all want to see.
The hon. Member for Bristol, South rightly attacked Victorian institutions with large wards. Obviously there will continue to be a need for various kinds of institutions, but community care—
§ Ms. PrimaroloWill the Minister give way?
§ Mr. MellorThe hon. Lady took over 20 minutes, although I do not blame her for doing so. She is entitled to have her say, but I should like to say a few things myself.
Similarly, when one considers mental illness, between 1976 and 1986, the number of residential care places almost doubled and places in day centres increased by almost two thirds. 151 It has been pointed out that the number of people over the age of 85 will grow. Our figures suggest that the number will more than double by the year 2011. Obviously there is a formidable task ahead of us and we will be better equipped to meet it if there is genuine partnership between national and local government. Local government is full of people who recognise the need for good voluntary activity and that the private sector can play its part. If one cuts away some of the ideological overlay in the speech of the hon. Member for Wakefield. one sees that there was at the heart of it a point that few of us can deny—that there is a perverse incentive that makes it easier for people to go into residential care than to stay in the community. I regret that. It is not helpful and I note that almost everyone who has looked at community care has denounced it and has asked for a proper gatekeeper.
I am sure that there are certain truths that all of us who work in the community in a practical way—as Members of Parliament do—cannot deny. One of them is that people do not want to go into institutions. They go into them as a last resort. Central to any reshaping of community care, which cannot be delayed for long, is a recognition that domiciliary services will have to expand and we will have to look far more carefully at the basis on which people enter long-term care which most people would not enter it there were the opportunity to stay in the community. It is not simply a matter of keeping people in the community. We must also consider retraining people to return to the community. There is a good record of that around the country and we must build on it.
I accept that in closing the large institutions we must not consign patients to the wind or breeze of fortune. There must be adequate provision for them in the community. That provision is being built up. I have had the privilege to visit many marvellous projects established to satisfy that provision. We want more of them, and I believe that between us we should be able to find the resources to make that possible.