§ Mr. David Hinchliffe (Wakefield)
I beg to move amendment No. 1. in page 2, line 34, at end insert—'(1A) No arrangements shall be made by virtue of this section with respect to a person being transferred into accommodation from an NHS hospital or trust unless the voluntary organisation or other person concerned has ensured that that person is provided with a care plan and the authority is satisfied that such arrangements will facilitate this plan.'.The purpose of the amendment is to provide for a clear care plan when individuals are placed in an establishment under the Bill. I shall give the reasons behind the Opposition's concern, and will refer first to the White Paper "Caring for People—Community Care in the Next Decade and Beyond". It sets out clearly the national health service's role in providing continuous health care. I refer to the White Paper because my hon. Friends and I believe that the Government's actions do not follow the words of the White Paper. Paragraph 4.20 states:There will … always he some people who cannot be supported in their own homes. Where such people require continuous care for reasons of ill-health, it will remain the responsibility of health authorities to provide for this.In practice, that paragraph is meaningless. Continuous care is not occurring in hospitals and other places throughout the land.
There have been huge reductions in the provision of care for the elderly. The national health service is clearly divesting itself of its responsibilities, with, I believe, the implicit blessing of the Government. Figures in the "THS Health Summary" of January 1992 show clearly what the position is. According to that journal, three quarters of health authorities had reported that in recent years they had cut the number of long-stay beds for the elderly. It also stated that closure plans would reduce NHS beds for the elderly mentally ill by 36 per cent. from 1990 levels. Everyone is aware that that number had been substantially reduced before 1990. The plans would reduce other geriatric beds by 25 per cent. and, even counting the private beds that have been bought for the NHS, the numbers would be down by 15 per cent. and 12 per cent. respectively.
There have been many expressions of concern about the implications of that process. The Age Concern report entitled "Discontinuing Care" and published in 1991 shows great anxiety about the attitude of the NHS towards care of the elderly. At that time, the director, Sally Greengross, said:Long term hospitals may not have appropriate places for the care these people need, but this does not relieve them of the responsibility to provide and fund care for people who are defenceless and in need of total care.The Age Concern report showed that some district health authorities now have no provision for elderly people needing continuing nursing care. That is worrying for many patients and their relatives and carers.
857 The Government say that provision is now in the private sector. The National Association of Citizens Advice Bureaux evidence produced not long ago shows that many patients and their families are never told that NHS funding is available for continuing nursing care. When they have to obtain such nursing care within the private sector, those patients and their relatives are often forced to meet the huge gap between what income support will provide and the weekly cost of the fees. I am aware of many people who have to spend their entire pocket money from their allowances on meeting the cost of care fees. This has been discussed many occasions.
I am concerned about the implications in my locality of the process that I have described. Since 1979, in the Wakefield health authority area, I have seen 1,000 beds removed from the NHS. Those beds were taken from hospitals catering for people within my constituency and were used mainly for elderly people. That shows why we feel that, especially in care for the elderly, there must be care plans for people discharged from hospitals and trusts. Some 200 of those beds in the Wakefield area were in the acute sector. The Government's figures show that about half the people catered for within the acute sector are elderly people.
In my constituency I have seen the closure of County hospital and Snapethorpe hospital in Wakefield, both of which catered primarily for the elderly on a long-stay or short-stay respite basis. The needs of those people are now met primarily, if they are met at all, by carers in their own homes or by the private sector. We know from the Carers National Organisation the struggles that many people have in caring for their relatives or loved ones. The recent report, "Speak Up, Speak Out", produced by the Carers National Organisation reveals the problems. Those who are not cared for within their own homes are placed in private homes. The process in my constituency—it is reflected in every constituency throughout the country—is that NHS provision has been run down or closed and people are shunted into the private sector. If that is not privatisation of the health service, I do not know what is.
At a national level, we are seeing the trend towards shifting the cost of long-term care from the health budget to social security. The National Institute for Social Work produced a commendable report in January 1992. It was entitled "Great Expectations". That report says that the transfer of elderly care from the NHS to the social security budget is feasiblewhile the social security budget for such care remains open ended but will present a very different picture when that budget becomes cash-limited on transfer to local authorities in 1993.There are serious questions being asked about whether the 1993 changes will go ahead as planned. That point may be picked up by my hon. Friends or by some Conservative Members. We are well aware that the options include a further deferment of these proposals or the transfer of the lead agency-purchaser role directly to health authorities either at local or regional purchasing level. That would avoid the local authorities having that lead agency function.
That option has been talked about widely within the care community. Such uncertainties make the need for care plans related to the placement of' people directly from hospitals or from trusts even more essential and back up our belief in the need for such plans to be prescribed in the Bill.
858 Amendment No. 1 refers specifically to trusts as well as to NHS hospitals. We have reasons for including the term "trust". We believe that there is clear evidence of trusts positively obstructing the processes of proper community care planning. I made the point in Committee on the National Health Service and Community Care Act 1990 that the NHS and community care elements of the Act were contradictory. We are now beginning to see in practice that those of us who made that point on many occasions were correct in our assessment of what was likely to happen.
I give one fairly well known example which explains our belief in the need for the amendment and ties in with the concern about trusts. The City and Hackney health authority, which was slimming down for trust status, shunted about 30 elderly demented patients to a private nursing home called the Pines near Skipton in Yorkshire. That private care home was run by an organisation called Burley Health Care. I asked the Minister where the care plans were in respect of the placement of those vulnerable demented people. The care plans did not exist. That case, along with many others that we could quote, evidences the need for amendment No. 1.
The case of those elderly people was exposed by "Panorama", to its great credit. Those people were dumped by a trust applicant and sent up to Yorkshire, where there would be Department of Social Security funding away from the health service budget and away from the area in which they had been brought up and had lived all their lives. They were sent to a strange locality and to a different system of funding. As we know from "Panorama", conditions at the Pines were appalling. Serious questions need to be asked about the role of the City and Hackney health authority and about Airedale health authority.
I am pleased to see the hon. Member for Macclesfield (Mr. Winterton) in his place today. He was Chairman of the Select Committee on Health, and I normally have a reasonable relationship with him, but on one occasion he ruled me out of order. When we were studying the issue of trusts, I asked a question about the role of Airedale health authority. The hon. Member for Macclesfield will recall that, on 4 March 1992, Mr. Edward Bishop, who was described as "director of healthcare contracting" in the Airedale health authority, gave evidence on trusts. I raised with him the way in which the 30 people from City and Hackney health authority had been treated and the role of Airedale health authority in that respect.
I am not sure that the hon. Member for Macclesfield, for whom I have some respect in his role as Chairman of the Select Committee, fully understood my point. What was clear from the evidence given by Mr. Bishop was that he washed his hands of any responsibility for those people's appalling situation. I quote from Mr. Bishop's response to a question of mine on 4 March 1992 in the Select Committee:I have to make it quite clear, there is no role for what might become the Health Authority of residence to play in that we are free as individuals in this country to move from one part of the country to another.That was his response to the case of people who had been sent from London and dumped in a completely unsuitable, shabby private nursing home in the Yorkshire dales. There was no proper monitoring and no proper care plan.
When Mr. Bishop talks about freedom, he is talking about 30 seriously demented elderly patients who, I 859 suspect, had no choice about moving from London to Yorkshire. On care planning, the key issue is that Airedale health authority was responsible for the registration of the Pines nursing home. It had a clear responsibility, although that was obviously not accepted by the gentleman who gave evidence to the Select Committee. That is one example among many that we could cite to show that the need for clear care plans in the Bill is self-evident.
The need for care plans as a result of the creation of trusts is also evident from comments on behalf of other service users. I have spoken primarily of the elderly, but other groups such as the mentally ill benefit from care provision and will be affected by the Bill. In its evidence to the Select Committee, MIND made it quite clear that it saw no incentive for trusts to collaborate with agencies outside the health sector.
In respect of people with learning difficulties—some use the term "mentally handicapped"—with the advent of trusts, the Government have introduced a policy that contradicts the thrust of community care policy over the past 30 years. The Mental Health Act 1959, the 1971 Command Paper "Better Services for the Mentally Handicapped", the 1979 Jay report and numerous reports issued by the Department of Health and Social Security in the 1980s, including "Getting Mentally Handicapped Children Out of Hospitals", were all about the normalisation of care of people with learning difficulties, away from hospitals. They were all about the community. With the advent of trusts, the Government are thus running counter to the trend that has prevailed for the past 35 years. No one seems to have picked that up.
I note with interest the evidence given to the Select Committee by the organisation Values Into Action. The hon. Member for Macclesfield will recall that evidence, which was impressive. According to that organisation, the effect of granting trust status to health service learning difficulties units has been actively to promote the concept that they are the appropriate provider of care for people with learning difficulties, and that those people should be retained in long-stay hospitals. That contradicts the thrust of successive Government policies on community care over the past 30 years.
The Values Into Action report "When the Eagles Fly" substantiates that argument in great detail and clearly shows that the Government's health changes are working against the wishes and best interests of people with learning difficulties. The report states:As far as learning difficulties are concerned, the 1990 National Health Service and Community Care Act introduces a direct conflict between ongoing health care, as perpetuated by the new trusts, and the development of community care as the responsibility of social services.The organisation's worrying comments conclude:The overall picture emerging from the research is one of chaos and confusion in services for people with learning difficulties … Anarchic is hardly too strong a description of a situation in which service models vary so widely and frequently display disregard for stated public policy.The organisations that gave evidence to the Select Committee stated clearly that community care is in disarray. The term "anarchic" is used by an entirely responsible national organisation that knows what is happening at grass roots level. It is deeply concerned—as 860 are a vast number of organisations dealing with a whole range of client groups—about where we are heading on community care.
§ Dr. Liam Fox (Woodspring)
If there is disarray in the implementation of the community care provisions, it is because left-wing social service units are refusing to take full account of the discussions that they were supposed to have with medical units and so on. Why is it that the Royal College of Nursing tells us that 75 per cent. of carers are not being asked by social services what they should do, that local management committees are not being asked, as the British Medical Association told us last week, and that private homes are having no discussions about how they can be involved in the plans? The failing lies not with Government plans but with implementation by social services.
§ Mr. Hinchliffe
The hon. Gentleman will get a chance to air his views as the debate continues. It is silly and naive to talk of left-wing councils because there are concerns about local authorities of a variety of political complexions. There are also concerns within local authorities that they have not been enabled to enact the provisions contained in the National Health Service and Community Care Act 1990.
If the hon. Member for Woodspring (Dr. Fox) wants to debate the position of local authorities, I am happy to refer him to information in the House of Commons Library which shows that the Government that he supports have taken £6 billion out of local authority personal social services, which is one reason why community care is in such a shambles at local level. I shall be happy to intervene on the hon. Gentleman when he is able to advance his argument in more detail.
In Committee, the Minister responded that we were suggesting interference with the free play of market forces by proposing additional legislation for care plans and a range of other issues that we felt should be covered by statutory provisions in the Bill. The Government's philosophy is clear from their record on community care. It entails abandoning vulnerable people to the free play of market forces. We are not talking—[Interruption.]
If Conservative Members do not agree, we can consider what has happened in detail. Frankly, the record of some care homes is abysmal; care is being left to the market. We are not talking about distributing sacks of potatoes, but about human beings. Sacks of potatoes might well be usefully distributed by market forces, but that is not a mechanism to deal with the care of elderly, learning-disabled and handicapped people. It is not the correct model. That is apparent if one studies what has happened in the past decade.
The Bill deals with human beings and they deserve proper treatment—the best treatment, which should be secured by ensuring that appropriate plans are made. They are set out in amendment No. 1 and I hope that the Minister will see fit, just for once, to accept an amendment to the Bill.
§ Mr. Nicholas Winterton (Macclesfield)
I am pleased to follow the hon. Member for Wakefield (Mr. Hinchliffe), who has deployed his case in support of the amendment extremely well. He played a vital and informed role in the previous Parliament as a member of the Select Committee on Health. He drew our attention to an occasion when, as Chairman of that Committee, I was forced to rule him out 861 of order. He has not advanced all the detail of the incident to the House, but I am sure that he will admit in the mature light of day that I was not out of order in ruling him out of order in what he was seeking to do. Having done so, I was entirely confident that the hon. Gentleman was ingenious enough to secure an even larger audience for his remarks, and he has done so today. I commend him for doing so because, as a Conservative Member, I share his concern. We must ensure that proper, responsible and well-prepared care packages are available for every person discharged from a long-stay care institution into the community.
The hon. Member for Wakefield drew our attention to 30 demented and confused elderly people, who were discharged from a hospital in the City and Hackney health authority to an institution in Skipton, Yorkshire. That is thoroughly undesirable, and I was tempted to intervene when he discussed the matter to ask whether those involved with the 30 elderly people—parents, relations and other close acquaintances—were consulted about whether the elderly people should be discharged to places almost at the other end of the country.
Surely, part of any care package is visiting rights for the friends, next of kin and relations of the people in care. That is clearly important when caring for elderly people. I wonder whether any thought was given to how those who were involved with the 30 elderly people might keep in contact when the group was moved hundreds of miles away to Skipton in Yorkshire.
My hon. Friend the Minister has a splendid history of concern and, dare I say it, involvement in working for vulnerable and minority groups. His involvement with the Spastics Society was well known and respected. Is he worried that the national health service appears to be interested only in treatment and is decreasingly interested in the provision of care? That is a matter about which Conservative Members are gravely worried. I have expressed my anxiety to the Government for a long time, so my hon. Friend the Minister cannot find my position unexpected.
I suspect that I share much of the anxiety expressed by the hon. Member for Wakefield about establishing almost a private sector monopoly in the provision of care for the elderly. Many of us believe that the health service has a role in not only treating but caring for people. We fear that the role is increasingly being discharged to the private, independent or charitable sectors.
I do not suggest that the independent, private or charitable sectors do not have a vital role to play. I believe that they have and that in many instances they can make provision that is supplementary and complementary to NHS provision. I should hate however, to see the provision of care for the elderly, the mentally ill and the mentally handicapped fall entirely into private and independent hands. I hope that when my hon. Friend the Minister replies to the debate he will give us some assurances. Those of us who have taken a deep interest in these matters for many years are worried that some of the accommodation provided by the independent sector leaves much to be desired.
We also place in some difficulty the families of people who are discharged from the NHS into the independent and charitable sectors. As the hon. Member for Wakefield said at the beginning of his speech, when people are cared for by the health service all the facilities are provided free. The total cost of the care, the accommodation and so on 862 is covered. When people are discharged from the NHS, however, charges are levied. Whether those charges are picked up by the social security system through income support or in other ways, or whether they are picked up in part by the families, charges are made.
I and many hon. Members on both sides of the House have had traumatic experiences in dealing with families who have come to us about their difficulty in meeting the additional cost, which cannot be met through social security, of care for relatives who have been discharged into accommodation in the independent, private or charitable sectors.
I hope that in this short debate my hon. Friend the Minister will give some assurances, especially to Conservative Members who understand the concept of what the Government seek to achieve. We believe in the concept of community care, which draws considerable additional private resources into the provision of care for the elderly and other vulnerable groups, such as those with learning difficulties. Those additional resources were not available previously. We believe that our policy will provide choice.
The hon. Member for Wakefield always speaks with great clarity, knowledge and experience, but he did not refer to the element of choice. One of the key concepts of community care is the provision of genuine choice for the individual. I wonder whether the system that will operate after 1 April 1993 will provide such genuine choice, which is the essence of a successful community care policy.
I hope that, on this occasion, my hon. Friend the Under-Secretary will be a little more generous and perhaps a little kinder in his response to a very humble Back-Bench Member who feels things deeply.
§ Ms. Liz Lynne (Rochdale)
I support the amendment because it is essential that we have a care plan for those who leave NHS hospitals and trusts. Without such a plan, tremendous difficulties could arise. That plan must be the result of full consultation with everyone concerned. The user, the client, must be consulted or, if that is not possible, that person's relative or advocate should be consulted.
Without a care plan, problems could arise as a result of people being transferred into inappropriate residential accommodation. I accept that large organisations, such as Age Concern, have been consulted and I know that carers in some local authorities have also been consulted. However, smaller voluntary organisations have not had access toomuch of that consultation process.
In Rochdale, I formed the alliance for community care with another person to ensure that smaller voluntary groups were consulted and were able to discuss the care plans for people coming out of NHS hospitals. It is essential that the Bill is amended to ensure that all voluntary organisations are consulted.
Adequate resources must be made available to assist transfers. The other day, I met the Rochdale social services director to discuss the problems that might arise when people are transferred to private or residential nursing accommodation without the necessary resources being made available. In the past, I have drawn attention to the problems caused by the income support levels, which do not meet the costs of residential or nursing home care. Invariably, a patient's relatives have to top up the patient's share of those costs. It is essential that the actual cost of 863 residential or nursing home care is met by the Government rather than through income support. The problem is particularly severe in the north-west where more people are in residential accommodation than the population figures would suggest. For that reason, I make a plea for the real costs of such accommodation to be met.
Local authorities of different complexions—Labour. Conservative and Liberal Democrat—have had problems in attempting to implement all the community care provisions by 1 April 1993. We therefore need a national plan so that each local authority knows what is expected of it. I know that the Bill provides for some planning, but a true care plan for those coming out of NHS hospitals is essential. For that reason, I support the amendment.
§ Mrs. Helen Jackson (Sheffield, Hillsborough)
I support the amendment. I was not a member of the Committee that considered the Bill, but I know that the majority of its discussions centred on the transfer of patients out of local authority care into that of the independent sector. I am concerned about the future role of health authority care and the transfer, or non-transfer, of patients who currently receive chronic, long-term residential accommodation and nursing care in the NHS.
I was struck when, in October 1991, I saw the concerns that were expressed in the fourth report of the Select Committee on Social Security. One of these wasthat the obligation on health authorities to provide nursing care for those who cannot or do not wish to pay for it should be strictly enforced and that health authorities should not evade what are properly their responsibilities.That is an important recommendation, and it is well understood by patients in my constituency who live in one of the few community-based residential nursing homes run by the health authority. It is a small establishment in which there are 30 elderly patients. The staff are most experienced and very well established. The home has close links with the community and the local general practice. I have some personal experience of private and independent sector private nursing homes, having been involved in casework, and I know that the home is a model of what residential nursing homes should be.
When it was proposed that these elderly patients should be transferred from health authority care into the independent sector, it was clear that they understood exactly that the central feature—with which I agree—of the NHS is that it is not free and that they had paid all their working lives for what they were to receive. They were of the view that, having reached the stage of requiring nursing care day and night, they should be entitled to receive it through the health service.
This point must be made strongly. Like Sheffield community health council, I am extremely concerned about some of the implications of the report of Sheffield health authority on the future strategy for services for elderly people in our area. In the report it is argued:There are no clinical reasons … why an individual in a chronic, stable condition should be cared for in an NHS setting rather than in a nursing home outside the NHS, or"—and this is fine—in his or her home".The authority tries to draw a distinction between elderly people with dementia and elderly people who simply require nursing. It is quite impossible and entirely inappropriate to draw such a distinction.
864 The authority goes on to argue that the NHS should therefore work towards supporting provision in the independent sector and should seek to withdraw its own capacity to provide long-term care for such individuals. It then argues, entirely illogically, that that is especially important because there is an increasing need for elderly people to receive such long-term care, that the cost is too high for the NHS to bear and that there must therefore be faster work to transfer the duty from the NHS to the independent sector.
It is my view, and the view of Sheffield community health council, that the important thing is need and not the resources of the health service in any particular areas and that, until it is absolutely clear that there is adequate provision in some other context for elderly people in need of long-term nursing care, no more beds in the health service in the Sheffield area should be withdrawn.
The debate is an opportunity for the Minister to make it clear to health authorities that they have a duty to provide a service for chronically sick or disabled people in need of day and night nursing, whether it is provided in their own homes through community nursing services, by a combination of home, day or short-stay residential care, or in long-term accommodation. The Government will accept that the most appropriate residential care is delivered in community-based nursing homes with easy access to family, friends and local general practitioner services. We have heard about the appalling example of the transfer to Skipton, where people were moved a long distance from where they were content and felt comfortable.
Patients in the model nursing home in my constituency kept saying, "This is our home." They meant that they were familiar with the rooms, the staff, the locality where they had lived all their lives and the costing system. It was helpful w hen the Minister said a few weeks ago that it was Government policy that no NHS patient should be transferred into private or independent care without his or her consent. That is an important principle, but we need to go further and recognise the significant difference between long-stay patients in the NHS and residents in nursing homes for the elderly, run by private or charitable institutions. In the first instance, payment has been duly made during a lifetime of work. In the second, payments must be requested from the social security system after full disclosure of the household's income and means. If top-up moneys are required, the family pays a second time for a service that it has already financed.
Will the Minister make it crystal clear to health authorities throughout the country that whenever a transfer is proposed, whether patients are to be physically transferred to another place or not, it amounts to a substantial change for the patient and his or her family. It must therefore be the subject of full consultation with the patient and his family, as well as the community health council in the case of an institution such as the one in Sheffield. It needs to be made clear that the financial change is so substantial that it must be subject to the full consultation procedure.
I make these points not only on behalf of my constituents and my relatives, with whom I have a personal and close relationship, but for ourselves, too. We are paying into the NHS, week in, week out, and so are our families. Where do we want to receive nursing care when we reach an age at which we may require it?
§ Mr. Kevin Hughes (Doncaster, North)
It makes a change to take part in a debate in which there are few differences between the Conservative party and the Opposition. However, that has its drawbacks, as it tends to attract little, if any, media attention. The issues, which we have already debated in Committee and on Second reading, are important to those they affect. It is unfortunate that, as there is little difference and not much political fighting between the parties, there will be little media coverage.
Amendment No. 1 seeks to ensure that a person in residential care such as the Bill provides is given a care plan. In the context of community care, the provision's central plank is high-quality care for vulnerable adults who require it. While much emphasis is placed on the care needs of those living in their own homes, there is a danger that the needs of those in residential care will take a back seat, so enabling such residential establishments to be seen as a place of last resort. That is unacceptable.
As I said in Committee, residential care should be a positive choice made by the resident, the carer and, ideally, the care manager who helps to put together the care package. There should be plenty of time for people to shop around and see which care home is appropriate for their needs. They should have time to look at the inspection reports of various homes and make a positive choice of which one they prefer to live in. If that is done properly, care plans—emphasising the needs and views of the person involved—can be made. The informed choices and expectations of the individual should be followed wherever possible.
Care plans should recognise the rights of individuals to achieve the highest possible quality of life and, where appropriate, to receive a range of therapeutic and remedial services to maximise and maintan levels of independence. They should be able to exercise choice about how they live and ensure their dignity and self-respect, including their physical, emotional and spiritual needs.
Research has shown that most older people do not wish to live in residential care. It is widely acknowledged that, given a choice, they would prefer to live in their own homes. The importance of residential care as a stepping stone hack into the community has been neglected. A good care plan would seek to achieve that preferred option for the individual where appropriate. That would apply particularly to many of those who live in the smaller residential homes to which the Bill relates.
However, there is no incentive for private residential homes, particularly smaller ones, to have a care plan that envisages using those homes as a stepping stone back into the community. I do not want to repeat the arguments adequately made by my hon. Friend the Member for Wakefield (Mr. Hinchliffe) in Committee. Due to the funding that private residential homes receive, there is no incentive for them to work towards getting people back into their own homes and into the community.
National health service hospitals and trusts should not be allowed to divest themselves of their responsibility to provide continuing care where appropriate. It is unacceptable to place pressure on vulnerable adults and their carers to accept a standard of care that is inappropriate for them. If it is to have real meaning, the concept of choice and seamless care requires recognising an individual's needs as paramount.
§ Mr. David Lidington (Aylesbury)
I agree with the hon. Gentleman about the need for close co-operation between NHS trusts and county or borough social service departments, which is exactly what is happening in my own authority, Buckinghamshire. Will the hon. Gentleman and his hon. Friends give the House an assurance that they will do all in their power to encourage and persuade Labour-controlled local authorities to consult those in NHS trusts about how they can work together to provide the highest quality of care?
§ Mr. Hughes
I am grateful for that intervention, because it gives me the chance to tell the hon. Gentleman that I spent five years chairing the social services committee of Doncaster metropolitan borough council. The consultation process that took place in Doncaster. a Labour-controlled authority, included as many bodies as possible—the area health authority and voluntary and private sector organisations. Some Conservative Members get carried away by their own propaganda and forget the facts of real life.
I had a meeting with the management of the Doncaster Royal Infirmary and Montagu trusts a week ago at which I asked board members why they never sent delegates to the joint committee meetings. I was none too happy with their answer.
All the services in Doncaster have opted out, which is unfortunate because it will now be even more difficult to put together seamless services for vulnerable and elderly people. So many organisations have to be consulted: social services departments, district health authorities, the Doncaster Royal Infirmary trust, the priority and community care trusts, South Yorkshire ambulance service, GPs and GPs who have become fund holders. The list is becoming endless.
I think that we all agree that under this legislation we are trying to do away with many of these problems. The customer should enjoy a seamless service and not suffer from the unfortunate arguments that can take place between the organisations that I have mentioned.
The establishment of the trusts in Doncaster—the DRI and the priority and community care trusts—with their emphasising cost-effectiveness and increased bed throughput, has led to considerable anxiety among many professionals that too many rushed and unplanned discharges are taking place. Some of these discharges are into residential care, with no discussions, no choice and no care plans. If matters are not to deteriorate further, the production of an individual care plan and the provision of the time in which to ensure that it is effectively implemented are essential.
A care plan is not carved in tablets of stone. It needs to be subjected to regular review and, if necessary, renegotiated. The process must involve those concerned and especially the residents. Systems of review must ensure their full participation and must be structured accordingly. It is essential to recognise that many residents will need a formal or an informal advocate to assist in the process. Such involvement should be covered by the legislation, to ensure that residents can exercise their rights and not have their future left to the sole discretion of the professional workers. We must put a stop to the agist attitude that seems to prevail in our culture which presumes that professionals and others can make decisions for people without seeking their opinion or consent.
§ Mr. Hugh Bayley (York)
I had not planned to speak on this amendment, but I want to respond to one or two of the comments of the hon. Member for Macclesfield (Mr. Winterton)—I see that he is smiling, so I must have got his constituency right. It is a peculiar tradition that we do not use people's names in the same way as anyone else would.
I agree with the hon. Gentleman's comments on the fears that have been expressed about a move away from a mixed economy of public and private sector care to a reliance on private-sector accommodation. That implies a lack of choice between the types of regime offered by the public and private sectors.
About two years ago I conducted a study into care for the elderly which involved interviewing 1,300 elderly people in nursing and residential homes, sheltered housing and health service long-stay accommodation. We asked people in public sector homes whether they had considered entering a private sector home and we found that fewer than one in 20 had even considered such a home. We put the same question to people in private sector homes and found that they were even more determined about the rightness of their choice. Fewer than one in 30 had considered moving into public sector homes.
I fear that the choice will be reduced if the number of public sector places continues to be reduced. North Yorkshire county council is considering divesting itself of 20 of its part III homes to a private or voluntary sector body. That will change the nature, pattern and mix of the accommodation that is available in the county.
§ Mr. Nicholas Winterton
Developments similar to that which the hon. Gentleman describes in his county are taking place in many counties, not least in Cheshire where the county council has contracted out the running and management of its part III residential homes to a non-profit making charitable organisation but has retained ownership of the capital assets. Has that happened in North Yorkshire? Labour controls Cheshire county council with Liberal Democrat support and has engaged in contracting out in order to avoid being capped. It has transferred the cost of provision to the Department of Social Security until 1 April 1993. Has North Yorkshire county council disposed of all its capital assets as well as its revenue costs?
§ Mr. Bayley
That is a perceptive comment. North Yorkshire county council has commissioned a firm of consultants to carry out a study and is examining the option that the hon. Member for Macclesfield (Mr. Winterton) describes. However, for whatever reason, Cheshire has for some time had the benefit of being able to transfer the cost of part III accommodation from the poll tax payers' budget to the Department of Social Security budget. Even if North Yorkshire county council moves with lightning speed—an uncharacteristic speed for that council—transferring the budget would benefit it for only a month or two.
§ Mr. Hinchliffe
Is my hon. Friend aware that the Government have taken steps to stop local authorities taking action of the kind that the hon. Member for Macclesfield (Mr. Winterton) describes? The Minister may correct me, but I understand that the Department of Social Security has prevented claims for income support for people placed in local authority trust homes. It has blocked the loophole that allowed the sort of policy development that took place in Cheshire.
§ Mr. Bayley
I think that my hon. Friend is right and therefore I should withdraw the comment about a month or two of benefit for North Yorkshire county council if it gets its skates on.
It is not just a matter of playing with figures in the budget but of the type and quality of care that an authority is able to provide. One of the sets of data collected in the study to which I referred was a standard form of dependency assessment for residents. We were able to compare dependency over time because of an earlier survey carried out in the authority area in which we were working. We discovered that although the overall dependency of public and private sector residents was similar, the physical dependency of those in private sector homes tended to be greater. However, what might be called the mental state dependency of people in public sector homes was greater and getting greater than that of people in private sector homes.
The private homes were good at dealing with the physically frail but mentally alert, while the public sector homes were left to deal with a growing proportion of the mentally frail and confused. That meant that the nature of the regime in the public sector homes in Lincolnshire, the county in which we undertook our study, was changing. The quality of life was deteriorating in public sector homes because people who are mentally alert prefer to be surrounded by others who are mentally alert, albeit physically frail, than by people who are confused and who may exhibit unnerving behaviour.
If the North Yorkshire plan goes ahead, the council will divest itself of more than half its homes, and that will speed up the process of concentrating the confused elderly in public sector homes.
The hon. Member for Macclesfield expressed surprise that relatives of those elderly people from east London who were placed in a home in Skipton had not complained that they found it difficult to visit. Many people in long-stay residential and nursing care receive no visitors at all. Our study showed that one in 10 residents were never visited. They are on their own. We also found that one in three received fewer than one visit a month. Many people will be lost unless local authorities take action to befriend them.
Some of the people whom I interviewed said, "There is no way out." They were in places such as old rectories and probably 3 miles from a main road and 15 miles from a town. They said. "I have no one to turn to and if I have a complaint I have no means of redress." Later amendments address that extremely worrying issue.
§ Mrs. Alice Mahon (Halifax)
I should like to address the need for a care plan based on what we should have learnt from our past mistakes and from the wholesale institutionalisation of a generation of elderly people. That happened because the Government were ideologically committed to closing parts of the national health service and to waging war on local government authorities because most local authorities were Labour controlled. Over the past 13 years, some destructive policies have resulted from the Government's rather bigoted and narrow-minded approach to community care.
I shall concentrate on an excellent document produced by the Royal College of Nursing. It is called "A Scandal Waiting to Happen—Elderly People in Nursing Care in 869 Residential and Nursing Homes". I commend it to every hon. Member as a well thought out document showing not only what has happened in the past but what we can expect to happen in the future if the Government are not truly committed to community care.
Over the past decade, there has been wholesale privatisation of care for the elderly. To all those who shout, "You can trust the Government", I say that, when I took part in a series of "World in Action" programmes in 1985, I was more or less marginalised by health managers and Conservative politicians, who said that I was telling scare stories and making things up about the care of the elderly in the NHS. I have been completely vindicated. The Government closed NHS beds and starved local authorities of precious resources. The elderly had to vacate long-stay beds, and were left with no choice but to enter private nursing homes.
We all know of the huge amounts of income support paid by the Treasury to prop up the private sector. That is meant as a wholesale criticism not of the private sector but of the Government's privatisation of the elderly.
The Royal College of Nursing is concerned at the amount of money allocated to local authorities to implement the National Health Service and Community Care Act 1990. They argue, as we have done many times, that those resources should be ring-fenced, and there remains a desperate need for that to be done. Care plans are also needed if past mistakes are not to be repeated. The RCN's report highlights many reasons why that is important
One of the 1990 Acts pruposes was to shift the emphasis away from institutional care to care in the community. The RCN's report points out that there are inadequate resources to allow people to remain in the community. Their institutionalisation flies in the face of the cross-party consensus on keeping the elderly in their own homes. Because local authorities were given insufficient funds, care packages that would have provided home helps and intensive care—by ensuring that nurses were available to put people to bed and to nurse them early in the morning—were not made available to district or community nurses.
The royal college's report highlights that many elderly people were institutionalised when there was no need. Its report quotes a community nurse manager saying that the elderly were admitted to residential homes because community care could not be provided. That is a real tragedy. That manager stated:Too great a demand is placed on the district nursing service, and they are operating with unsatisfactory accommodation and with insufficient resources, placing an ever-increasing strain on neighbourhood budgets.We know that the elderly are being shifted into residential care at great personal cost, and at a high financial cost to the Treasury and the taxpayer.
The absence of any care plan also means that some of the elderly are given inappropriate assessments of their nursing needs and accommodation. A plan would take such factors into account. I repeat that I criticise not the homes themselves but the system that has developed. The RCN report adds:Others were readmitted to residential homes from hospital because of pressure on health service beds.We know that many of the elderly are not given a choice, and that many NHS forms list only private homes.
There is no plan either to meet the changing health and social needs of those in residential homes. Like the rest of 870 us, their lives do not stand still, and a medical condition will often develop further. Residential homes often do not have staff who are sufficiently trained to identify the progression of the many illnesses and disabilities to which the elderly are prone.
The RCN's excellent report highlights many of the problems created by the Government's disastrous policies over the last 13 years. If the Government fail to grasp the nettle and to do something, even at this late stage, there will be depressing consequences. I do not trust the Government when it comes to community care. There is no evidence that we will get from them anything but nice words, glossy pamphlets, and lots of press releases. I do not know about other right hon. and hon. Members, but I am sick of receiving copies of Department of Health press releases that mean nothing.
The Royal College of Nursing's report concludes that, as the elderly population increases, there is mounting unease that their health and social needs will not be met. Nor are the financial difficulties encountered by the elderly when they move into private homes being dealt with by the Government, who are abandoning their responsibilities. The gap between the cost of public and private care is growing wider, and someone has to pick up the bill. It should be the Government, and it is time they took their responsibilities more seriously.
The Government's own guidelines in health circular HC 895 are being ignored. The elderly are being offered no choice. Nothing is on offer to those who choose to remain at home. It is no secret that many concerns have been expressed about the standards of care in some residential and nursing homes—notably in a "Panorama" report in January. The Government have yet to make a convincing response to some of the criticisms highlighted in that programme. I am pleased that the Royal College of Nursing's report chose to mention it. Sadly, I expect that there will be grounds for similar criticisms in future.
I want the growing number of elderly people in nursing or residential homes matched by an increase in nursing resources, so that we can correct the scandalously inadequate treatment, because staff are not properly trained, of elderly people suffering from illnesses associated with old age. Unless the Royal College of Nursing's recommendations are acted upon, the elderly will continue to suffer—until a major scandal forces the Government to take action.
§ Ms. Tessa Jowell (Dulwich)
This is almost a technical amendment—a statement of good practice. It has been tabled because common-sense arrangements are frequently not observed. One of the difficulties of developing high-quality community care and of creating around the elderly or disabled person a set of arrangements that maximise the quality of that individual's life is that their effectiveness is only as strong as the weakest link in the chain.
Someone must take responsibility for specifying who will implement the various elements of a care plan. Someone must also be named as the person responsible for implementing the plan. Arguably, that is the job of the care manager, who should be independent and speak. in a partisan way, on behalf of an elderly or disabled person. He or she should safeguard the interests of such a person. and ensure that the needs identified in the assessment are met with practical care and support.
871 5 pm
There is a good deal of evidence that people have been placed in residential care and nursing homes a long way from their own homes. As other hon. Members have pointed out, that results in their not being visited and leading isolated lives. Such people may derive no more benefit from the new policy than they derived from the old one.
Earlier this week, a constituent rang me in tears, having just been discharged from hospital. She had not been placed in residential care; she had gone home. No plans seemed to have been made for her support, and she telephoned me in desperation. When I visited her, she was writing to her only relative, a daughter living in Cheshire. Cheshire is a long way from Dulwich, and my constituent —desperately frail and ill—was left with no means of support. That is one of many such instances, which show that nothing can be left to chance. We cannot simply hope that, because there has been so much talk suggesting that this is the best way of managing people's care, it will prove to be so.
A care plan creates a specific set of guarantees for elderly people and their relatives, who will then know what to expect. We know that there will be a discrepancy between the assessment of people's needs—led by the local authorities—and the resources that are likely to be available. Broadly speaking, people accept the inevitability of that, but they need to know what they can rely on. An elderly person once said to me, "One promise is better than 30 maybes.- We need to remember that; it is an important mechanism for the achievement of the commitment to more user-centred community care that I know is shared by hon. Members on both sides of the House.
The establishment of a specified care plan is also an important way of turning the needs and experiences of hundreds of thousands of elderly and disabled people into the big decisions that bring about changes in the nature of services. The information should be fed into the community care plan, which can then be used constantly to audit the quality and range of provision. The amendment proposes good practice. It commends user-centred community care, and it will be welcomed by elderly and disabled people all over the country.
§ The Parliamentary Under-Secretary of State for Health (Mr. Tim Yeo)
The hon. Member for Wakefield (Mr. Hinchliffe) appeared still to doubt the Government's determination to proceed with the implementation of stage 3 of our "Care in the Community" policies. Let me make what I hope is an unequivocal statement, which has already been made by my right hon. Friend the Secretary of State, my hon. Friend the Minister of State or me each time one of us has spoken from the Dispatch Box since the general election. Stage 3 of the implementation of "Care in the Community" will go ahead in April 1993. It is on target, and there has been no change in either the policy or the timetable. The local authorities will assume their enhanced responsibilities at the time of implementation —responsibilities that will include assessing individual needs and arranging for them to be met.
§ Mr. Bayley
When will the Government tell local authorities what additional resources they will receive? The new regime will begin in exactly nine months, but it is almost impossible for authorities to plan if they do not know what resources they will have.
§ Mr. Yeo
Local authorities can be assured that the funding of the policy will be fair. The details will be available to them in the autumn.
We believe that one of the consequences of giving local authorities an enabling role will be the introduction of a larger element of market forces in the provision of community care. I am sorry that that has caused the hon. Member for Wakefield so much dismay. I am confident that it will drive standards up, and ensure that we receive the best possible value for money. The Government want all local authorities to make the fullest possible use of the independent sector.
§ Mrs. Mahon
Has not the Minister learnt any lessons from the Royal College of Nursing report, which states that the independent sector is not equipped to deal with some of the health problems of elderly people?
§ Mr. Yeo
There is abundant evidence that the arrangements that we have put in hand for the inspection of nursing and residential care homes run by independent sector organisations are adequate to ensure that standards are maintained at a high level.
I am pleased to see my hon. Friend the Member for Macclesfield (Mr. Winterton) in the Chamber, and I am grateful for his contribution. He is well known in the House for his expertise in this regard. He and I served together for a number of years on what used to be the Select Committee on Social Services; I did not serve for quite as long as he did, but I recall his robust and independent contributions with much pleasure. His style has not changed at all since those days.
My hon. Friend raised a serious point about possible changes in the national health service. He need not fear that the NHS is losing interest in provision and becoming interested only in treatment. It remains the duty of all health authorities to arrange to meet the health needs of the population in the districts that they represent. As health needs and social needs are so closely related—in some cases, they are intertwined—we have required local authorities to consult health authorities when drawing up their community care plans, under the terms of the National Health Service and Community Care Act 1990. We have also required them to consult the voluntary organisations, and the same applies to users and carers.
The hon. Member for Wakefield mentioned NHS trusts. It is highly desirable for trusts, as well as other bodies, to become involved in local community care planning if they are involved in the provision of community care services. The hon. Member for Doncaster, North (Mr. Hughes) was rather smoked out by an intervention from my hon. Friend the Member for Aylesbury (Mr. Lidington), which finally exposed his underlying hostility to NHS trusts.
The hon. Member for Wakefield mentioned a cut in the number of NHS beds. It is true that the number of geriatric beds in the NHS has fallen, but the hon. Gentleman did not mention the enormous increase in the number of nursing home beds, which has risen from 28,000 to 119.000. There has been a similar increase in provision in private residential homes, and a substantial proportion of the occupants of those beds are funded by income support payments—a quarter of a million people, compared with 10,000 13 years ago.
§ Mr. Hinchliffe
Does the Minister not accept that that is precisely the example of privatisation of the national 873 health service that the Opposition gave during the general election campaign? It is happening in my area and in every other area. Individuals previously received a free service from the national health service; now they have to pay for it. Many people in my area do not have a penny to spare after all their income support and pocket money has been spent on their care fees. Is that acceptable to the Minister?
§ Mr. Yeo
When people are funded by income support payments, that is not privatisation. The hon. Gentleman knows that the cost to the Department of Social Security has risen from £10 million to getting on for £2 billion today. If people's fees are paid from income support, that is not privatisation. It is not a definition of privatisation that any of my hon. Friends could even begin to understand.
§ Mrs. Helen Jackson
Does the Minister agree that privatisation is about the operation of a service? It is not about how the client of the service gets the money. The question, as I understand it, is whether a privatised industry is run for profit. The private nursing homes that we are talking about are, in that sense, privatised institutions.
§ Mr. Yeo
I shall not be inclined to give way again if there are to be somewhat arcane debates about what the word "privatisation" means, but according to my book —and, I believe, according to all my hon. Friends—as long as the Government accept responsibility for assessing needs and for funding the provision of those needs, that is not privatisation. Indeed, I positively welcome the fact that we now have a much greater variety of providers many of whom are in the private sector. Some conic from voluntary organisations; others remain in the statutory sector. That is a wholly welcome development.
§ Mr. Yeo
No, I must make some progress. I have already given way a great deal.
The hon. Member for Rochdale (Ms. Lynne) raised an important point about the shortfall between income support levels and the cost of residential care. We expect that, after April next year, local authorities will be able to negotiate very good terms in order to keep the costs of residential care down. We have acknowledged, however, that there is a gap between income support levels and the actual cost in some areas of residential and nursing home care. We shall take that gap into account when we make decisions about funding.
§ Mr. Nicholas Winterton
Will my hon. Friend deal with the point that I raised during my contribution to the debate on the amendment: that people are being discharged from national health service hospitals into accommodation in the independent private or charitable sector and that, as the hon. Member for Rochdale (Ms. Lynne) pointed out, there is a gap between what people will get from the Department of Social Security through income support and the fees that they or their families may be responsible for paying? Is it not wrong that they should be discharged from, perhaps, a geriatric ward, where all the costs are met through the taxation system, and put into a system whereby they as individuals, or their families, have to pick up an additional bill for their accommodation?
§ Mr. Winterton
Does that apply only at the time of the person's discharge, or does it also apply if the cost of the accommodation goes up?
§ Mr. Yeo
It is difficult to envisage being able to define at the moment of discharge every conceivable possibility that might arise in the years ahead, but in general I do not think that we shall have a significant number of cases where the rate at which costs go up exceeds the rate at which public funds are available to meet those costs. From April next year, anyone discharged in that way for whom the local authority accepts responsibility will find that the local authority has to negotiate, year on year, the cost of maintaining that provision.
The hon. Member for Sheffield, Hillsborough (Mrs. Jackson) referred to the role of the health authorities. Their role is to secure provision where there are continuing medical needs. As the hon. Lady acknowledged, that does not have to be in a hospital. It could be in a nursing home. Nevertheless, where medical needs continue, the health authority has a continuing responsibility.
§ Ms. Ann Coffey (Stockport)
If I may return to the point made by the hon. Member for Macclesfield (Mr. Winterton), does the Minister agree that, contrary to what he said about being unable to envisage the cost of private care rising to the point at which it cannot be publicly funded, that is exactly and precisely what has happened over the past few years? Public funds that have been made available through Department of Social Security grants have been insufficient to meet the actual cost of care. The resulting gap has caused enormous difficulties for a great number of people. Does the Minister not accept and envisage that that might continue to happen, even though the funding is being transferred from the Department of Social Security to the local authority?
§ Mr. Yeo
From April next year, if discharge is to an independent sector establishment and the local authority accepts responsibility for funding, it will be for the local authority to provide the resources to cover any increase in charges. I hope that the local authorities will use their strong position as negotiators in contracting with the private sector to ensure that any increases are kept to a minimum.
§ Mr. Yeo
No, I really must make some progress. I have already been speaking for 13 minutes.
If I may comment specifically on the amendment—I sympathise with the principle behind it—I believe that it is unnecessary in the context of the Bill. When the National Health Service and Community Care Act 1990 is fully implemented, local authorities will have this responsibility for assessing individual needs, for designing care arrangements and for securing them within the available resources. That will include all individuals requiring public support who are discharged from hospital into private and voluntary residential or nursing home care. Our intention is to ensure that all individuals, whether in hospital or 875 referred from the community, receive a proper assessment of their needs and that an individual plan is put together for the care that should be provided.
§ Mr. Roger Sims (Chislehurst)
Is my hon. Friend aware that, in the London borough of Bromley, assessments along the lines of the guidance issued by his Department are already being carried out and that they are not considered complete until the assessment itself and the care package proposals have been completed and agreed by the client? Does my hon. Friend not think that that is good practice which could be adopted generally?
§ Mr. Yeo
I certainly agree with my hon. Friend that it is good practice and it is certainly our intention that where an assessment has been made the results of that assessment should be shared with the client. I am glad to hear of the practice already adopted by my hon. Friend's authority.
Work is in hand to develop arrangements for the introduction of needs-based assessment. It is a key task for local authorities. It is one on which they should co-operate closely with health authorities and other agencies. We have made it clear that authorities should make effective arrangements to inform the public about the details of any new arrangements for assessment and care provision. Effective arrangements for community care require robust agreed procedures for discharging patients from hospital —either, where possible, back into their own homes with the right package of support and care or, if appropriate, into nursing home or residential care. We have issued guidance to health and local authorities about discharge. Discharge arrangements are also covered by the patients charter. We have encouraged health authorities to undertake a sample quality audit of their discharge arrangements to get a better understanding of how these policies work in practice.
The new arrangements for assessment and the provision of care that are being introduced next April will address the concerns behind the amendment. Social services authorities will assess the needs of individuals who are about to leave hospital and who are in need of residential or nursing home care and will plan a package of care accordingly. Contracts with providers will reflect those care plans and specify the service which they are to provide to the resident. These arrangments, including individual assessment of need and the agreement of a care plan, will cover those patients discharged from hospital into nursing home and residential care who require public support. Most local authorities and health authorities are working hard now to ensure that those new arrangements are introduced smoothly and that across the board they work closely to ensure a seamless provision of care. For all those reasons, I believe that this well-meaning but unnecessary amendment should be rejected by the House.
§ Mr. Alun Michael (Cardiff, South and Penarth)
The debate shows the importance that the Labour party attaches to care in the community. That is why we have given the Bill a speedy passage through the House, but taken the opportunity, as we do again now, to voice concern about the danger of failing to get community care right. It was an instructive Committee stage and I appreciated the opportunity, with my hon. Friend the Member for Birmingham, Perry Barr (Mr. Rooker) and others, to probe the Government on a series of points. It 876 is notable that many new Members played a significant part in Committee, and it is clear today that we have a remarkable number of hon. Members in the Chamber, considering the hour and the nature of the debate.
In moving the amendment, my hon. Friend the Member for Wakefield (Mr. Hinchliffe) has brought us to the heart of concern over the implementation of community care; a principle that is supported on both sides, but which is meaningless unless we will the means, the resources and the methods.
The amendment looks at method at the difficult interface between health provision and care provision and suggests that no arrangements should be made for a person being transferred into accommodation from an NHS hospital or trust.unless the voluntary organisation or other person concerned has ensured that that person is provided with a care plan and the authority is satisfied that such arrangements will facilitate this plan.The amendment seeks to place those clear obligations on the organisations concerned in decision making. Advocacy is involved in the next amendment, but in this debate we are stressing the need for personal consideration and real care for the individual.
The hon. Member for Macclesfield (Mr. Winterton) responded to the amendment by demonstrating the breadth of concern on this issue. He made a thoughtful contribution and it is sad that, apart from the Minister, his was the only speech from the Conservative benches, unless one counts the intervention from the hon. Member for Aylesbury (Mr. Lidington), which I can describe only as a petty party political sound bite. He has clearly spent too long working for Conservative Members and I hope that in time he will learn to listen to Opposition Members who have knowledge and experience. In fairness, that is the spirit in which the Minister approached the Committee stage and appears to be approaching today's debate, although I disagree with some of the points he made in his response.
My hon. Friend the Member for Sheffield, Hillsborough (Mrs. Jackson), who has direct experience of residential care, made it clear that we are dealing with the way in which individuals see their placement—as the place in which they live, their home. She was right to do so and to say that the patient and the family should be involved. It is easy to say that, but it is difficult to achieve and even more difficult to guarantee. She is right to stress that as a reason for the amendment.
My hon. Friend the Member for Doncaster, North (Mr. Hughes) made a valuable contribution to the Committee, and emphasised the need for choices to be positive choices, not just to be imposed on the individual as a matter of convenience, without attention to the long-term care and needs of that individual.
When he responded to the debate, the Minister confirmed the Government's determination, as he put it, to implement the rest of the community care provisions in April 1993. We still wonder whether he and his colleagues will do it properly. Will the cash be there? My hon. Friend the Member for York (Mr. Bayley) asked about that, and the Minister answered with as near to a straight face as he could manage. If, as he suggests, the resources and cash are to be there, why is the Secretary of State for Health finding it so difficult to achieve ring fencing?
Some of my hon. Friends who have been dealing with this Bill were also members of the Committee dealing with 877 the National Health Service and Community Care Bill. From the outset, we told the Government, "If you are going to do this properly and if you are serious in pursuing the idea of ca re in the community, you must ensure that the resources are provided and seen to be provided." We still wait for a positive response to that. It seems that the Secretary of State for Health has been convinced of the case we made in Committee. I do not know whether she was convinced by the golden tongues of Labour Members or by experience since becoming Secretary of State. The important thing is that she appears to understand the point we were making at that time, which is still the kernel of our concern.
I regret that the Minister characterised the comments of one of my hon. Friends as antagonism to trusts. Throughout the consideration of trusts, we have said that we do not believe that they will work to the benefit of the community and the individual. We are making predictions about what will happen as a result of the pressures on those running trusts, however well meaning they may be. At the time of the privatisation of water, we predicted precisely the behaviour of plcs, and we have seen our words justified. If one is to introduce trusts, one must put in place the systems to protect the individual in the market that is being created.
The Minister also said that it was not the Government's intention to see discharges into residential care at a cost greater than that available for public funds. As has been said by several of my hon. Friends, that is not what happens in practice. Often, families with a loved one in care or being cared for in one of a number of circumstances, are under great pressure and find themselves filling a gap to avoid that relative being moved and unsettled. It is not just a question of convenience of placement to lit the finance available: we are talking about the loss of someone's home.
There is also the issue of the loss of disposable assets. That is a matter for this Minister and for the Department of Social Security. It is not good enough to leave it to the local authority to tighten the screw on providers, which is effectively what the Minister is saying. A theory that the Government have applied in a variety of circumstances is that, if one places a cap on the money, magic will create greater efficiency, and an improved quality of service will be provided for less money. Good practice needs resources. We all applaud the search for efficiency, but too much capping will distort the quality of service provided. In his response, the Minister described the Government's intention to cap the funds available for care in the community.
My hon. Friend the Member for Halifax (Mrs. Mahon) referred to the effects of policies that may look fine on paper but which fail to provide individual care. She referred to the worrying report that has been produced by the Royal College of Nursing. Another example is day surgery. That is promoted on the grounds of efficiency, but it is risky if community support and care are not adequate.
My hon. Friend the Member for York made a clear distinction between the needs of different clients or patients and the importance of the environment in which individuals find themselves. He was right to underline the position of those who are never visited. He said that they are on their own. At certain times during this debate, and, I suspect, in later debates, the Minister will start to 878 understand how they feel. Those individuals are on their own, and they need the protection of proper procedures to ensure that they are not abandoned.
My hon. Friend the Member for Dulwich (Ms. Jowell) rightly said that all that we are talking about in this amendment, and in many others with which we shall deal, is good practice and arrangements that maximise the quality of life. That is what the Opposition are pursuing in our amendments. The importance of this amendment is that key decisions are made at the point of discharge. If the arrangements are not made properly or if issues are overlooked, the arrangements can become dangerous and potentially disastrous for the individual. As has often been said, care in the community is in danger of becoming neglect in the community or neglect in a home unless these matters are addressed properly in procedures that must be taken into account of and followed at the time of discharge.
There has been great concern about the closure of certain health service institutions, such as the William Nichol home in my constituency, because people are being moved from NHS institutions which have been their homes, often for many years. We should not treat lightly the arrangements made for those individuals at the time of discharge.
The pressure for arrangements for discharge to be made long before the date at which it has to happen and to be tailored to the individual has been accepted by the health authority and the Welsh Office after a lot of debate. We want such good practice and such important considera-tions to be written into the legislation and into the regulations that have to be observed. It is a personal matter; we are dealing with individuals.
There have been occasions when hospitals have discharged patients, especially the elderly, into circumstances in which they were without the care and support they needed and the pressure of cash limits is always there. The hon. Member for Woodspring (Dr. Fox), who also intervened with a sound bite, may not share our view but this is now generally accepted as being bad practice. In recent years, efforts have been made to ensure that discharge is properly planned but the change to trusts, and indeed a financially driven regime for directly managed units too, will increase the risks of hasty discharge or discharge into inappropriate circumstances. We must take great care.
I hope that the Minister will take on board the spirit of the amendment. We have made it clear that it is not the Labour party's intention to delay this limited and sensible Bill. We seek to persuade the Minister and his colleagues of the importance of the Government acting on their own and in their own right to respond to our concern, to recognise the strength of our case today and to ensure that proper procedures are put in place to protect the individuals concerned.
We believe that history will show the need for the arrangements proposed in the amendment, but because we do not want to delay the House or the Bill, I invite my hon. Friend the Member for Wakefield, who moved it so ably, to withdraw the amendment.
§ Amendment, by leave, withdrawn.879
§ Mr. Tom Clarke (Monklands, West)
I beg to move amendment No. 2, in page 2, line 34, at end insert—'(IB) Arrangements shall only be made by virtue of this section where the voluntary organisation or other person providing the accommodation operates clear procedures providing opportunities for residents to review their own situation regularly with a friend or adviser and the care managers.'.The amendment deals with opportunities for elderly people to review their situation with a friend or adviser and the care manager. We are debating community care yet again. I am pleased by the opportunities to do so in this Parliament, in contrast to the previous Parliament. One reason for the change was suggested by my hon. Friend the Member for Dulwich (Ms. Jowell) when she referred to a constituent who came to see her. She underlined what some of us said on Second Reading, which is that, although the House may be packed for debates on Maastricht, people come to our surgeries on community care issues far more than they do on the bigger issues. That will be reflected as our debates on these matters continue.
The reason for tabling the amendment is that community care cannot be complete unless an essential ingredient is the recognition that the individuals whom we seek to serve in our communities and in residential homes have rights and views, and a desire to have an environment that is acceptable to them. We believe that the case for advocacy, which we debated in Committee, is overwhelming. Although the amendment does not go as far as we wish, it would give the opportunity, when vital decisions are being taken about community care, for the involvement of a friend or adviser, or for the presence of someone acting for and with the person. The person's needs are absolutely paramount when care managers make recommendations and take crucial decisions about the lifestyle of the individual.
As we debate community care, we recognise the growth of private residential homes, with which the Bill deals. One Scottish Tory newspaper refers irreverently to "granny farms". That term could apply if we denied the residents of such homes the rights that an advocate would insist that we recognise.
Demographic changes mean that there are more elderly people, so a strategy for care in the community must recognise that there will be some people in residential care. However, we strongly assert that support should be given within the community to ensure genuine independence for elderly people. We believe that the existence of advocacy would be a step in that direction. The Bill concerns the rights of many elderly people who may, at their age, become a little confused. If people are confused, the need to have a friend, an adviser or an advocate when decisions are being taken about individuals becomes all the greater.
Some of us received a report yesterday published by the Consumers Association. It was headed:Contracting for residential care: individual contracts for older people in residential care and nursing homes.It dealt with contracts and specifically with confused residents. The House will recognise, as I quote from the report, that some of the points made are consistent with the wording of the amendment although the amendment was tabled before the report was published.
The report says:The situation becomes less easy with people who are confused or suffering from dementia. The same principles apply—just because someone is mentally impaired, it does not mean that they do not have preferences which are worth 880 formalising … Also, it may be that more active participation would be needed on the part of a spouse, relative, friend or professional advocate drawing up the contract.That is almost the wording we have chosen to use in the amendment.
The amendment also refers to voluntary organisations, if only because so many voluntary groups are involved in the provision of care and in preparing care plans. It is important for us to acknowledge that the National Council for Voluntary Organisations Community Care Alliance has given support to the general principles in the amendment. In its manifesto prior to the election, the alliance said about user and carer participation:Community care envisages the active participation of service users and carers both in individual needs assessments and in the planning of services. Achieving this will involve challenging vested interests and shifting power to service users.Training and support, in some cases advocacy support, are needed to give service users and carers the confidence to participate.I suggest that that applies to elderly people, too. Elderly, frail, vulnerable people in residential homes are in a difficult position. The decisions that are taken about them and the services that are or are not provided are of crucial interest to them. In that context, health provision becomes a very personal matter and is pivotal to the lifestyle and the quality of life of elderly people.
The amendment gained considerable support in the BMA's recently published document on this very issue— the tensions between care provision and what is happening in the health service and the health care problems of individuals. At risk of wearying the House, I should like to quote from that BMA report, which the all-party group on disability considered yesterday:The provision of residential and nursing care perhaps demonstrates most clearly the need for effective collaboration between health and local authorities, relevant professionals and voluntary organisations. The 'Caring for People' White Paper imposes a delineation between health and social care to explain the funding of the new arrangements. In reality, many dispute that this delineation actually exists. This is especially apparent when related to care for people with chronic, severe ill health, such as the frail elderly. As both health and local authorities will, understandably, he keen to limit expenditure, there is a danger that each will view the patients' needs as being the responsibility of the other authority.In the absence of the advocacy of a friend or companion who is willing to speak for the patient, and with two authorities tugging away at the provision of health care, what opportunity do frail or vulnerable people have to say anything about their needs and rights?
§ Mr. Clarke
I entirely agree, and I hope to come to that point in due course.
Let me quote another section of the BMA report, remembering the crucial importance of health care for elderly people:The BMA has received several reports from hospital specialists who have been frustrated by the lack of information on the rapid changes taking place in the private home sector. The lack of consideration given to the provision of general medical services when private homes are set up is also of grave concern.881 If it is of grave concern to an organisation as professional and as well informed as the BMA, is it not also of considerable concern to elderly people who are placed in such difficult circumstances?
Fundamentally, the amendment advocates good practice, because advocacy is good practice. It would also give value for money. All the reports that we have considered—the Griffiths report, the Wagner report, which I know is of great interest to my hon. Friend the Member for Morley and Leeds, South (Mr. Gunnell), and, indeed, the White Paper "Caring for People"—suggest that we may not be getting value for money even from the sums that are being made available for the services. If there is any doubt about an individual's needs, rights or desires —perhaps the word "desires" is more important than the others in terms of the individual's rights being paramount —we are not likely to get value for money.
Each of the reports that I have mentioned supports the view that many elderly people are placed inappropriately, either in homes that are not suitable for them or in residential care rather than elsewhere in the community where they could benefit greatly. That is why advocacy is important.
§ Dr. Liam Fox
I do not doubt the hon. Gentleman's sincerity, but can he give us some examples of who the advocates will be and who will appoint and regulate them so that they look after the interests of patients independently and are not in someone else's pocket?
§ Mr. Clarke
I hope to come to that point in due course. If he feels that, by the end of my short speech, he has not received an adequate reply, the hon. Gentleman would be well advised to read the report of my speech in Committee. He could have intervened or even made a speech on that occasion, and I am sorry that he did not take that opportunity. He may find that speech good reading, none the less.
We hear much about choice in relation to care in the community and care of the elderly, but we know that, in practice, it is, for the most part, mere waffle. How can an elderly person who has had a stroke, whose speech is impaired, who is blind—in some cases, deaf and blind—express his or her choice in the absence of advocacy? The community care provisions in the National Health Service and Community Care Act 1990 were introduced in response to the problems that we are discussing, and if that Act is to be given meaning, it is important that the amendment should be given a proper hearing. How can someone suffering from Alzheimer's be represented adequately when decisions are taken about him? In the absence of the kind of help that the amendment seeks to provide, how can the wishes of their carers be adequately represented when in some cases they are absolutely exhausted?
Hon. Members have mentioned social security—not just individual payments for income support which might give rise to individual problems, but the whole system which the Minister tells us is still to be introduced in April next year; we wait with interest to see whether his words are prophetic—whereby the money will be switched to the local authorities which will be seen as enablers rather than providers. With all those changes taking place, life may become extremely confusing, and not just for professional bodies such as the BMA or for local authorities—my hon.
882 Friend the Member for Doncaster, North (Mr. Hughes) gave an excellent response suggesting that local authorities are aware of the problems and genuinely seeking to deal with them on a day-to-day basis.
Even when people are elderly, vulnerable and frail they have rights, such as the right to privacy and the right to make choices about clothing and food. That came to the fore in Committee, and we heard much disturbing evidence about those rights being challenged. People's privacy had been impinged upon and, although I do not say that it happens often, some elderly people have been locked up all night in circumstances that we regard as utterly unacceptable. We are entitled to ask who will protect those vulnerable people. In the absense of advocacy, do we really think that we can conceivably solve problems such as those discussed in Committee, which all of us found distressing.
In Committee, the views of directors of social services were related to us by my hon. Friend the Member for Dulwich. If we wantto get to grips with the problem. examine what happens in residential care homes and improve matters—I accept that the challenge is enormous —the views of such directors are important. My hon. Friend quoted one director as saying:It's not the children at risk who keep us awake at night, it's what might be happening to elderly people in residential care in the local authority's own homes and to the thousands of elderly residents who are cared for often a long way from home, in private residential and nursing homes.When directors tell us that, it is time for us to worry about what is happening to our elderly folk.
How would any of us feel if such things were happening to any of our own parents or people in our families? We would be greatly worried and rightly so. When we have an opportunity such as that offered by the Bill to improve the position and introduce changes, we are right to take it. We must have some strategy for examining the system, the position of individuals and the quality of care. Those responsible for providing that care must know that that strategy exists.
In Committee several of my hon. Friends, in particular my hon. Friend the Member for Stockport (Ms. Coffey), expressed anxiety about examples of elderly people being evicted from private residential homes. When an elderly person has no family or anyone to defend him or her, the availability of advocacy becomes important.
In an intervention the hon. Member for Woodspring (Dr. Fox) asked me to define the role of the advocate. The hon. Member for Rochdale (Ms. Lynne) raised the issue of the independence of the advocate. Those were both fair points, all the more so because we must recognise that there are times when the interest of the elderly individual and the interest of the family conflict. That can often happen. It is right that at the end of the assessment and the decision-making process, the elderly person is given greater priority. Therefore, I accept the case for independence in advocacy.
Of course, advocacy may vary. It does not always have to be on a professional basis. There are some excellent examples of voluntary advocates. For example, I commend the Sheffield advocacy alliance to the hon. Members for Woodspring and for Aylesbury (Mr. Lidington). I am sure that they wish to pursue the matter more fully and to see advocacy in practice, and I encourage them to do so.
883 We seek to discourage the idea that elderly people merely go into homes to receive services passively. They do not enter a home simply to be "helped". They want to feel that they are individuals who are encouraged to enjoy the best possible quality of life and to participate in their care. It is not always possible for elderly residents to participate if their views, needs and rights cannot be expressed.
I also commend to the hon. Members for Woodspring and for Aylesbury the views of Citizen Advocacy and Age Concern. Those organisations have spent a great deal of time on the matter. They understand that the quality of care provision for elderly people can be improved by making provision for advocacy. Sometimes even close members of the elderly person's family cannot get near to the right solution to particular problems. The very independence of the advocate can be helpful in reaching a solution.
We recognise the dedication of nursing staff, but we must accept that, despite their dedication, they are not always the right persons exclusively to take decisions on behalf of their elderly residents or clients. We dealt with that point in Committee. The independence of the type of advocate that we suggest in amendment No. 2 is extremely important. We accept that philosophy.
I finish by dealing a little more specifically with the definition of the advocate's role. If my hon. Friend the Member for Dulwich will forgive me for quoting her again, she did a service to the Bill and the debate about advocacy and representation when she gave the definition of advocacy drawn up by John O'Brien, one of the American pioneers of citizen advocacy. He described it asthe process whereby one individual represents the interests of another as if they were his or her own.That is the process which the amendment seeks to make available. The amendment is clear. It is consistent with the commitment to care in the community of my hon. Friends and the voluntary organisations the views of which we embraced in the amendment. As the amendment is both realistic and attainable, I hope that the Minister and the House will respond positively.
§ Mr. Hinchliffe
It is a great privilege to follow my hon. Friend the Member for Monklands, West (Mr. Clarke), who feels passionately about the issue and has spent much of his time in the House arguing the case for advocacy. I commend his continuing efforts to persuade the Government to take seriously the issue with which he dealt in his speech to amendment No. 2.
I also welcome you to the Chair, Mr. Deputy Speaker. It is the first opportunity that I have had to speak in a debate when you have been in the Chair. Those of us from the west riding of Yorkshire are proud to see you in the Chair. We all wish you well. It is a great privilege to have a Deputy Speaker who understands the important things in life like rugby league football and, of course, community care. I hope that you will see fit to call me on many future occasions.
Amendment No. 2 attempts to include in the legislation the Government's own policy. I simply refer to two documents published by the Government on the requirement to review cases where people are placed in some form of care setting. First, the Minister will be familiar with the document "Home Life". It is the 884 guidance issued by the Government on the implementation of the Registered Homes Act 1984. In paragraph 2.1.5, entitled "Review of Placement" it states:After the trial period the proprietor should discuss fully with the prospective resident and key supporter (relative, friend, social worker) the suitability of the placement and the prospective resident's feelings about it. The possibility of transfer if the placement is unsuitable and eventual discharge, should also be raised if appropriate. Review decisions should be recorded and implemented.Paragraph 2.1.6, entitled "General Reviews", states:On admission a programme of general reviews should be established and the purpose and process of the reviews explained. These reviews will include general health and social needs, and should always be regarded as an opportunity to extend methods of rehabilitation and prepare residents for leaving when this is appropriate. The resident and key supporter should normally be amongst those involved in such reviews.That is the Government's guidance. That is what they say should happen in our care homes.
The Government went on to commission a report which came out in 1988. The Wagner report was endorsed by the Government. Chapter 3, entitled "Enlarging and Safeguarding Choice", states:We wish to ensure that people who begin to need assistance in order to care for themselves are able to exercise a positive choice over the combination of accommodation and personal services which they require.Paragraph (v) says:The chosen service should be reviewed at appropriate intervals.On page 31, the same report states:As and when needs change, either users or carers should be able to call a review. We are particularly concerned with those residents who are unable to exercise effective choice or give effective consent.That point was made by my hon. Friend the Member for Monklands, West.
The report continues:where a general practitioner judges this to be the case, we recommend that it be a statutory requirement that a review be held at least every six months.In practice, reviews are virtually non-existent in care homes. Those reports, which supposedly form the backbone of the present Government's procedures for the management of care—whether in the public or in the private sector—are absolutely meaningless. Although they sound nice and have been endorsed by the Minister, his colleagues and his predecessors, in practice they mean nothing.
The reason why the Government are reluctant to give detailed consideration to the introduction of a formal review system is not purely and simply because of their laissez-faire, laid-back and "let market forces run the system" attitude. If they introduced a review system, it would prove that a vast number of placements, especially those in the private sector, are utterly inappropriate, as many Opposition Members have feared. People who do not need to be in private care and nursing homes are placed in them and it is totally wrong. If the Minister were honest, he would admit that he knows that to be the truth. Any hon. Member who has looked into care homes in their constituency, or has talked to people in the private care sector or in social services departments, will accept that that is true in many areas.
The main purpose of reviews is to check on the appropriateness of a placement. I recall a discussion with a gentleman for whom I have a good deal of respect— 885 Tony Pitacio—who was the chairman of the British Federation of Care Home Proprietors. Prior to that organisation having some internal difficulties, which I shall not go into, I attended a conference which I believe he chaired. The hon. Member for Shipley (Sir M. Fox) also spoke at the conference, which was held in Yorkshire. We gave different perspectives on our attitudes to private care and the care of the elderly. Mr. Pitacio told me that about one quarter of the people in his care home should not have been there. A substantial number of them would have been supported by finance from the Department of Social Security.
Evidence to the Select Committee on Health, when it considered the wider issues relating to the operation of local authority social services was clear. The evidence was also clear when the Health Select Committee joined the Select Committee on Social Security to consider the financing of private care homes. For example, we heard clear evidence from the Association of Directors of Social Services.
My hon. Friend the Member for Monklands, West was present in March 1991, when directors and deputy directirs from various London boroughs, controlled by different political parties, gave evidence. The consensus among them was recorded in the minutes of that meeting. They said that 50 per cent. of people in private care homes in London could and should have been living independently or semi-independently in the community.
§ Mrs. Angela Browning (Tiverton)
If I have understood the hon. Gentleman correctly, he is saying that many residents in care homes are capable of independently living or living with some protection in the community. In Devon, his party has had the most to say when the social services department has rightly analysed the needs of people in care homes and has proposed the closure of residential homes. At the last Labour party conference, great political capital was made of the proposals by Devon county council social services to close some homes. Yet now, as I understand it, the hon. Gentleman is saying that many authorities should be doing what Devon county council social services have been doing—providing more day care places and more care in the community for residents in care homes, having analysed their needs. Have I understood the hon. Gentleman correctly?
§ Mr. Hinchliffe
I have spoken in virtually every community care debate in this place since 1987. As I said on Second Reading and in Committee, the main error of the Government's ways is that they have allowed an open-ended investment of income support in institutional care. Therefore, in many localities, including my own and possibly in the hon. Lady's constituency, although I do not know Devon well, many people end up in care because resources have not been invested in alternatives to institutional care.
My authority in Wakefield had major problems with the standard spending assessment because it could not spend the money that it needed to provide statutory facilities and services for people outside care, because the Government prevented it from doing so by threatening it with rate capping; yet a huge amount of money has been invested in the private care sector.
I know of many people who have gone into care when they did not need to do so. Their relatives have told me that they could not get the services to maintain them 886 independently in the community because the local authority and the health authority did not have the resources to provide them.
Once people enter the private care sector, the money flows in—£288 per week. If that money were available to purchase facilities in the community, those people could have remained independent.
If the change takes place in April next year, assessment will be meaningless unless we positively invest in developing alternatives to care of the sort that the hon. Member for Tiverton (Mrs. Browning) described. In some respects, I go along with the trend in Devon, but I suspect that my political colleagues there were telling the hon. Lady and her party that the alternatives to care were not sufficient for the authority to take the action that it was proposing. I undertand her argument, and she may expand it if she wishes to contribute to the debate.
Reviews allow us to check on the appropriateness of placements in whatever sector—whether in what the Government call the independent sector and what I would call the private sector, or in the local authority sector.
It is only right that each person's case should be looked into. Whatever type of home they are in, we should be aware of whether they are being placed appropriately. A review would also afford the opportunity to make an informal, objective check on the well-being of residents. At least every six months, there is a statutory check on whether a child is being properly looked after in the environment in which it has been placed, whether at home on trial, in a foster home, a children's home or a community home. That should also happen with elderly people.
My hon. Friend the Member for Monklands, West said that a person's medical position may change. I know of people who have entered care homes in an appalling state, but have made a marked improvement within a couple of weeks or months because they have been properly fed and looked after. They have changed fundamentally, put on weight, regained strength and sometimes been capable of returning to independent or semi-independent living in the community.
People's social circumstances may also change. Relatives, friends or carers who could not look after or support a person at the time of admission to a home, may now be able to offer additional support.
My hon. Friend also said that a review would offer a formal opportunity for residents to voice their opinions about what should happen to them. The Minister will recall that we discussed that in Committee, when I said that, for many elderly people, the idea of freedom of choice is nonsense. They are placed by hospitals or relatives in homes and often they do not want to go. I know of many people who have been placed away from their home area. They have had no choice. A review would allow them to have some say in what is happening in their lives and in what is often intimate care, in the establishment in which they have been placed.
A review would also offer an opportunity to consider rehabilitation—an opportunity which is not allowed under the present system. I also said in Committee that there is an assumption that once an elderly person is in care, that is the end of it. That is nonsense. We should work towards rehabilitation for each elderly person, if it is at all possible and if they desire it.
The assumption is that, once an old person is admitted to care, it will be downhill and decline until the end comes.
887 That is wrong. We should offer people a positive choice, should they leave care, between perhaps some sheltered accommodation and return to some form of semi-independent living. Such choice is not on the agenda now, and that is why we need a formal review system.
It is worth repeating what was said in Committee about the central weakness of the Government's funding system for private nursing and residential care homes. That system rewards those private home owners who increase a resident's dependency. If one owns a jointly registered care home, one can make more money if one gets more of one's patients to transfer from just residential care to nursing care.
What incentive is there for that owner to get someone back into the community? The private care sector is under pressure at the moment and there are vacancies in many homes, so what incentive is there for the private care home owner to rehabilitate a patient? If he does so, he will lose profits by virtue of the fact that he has one fewer resident. The Government's system of funding works against the idea of rehabilitating the elderly, disabled and handicapped people or persons with learning difficulties or mental illness. Rehabilitation means lost income—such is the inherent nonsense of the private care market.
The Minister believes that our objections to the private care market rest solely on ideology, but I have sound practical concerns that make me argue that that market is the wrong one for the care of the elderly and other similarly vulnerable people. For that reason, the review system is urgently needed.
In the past few months, I have also spoken to two Ministers at the Department of Social Security about the need for a review system to check the appropriate or inappropriate use of public funding through the payment of income support to care home owners. A worrying case that has arisen in the constituency of the hon. Member for Batley and Spen (Mrs. Peacock) illustrates my concern. I shall pass on the details of that case to the Under-Secretary if the hon. Lady is happy about that, but I believe that it is the prime responsibility of the Department of Social Security.
That case involves a woman who was moved from the care section to the nursing section of a jointly registered home without any need and without her consent. That lady is not even receiving any nursing care, but that transfer means that the home is getting more money a week because of the cost differential between the two types of care. Those who own that home may receive more income, but such nursing care is inappropriate for that woman. A review system would introduce a formal check on the appropriate use of public funding in such circumstances. It would also act as a check on the standard of care in any particular establishment.
The amendment tabled by my hon. Friend the Member for Monklands, West reflects our practical concerns about the way in which the community care legislation is operating and will operate after 1 April 1993. Let us be honest about this: we are talking about the lives of individuals. The National Health Service and Community Care Act 1990 is about individual human beings—our constituents.
The case of one of my constituents—I have his family's permission to raise it—illustrates precisely the need for the 888 amendment. I hope the Minister will take careful note of the circumstances of the gentleman's case, which is worrying, but not that unusual. His name is Mr. James Edward Bull, and he is 39. His two sisters, Mrs. Mary Banham and Mrs. Susan Turton, saw me on Monday to express their concern about their brother's circumstances and the way in which his case has been handled under the current community care system.
Jimmy comes from Wakefield. In July 1986, this young man—39 is still young—lost his feet and fractured his skull when he was run over by a train. Unfortunately, he took a short cut across a railway line and was knocked down and seriously injured. In fact, his life was threatened as a result of the injuries he received. Sadly, while he was in hospital, he became ill with meningitis, and he is now severely brain-damaged, he has no sight, no hearing and little speech and he must take food intravenously. In a letter from his sisters, which I received yesterday, they describe him as a cabbage.
That man was transferred from Pinderfields hospital in Wakefield in September 1991 to a private nursing home in Dewsbury. The hospital could not offer continuing care, and it was felt that he should be cared for permanently in a nursing home. That nursing home cared for him for a fortnight and subsequently returned him to Pinderfields. His family were very concerned at the marked deterioration in his general condition and weight in those two weeks.
The family maintain that Pinderfields hospital exerted great pressure to discharge Jimmy. They maintain that the hospital felt that he did not require hospital care. In the letter that I received, one sister notes:I was given a book of private nursing homes and told to get on with it myself, even mentioning the Yellow Pages.Unfortunately, that is the reality behind the care plans of the NHS. I am not singling out my authority for criticism, such practice is common across the country. All our constituencies are facing similar problems.
Eventually, after various developments in Jimmy's case, he was placed at Stallingborough nursing home at Grimsby, 80 miles from his home town of Wakefield. He has been at that nursing home since last October. I had a meeting with his elderly mother, Mrs. Brett, about the problems caused to her because of his distance from Wakefield. She loved and cared for him very much, but a round trip of 160 miles meant that it was virtually impossible for that elderly lady to see her son regularly.
I saw Mrs. Brett about that problem only recently, but I am sorry to report that she died a couple of weeks ago in hospital. I will not go into the circumstances of her death, but I am pursuing that matter with the health authority. Jimmy's sisters maintain that the fact that he was so far from home broke their mother's heart. I can accept that, given what I know about the case.
I want to make it clear that the sisters are not in any way attacking the private care home. They have spoken highly of the care provided, and say in their letter:He is loved and cared for as a person".However, they add:but there is no follow up regarding his quality of life.Jimmy's case vividly illustrates the problems faced by many in care who have no voice and who cannot stand up for themselves.
In their letter, his sisters list the problems caused by that lack of follow-up: 889His eyes—we have got a TV for him—but can he see it and how much can he see?Hearing—we know there is a problem with his hearing due to the fracture of his skull at the time of the train accident. But there has been no follow up on whether improvements can be made on his present hearing aid.Teeth—only roots left which cause recurring infections —needs specialised dental treatment.Speech—can say a couple of words—therapy may assist.Muscle therapy—after all this time just laid like a vegetable his muscles must have wasted away—can't they be improved?I stress that the sisters are not knocking the home where their brother lives. However, in common with their late mother, they want him to be nearer to his home town. Unfortunately, that is not a practical possibility at the moment, but we are making every effort to do that.
Those sisters want an independent, objective and comprehensive review of their brother's case, which will cover all the various points about which they are concerned. That is precisely why we have tabled the amendment calling for such a review procedure.
The current legislation does not impose on the Wakefield health authority or the Wakefield social services department any requirement to carry out a formal review of the case. Nor is there any requirement in the case of the Grimsby health authority or the Grimsby social services department to monitor this man's circumstances objective-ly. Yet, as his sisters say, that is urgently needed. We desperately need a system of the type to which the amendment refers. Jimmy Bull does not have a great deal to be thankful for, as must be fairly obvious from my description of his circumstances. However, he does have a family who love him, care for him, stand up for his rights, and are concerned about the fact that nobody is formally assessing his circumstances in the home—medically, socially or in any other way.
Many people in care are without mobility, hearing, sight or speech, and have no one like this man's two sisters to go to a Member of Parliament or kick up a fuss in the press. I hope that the Minister will take account of the circumstances of people like Jimmy Bull and do something about them. As someone who has worked with children, I can say that people like Jimmy have less of a voice than children do. There is a formal review system that gives children some voice and provides some check on the appropriateness of placement.
This amendment is vital if the well-being of people such as Jimmy Bull is to be secured. I therefore hope that we shall have a positive response from the Minister, even if that means his introducing, at a very early stage, legislation to provide the requirement that is envisaged in the amendment.
§ Mr. Gunnell
Following the very moving account of the case of the constituent of my hon. Friend the Member for Wakefield (Mr. Hinchliffe), which illustrates the points that we want to make, it is difficult to return to statistics. It is difficult to take a wider look at the issue and to make the case that the amendment would be extremely helpful to the Government in terms of financing the whole package of community care.
It is clear that there are many more people in residential care than there need be. The Firth committee, which was set up under the aegis of the Department of Health and Social Security, concluded that the increase in residential provision in the first half of the 1980s was not accounted for by the rise in the elderly population. That increase was 890 twice what was suggested demographically. Similarly, William Laing, a research specialist in private health care, concluded in his review of private health care, which was published in 1990–91, that there were 29 per cent. more elderly people in long-term residential care than might have been expected. There are in long-term residential care people for whom it is not the proper type of placement. A system of review and of advocacy, with a view to their possible removal from such care, is crucial to such people.
In this connection, I want to pay tribute to a group that operates in my constituency. I refer to the Belle Isle Winter Aid Group, which is in contact with about 500 elderly people in one of the major estates that I represent. In the last year or two, the group has been part funded by the Leeds social services department and the Leeds health authority. The reason for that is that it has contact with many elderly people in the area.
The social services department and the health authority were both very interested in the group's work. They wanted to ascertain how many of those 500 people wished to go into long-term residential care. I emphasise that this is a voluntary group and that, by and large, the people who did the visiting were volunteers. Their conclusion was that nobody they visited wanted to go into long-term residential care. Some people recognised that they might have to do so in the future, but they all emphasised that if services that would enable them to stay in their own homes were available, that is what they would want to do. This voluntary group does its best to see that services are in place for such people.
The case for advocacy and review in respect of those in residential care is very important indeed. As a social services chairman, I have seen to it that my authority has funded some advocacy work. Independent advocates have dealt with some clients of the social services department. It is also possible to have professional advocates, and I know that the city council has one or two such people who have taken up complaints, some of them against departments of the city council.
I want to draw the Minister's attention to a report called "Elderly People—Care, Participation and Satisfaction", which was based on interviews with more than 200 people, all of them over 75, some in community care, and some in residential homes. The carers, too, were interviewed. We have stressed how important it is that people should be able to make an informed choice. The report, which is reviewed in "Social Work Today" of 30 April, says:Only 6 per cent. of elderly people in residential care had been given alternatives, such as sheltered housing. Only half talked to anybody about moving to a home. For some the decision had been made so rapidly that they did not even know they were a permanent resident until after the move.It is then recorded that when people were first seen they wanted services to take pressure off them. A quarter of those looking for help recorded gardening—their gardens were in a terrible state—as their highest priority, yet they ended up in residential care. In those circumstances, one must ask about the process.
This report is somewhat critical of the practice adopted by some social services departments, but it takes the view that social workers have been, and are, under enormous pressure because of lack of resources. For that reason, discussions with people often do not take place at the appropriate level. Leaflets tend to be left. One organiser of domiciliary care said, "We should give advice, but we 891 don't. We are so busy that I just give a telephone number or a leaflet and don't get personally involved." Everybody knows that elderly people do not read those leaflets. They do not necessarily understand the choices that are available. It is evident from that report that people do not know how to complain if they are dissatisfied with what is happening to them. One woman who was interviewed was under the impression that she should write to the Foreign Secretary and one third of local authority home residents did not know where to start to make a complaint.
This report reveals the importance of having a case review for elderly people. It shows that many people have had very little say. In response to an earlier debate, the Minister emphasised the importance of choice. By way of the Bill, we are correcting omissions with a view to ensuring that people have a range of choices. At one level, we can ensure that there is choice, but we cannot ensure that it is made available to people going into residential care. The amendment would create that possibility. It seeks to provide for a review of people's cases and to ensure that someone is available to speak on their behalf.
The issue of advocacy is important. The Minister said that a great deal of money is being spent on residential care. If that money were spent on community services, it would help far more people. We should look seriously at the many people who are clearly misplaced in residential care, with no opportunity for a review and no knowledge about how to change their situation.
§ Mr. Jeff Rooker (Birmingham, Perry Barr)
I should have thought that of all the amendments that the Opposition have proposed, No. 2, which makes fairly modest demands, would be by far the easiest for the Minister to accept. It does not cost much and requires no money from public funds. It is not exactly the same as implementing the legislation proposed by my hon. Friend the Member for Monklands, West (Mr. Clarke). I was reminded of that legislation earlier today when a Conservative Member intervened in my hon. Friend's speech and asked about advocacy and what he was doing about it. I expected my hon. Friend to refer to the proceedings on his legislation that has gone through the House.
Most of my hon. Friends have given examples of people in residential and nursing care who may not need to be there. I do not share the certainty of some of my hon. Friends, but it is clear that some people end up in care away from their own homes, for no other reason than that they lost the opportunity to have aids and adaptations in their homes. The lack of opportunity for changes in their homes forced them out of their homes and into care.
§ Mr. Tom Clarke
My hon. Friend referred earlier to some Conservative Members who are no longer present, but who intervened in my speech. I was far too modest to mention the Act that I introduced, but my hon. Friend will be pleased to know that, because the anniversary of its Royal Assent is 8 July, those two Conservative Members, in common with every other Member of the House, will receive strong representations from the Royal Association for Disability and Rehabilitation—RADAR—and many 892 other voluntary organisations. Therefore, if those hon. Members do not know about the Act now, they will know about it then.
§ Mr. Rooker
I realise that my hon. Friend is much too modest to have mentioned the Act and that is why I mentioned it for him. Those absent Conservative Members should know that they challenged the one hon. Member who has done something about community care problems by putting an Act on the statute book.
The hon. Member for Tiverton (Mrs. Browning) mentioned Devon in an intervention. I visited Devon earlier this year—not the wider part of Devon which the hon. Lady represents, but your beautiful city, Madam Deputy Speaker. I visited two residential homes, both under threat of closure. One, Tory Brook, was purpose-built about 16 or 17 years ago. I do not think that it is in your constituency, Madam Deputy Speaker, although I saw your letter pinned on the notice board, supporting the demand of residents that the home be kept open. Let there be no misunderstanding about the reason given at the time for the home's closure. By and large, we were talking about all local authority homes.
The hon. Member for Tiverton intervened on my hon. Friend the Member for Monklands, West when he was specifically referring to the private sector. He was not talking about the local authority public sector.
§ Mr. Rooker
I invite the hon. Member for Tiverton to get up from her seat and make a speech to tell the House about social policy and community care policy in Devon. We should like nothing more than for her to make a speech rather than an intervention. We have not yet heard a speech from any Conservative Member on Report or in Committee about community care policies in their parts of the country. We want to share experiences with them. In the past few minutes, the Chamber has heard about the real-life experiences of ordinary people in the example given by my hon. Friend the Member for Wakefield (Mr. Hinchliffe). That is what community care policy is about. We must put legislation on the statute book to meet the needs of ordinary people, their life experiences and those of their carers.
The two homes that I visited in Plymouth were wonderful. I had lunch with and spoke to many of the residents who were in their 70s and 90s. They invited me to visit their rooms, explained their backgrounds and gave me letters to bring back to the Prime Minister, which I sent to him. They told me that people get a false impression when they visit such homes and see that the residents are well cared for and happy, with companionship. Visitors go away saying that the residents so look fit and healthy, can talk and are not stupid, that they should be living in the community.
However, the residents say that the quality of care that they receive in the home enables them to have a quality of life which they do not feel that they could get outside. That does not mean that some of those people could not be in sheltered housing if they had a choice. They may lose the companionship, and loneliness is a great scourge of the late 20th century. We underestimate it at our peril when forcing people to stay in their homes.
I came away from the two homes in Plymouth with mixed feelings. First, many of those people had not been consulted, which is the subject of the amendment. The 893 proof of that is that one of the residents—I think that her name was Annie—had got a judge to agree to a judicial review of the local authority's decision. That is positive proof that there has been no review of the residents' circumstances.
§ Mr. Rooker
I shall give way to the hon. Lady if she will undertake to make a speech at some time tonight.
§ Mrs. Browning
When I intervened on the hon. Member for Wakefield (Mr. Hinchliffe), he was saying—if I understood him correctly, and I asked him whether I had —that as circumstances, local area needs and the needs of the individual residents change, we should be much more open minded about considering the needs of residents who could go back into the community, having been in residential care. By the same definition, particularly with regard to local authority homes, if a review of immediate and future local needs is taking place, as happened in Devon—although I have not had the experience of visiting the two Plymouth homes, I know the situation in my constituency where local needs were deemed to be that more day care back up services, day care services for the elderly, and respite care for carers—
§ Madam Deputy Speaker (Dame Janet Fookes)
Order. I am sorry to interrupt the hon. Lady, but her intervention is now becoming too long.
§ Mr. Rooker
I simply invite the hon. Lady to make a speech when I sit down and before the Minister winds up the debate. We are under no pressure and do not intend to filibuster. We just seek to make a point about community care policy arid share our experiences in different parts of the country to send a signal to the Department so that matters can be put right from April. We are all concerned to ensure that the policy is right. We do not want a uniform policy across the country—it would be stupid for anyone to advocate that. However, we visit each other's constituencies and sometimes we have to share our experiences.
§ Mr. Hinchliffe
Does my hon. Friend agree that we should congratulate the hon. Member for Tiverton (Mrs. Browning) on her intervention, which was longer than the totality of contributions made by Tory Back Benchers in Committee and, so far, on Report?
The point being made by my hon. Friend the Member for Birmingham, Perry Barr (Mr. Rooker), which we need to clarify, is that there are differences between the level of need catered for by local authority part III accommodation and by private care homes. I take a different view from the hon. Lady on the closing of part III accommodation. With the advent and growth of private sector accommodation, part III accommodation has to cope with people who are more dependent and are frequently rejected by private sector homes, whose officials say that they cannot cope with such residents. There is a big difference between private care homes and local authority accommodation described by the hon. Lady.
§ Mr. Rooker
I agree with my hon. Friend. I came away from Plymouth believing that the decision had been taken on ideological grounds, and was not based on the residents' needs. I came to that conclusion because of what I heard in the two homes from the staff, carers and residents. It was that fact that we objected to; no one objects to change based on needs.
I should have thought that the Government would accept the amendment. The examples given today are not random, but it is clear that it is much more complicated for a social worker to assemble a community care package for someone in the community, either in their own home or in some form of sheltered housing, than it is merely to place them in residential care, which is the easy option. It saves on the leg work, the telephoning, the case conferences and avoids a great deal of organisation if one can say, "You need to go into this nice little home where you will be well looked after," and that is the end of the problem. We are seeking to stop that.
One way to place a check and balance on such a policy is to have regular reviews involving the residents, their advocates, friends, advisers and care managers. Like the hon. Member for Rochdale (Ms. Lynne), I distinguish between care managers and care providers. It is crucial that those undertaking the reviews do so with open minds and place the users' needs first.
Earlier, one of my hon. Friends quoted the views of the British Medical Association. While the BMA wants the assessments to be separate from the service provision and general practitioners to be involved in the assessment process—which is essential for the patients—it believes that the patients' GPs should not be involved, but someone more removed so that an independent overview is given.
There are many examples throughout the country of people who have entered residential care when they need not have done. How can we, as legislators, draft legislation to help them in future? One way to do so would be to introduce a systematic review. I think that the period of six months, which was mentioned in the debate, is too long. I think that the review needs to be carried out more frequently—perhaps every three months. I would not be too rigid about that, but there must be a review; people must know about it and must be able to share their experiences. Carers, care managers and individual users must know that whatever is wrong or whatever progress is being made can be reported to the review. The residents may well become more independent.
Private sector home owners have told me that the demographic changes in the country—the increase in the number of elderly people that has occurred this decade —mean that they will have no difficulty in filling residential places, despite the various adaptations and community care plans. Therefore, home owners are not reluctant to encourage residents to become independent or semi-independent. They know that allegations have been made—sometimes with justification—that they want their beds filled.
The financial policy suggests that home owners may have an incentive to keep residents in their homes—they may have, but they need not be the same residents. One test of whether private sector home owners are interested in quality care is whether they have regular, systematic reviews of their residents. If they are not having them now, 895 one task for Opposition Members next April will be to ensure that local authorities require such reviews to take place. If that policy is carried out, there is a good chance that some residents will regain independence or semi-independence.
§ Ms. Jowell
Given that the average age of elderly people admitted to residential care has increased in the past decade—those of us who have visited homes know that the average age is now about 85—and if the assessment has been properly carried out, it is unlikely that residents will leave residential care. The review process should identify ways in which the regime of the home should bend and adapt to accommodate residents' changing needs.
§ Mr. Rooker
I agree entirely with my hon. Friend. The thrust of the speeches of some of my hon. Friends has been that people are misplaced. I gave an example in Committee of homes in my constituency that had closed or changed, making it necessary to reassess residents. Assessments had not been regular events in the past. In one case, papers were studied and assessments carried out, and it was found that a resident was admitted to part III accommodation 10 years ago, who should not have been. That resident is now happily re-established in the community, but that was an exceptional case.
As my hon. Friend the Member for Dulwich (Ms. Jowell) said, of necessity, regular reviews involving friends and advocates, users and care managers, will be directed more towards improving the quality of care and the life style in the home than moving people around. Many people who are admitted to residential care today are at an age where they do not want to be moved around. They are looking for peace, tranquillity, companionship and care. They may have left behind the chores of looking after a property. They may have been carers who, worn out by caring for a loved one who has died, now need to be cared for themselves. They are not looking to return to the community or to move around, but they do not deserve to be forgotten. That can be achieved only by a regular review.
I cannot for the life of me understand why the amendment cannot be accepted. It will cost nothing—it contains no requirements for further public sector manpower and calls for no resources over and above those that will be needed if the community care policy operates as Ministers have said it will from next April. The Minister assured us that there would be no change in that policy.
Accepting the amendment would send the signal to the public, voluntary and independent sectors that the House of Commons is serious about community care and that we seriously intend to ensure that these policies, which are by and large bipartisan, operate successfuly from next April in the interests of our constituents. We must advocate a better system that will ensure improved quality. We all know of enough examples to prove that, without giving this idea a statutory basis in the Bill, it will not come about. That is the reason for the amendment.
§ Mr. Yeo
The amendment was moved by the hon. Member for Monklands, West (Mr. Clarke), who made another powerful speech in favour of advocacy. He is an expert on that subject, so his views will always be heard with respect. I shall return to the question of advocacy shortly.
The hon. Member for Wakefield (Mr. Hinchliffe), supporting the hon. Member for Monklands, West, 896 concentrated on the need for regular reviews of people's situations. Of course people should be able to have their circumstances reviewed and to take part in reviews themselves. As time moves on, so their needs will change. Some people may find that their health has deteriorated, so they have become more dependent; others move in the opposite direction—their health improves so the nursing that they needed at one stage becomes unnecessary.
It is also true that a person whose social needs were met by a particular type of establishment—a large home, say —might change his preferences and attitude and require a smaller, quieter, more family-like setting. All sorts of changes can take place, which is why our community care policies are based on the principle that just as the needs of any two individuals may differ, so the needs of one individual can change from time to time. Each individual situation requires an individual solution.
The policy puts the emphasis of care where it should be: on meeting the needs of the users of the services and, in certain circumstances, on meeting the needs of their carers, too. The White Paper is based on the idea of giving local authorities the freedom and flexibility that they need to develop individual solutions which will provide services and support, especially for frail, elderly, vulnerable or disabled people—always with the aim of enabling them to lead as full and independent a life as possible.
The hon. Member for Wakefield underestimated the effectiveness of the code of practice "Home Life", which, as I said in Committee, we are about to update in any case. I believe that there are many advantages in a code of practice which is more flexible than law and which can therefore reflect more quickly the latest attitudes and methods of providing services.
The assessment process and the third stage of our community care policies which come into force next year will eliminate the kind of problem to which the hon. Member for Wakefield referred. He deplored unsuitable placements—an issue about which the hon. Member for Morley and Leeds, South (Mr. Gunnell) was also worried. The solution to the problem of inappropriate placements is therefore at hand.
My hon. Friend the Member for Tiverton (Mrs. Browning) made an important intervention, which I welcomed, although I was not sure how much it was welcomed by Labour Members. They seemed inclined to tease her a little about it, but what she said about the delivery of domiciliary services in Devon was significant. The Government expect one of the consequences of the third stage of our community care policies to be an acceleration in the delivery and provision of services. We also expect the independent sector to play an increasing role in their delivery.
I must take issue with the argument of the hon. Member for Wakefield that the existence of the independent sector actually works against the process of rehabilitation. I share his concern to encourage rehabilitation—
§ Mr. Hinchliffe
The Minister distorts my point. I said that the financial arrangements for the private sector reward increased dependence—the Minister must accept that. If someone with a jointly registered home moves a person from residential care to nursing home care, thereby receiving more money, that is a financial incentive to making the person in question dependent. The Minister knows that I can give him examples of that.
§ Mr. Yeo
I do not accept that, for two reasons. The first reason is that the cost of providing nursing home care will be greater, so even if the fee charged is higher, the margin earned on the delivery of the service may be no greater. More importantly, there is a threshold which someone who moves from residential care into a nursing home must cross; the health authority will act as a policeman of that threshold and no one will be able to move from residential care into a private nursing home, even within the same establishment, without the approval of the local health authority.
As it will be the local authority contracting with the providers, the authority will buy a certain number of places. Someone whose condition has improved and who benefits from rehabilitation may leave an independent sector establishment and his place may be taken—the local authority may have contracted to take the place—by someone newly discharged from hospital who needs the services more.
It could therefore be argued that the independent sector favours rehabilitation more than the statutory sector does, as in the latter the local authority may feel that for its own financial needs it must keep its establishments full, and it may be reluctant to move people out even though their condition justifies that.
§ Mr. Gunnell
As the Minister knows, I was a member of a health authority for two years before coming to this place, as well as chairing a social services committee. I was worried because people discharged from hospitals almost always went into private residential care; very few went into local authority residential care. It is not true that local authorities seek to maximise the numbers in residential care. As I explained fully in Committee, my local authority outdid that of the hon. Member for Tiverton in respect of the number of residential homes that it closed, because we did not need the places. We did not try to keep places going for the sake of it. Nevertheless, I was worried about the disparity, so I looked into the health authority's procedures—
§ Madam Deputy Speaker
Order. I am sorry, but this intervention is getting rather long—although on this occasion the Opposition Whip does not seem to have made any comment.
§ Mr. Gunnell
Certainly, Madam Deputy Speaker. The health authority said that when it wanted to place people, it had to place them rapidly; it could not wait for the local authority's assessment procedures because it wanted a rapid move from hospital to residential care.
§ Mr. Yeo
I have tried to give way generously but it is not an incentive to generosity when interventions are prolonged. In any event, the hon. Gentleman has had a good opportunity to make his point.
The hon. Member for Monklands, West referred to the recent BMA report and spoke of health authorities and local authorities each trying to pass on to the other responsibility for meeting the needs of certain people. Health and local authorities co-operate properly in many parts of the country—I have visited a number of them in the past three months.
898 At member level, management level and at the sharp end there is good co-operation. The Government would take a serious view of authorities that could not reach local agreement about the responsibility for meeting a person's needs. That is a serious matter and local authorities must not try to shift responsibility. The hon. Member for Monklands, West used that as an argument in favour of the provision of advocates.
The hon. Member for Wakefield, in support of the need for advocacy, described the tragic case of a constituent. The family to which he referred has the sympathy of all hon. Members. In that context, the implementation of the third stage of our community care policy next year is important. If those policies are properly implemented and agencies co-operate in the right way, such tragic cases as that mentioned by the hon. Gentleman can be minimised.
§ Mr. Hinchliffe
What difference will the policy to be implemented in April make to Jimmy Bull's case? No one in a placement of that kind will find any difference. Jimmy Bull is more dependent than many children in care, but he does not have the same legal rights to independent objective monitoring of his circumstances in care.
§ Mr. Yeo
That case will not be affected by the changes in April because they will apply only to people who are coming forward for the first time. The change is incremental and will not affect people whose situation has already been determined.
It is difficult to define who should be the advocate in a particular case, and there is some difficulty about deciding accountability. The hon. Member for Monklands, West acknowledged that conflicts of interest can arise even within a family. As the hon. Member for Birmingham, Perry Barr (Mr. Rooker) said, sometimes residential care is an easy option not just for the authority but for the relations as well. The hon. Member for Perry Barr spoke seductively at the start of his speech when he said that the amendment contained few cost implications. The Government's approach, not just to the amendment but to the whole matter, is driven by the needs of individuals and community care policies. It is not driven exclusively by financial considerations, although of course they cannot be entirely ignored.
As the House is aware, one of the key objectives of our policy is to ensure that service delivery is based on an assessment of need and that clients are involved in that assessment and in the choices made about care provision. The basic aim is an individually tailored care package, not an off-the-peg version that may not fit a person's needs and circumstances or the needs of his carer. I agree with the hon. Member for Perry Barr that that will involve regular reviews, although, because of the diversity of individual need, I do not think that it is possible to prescribe a time scale.
The review of care needs is an integral part of the assessment process. It is right that responsibility for that should rest with local authorities because it lies better with them than with the operators of a residential or nursing home. Many people who will need regular reviews of their care needs are not in residential or nursing homes at all. Our policy guidance "Community Care in the Next Decade and Beyond" states:Care needs for which services arc being provided should be reviewed at regular intervals … The purpose of the review 899 is to establish whether the objectives set in the original care plan are being, or have been, met and to increase, revise or withdraw services accordingly … The other purposes of reviews are to monitor the quality of services provided and, in particular, to note the views of service users and carers and any changes in their wishes or preferences'.The Registered Homes Act 1984 also states that residents' wishes should be taken into account where possible and "Home Life" recommends that residents should, where possible, have access to external advice, representation or advocacy.
We recognise the importance of advocacy schemes but, as I said in Committee, we would prefer to see them develop flexibly according to local circumstances rather than under a uniform scheme imposed from the centre. The hon. Member for Morley and Leeds, South confirmed that local schemes exist and flourish. It is undesirable to enshrine every detail in legislation in order to achieve the desired results. We want good practice to develop in line with local circumstances, and we have asked authorities to develop local advocacy schemes or to use those that are already available locally for clients who need that kind of help. We have ensured that material on the subject is included in our guidance on complaints procedures and in care management and assessment guidance. A regular review of care needs and the care plan are fundamental elements of the assessment and care management process. That underpins the whole of our new community care arrangements.
§ Mr. Rooker
We have heard about a northern local authority suggesting to someone with a problem that he should look in Yellow Pages. I could give the name of a London authority which gave exactly the same information. I accept the thrust of the Minister's argument. Will he make it clear that the signal going from the House must be that no local authority should tell advocates, carers or anybody else to look in Yellow Pages?
§ Mr. Yeo
I agree that such a clear message must be sent. We are engaged in monitoring the preparations being made by local and health authorities for the implementation of the policy in April. We are satisfied that the bulk of the 108 social services authorities will have the right mechanisms in place, if they work hard, but some give rise, to concern. We have a list of authorities—I shall not describe it as a hit list—to which Ministers will pay close attention. The authorities on the list are not confined to any specific part of the country or type of authority. Given the emphasis that we all place on meeting individual needs, it is quite unacceptable for anyone to be told to look in Yellow Pages. For all those reasons, I invite the House to reject the amendment.
§ Mr. Tom Clarke
This has been an interesting debate and the Minister's speech seems to show that he knows what advocacy is about. He did not go much further than that, but in one sense his recognition is progress. We are debating advocacy and the role of the elderly in a changing and traumatic situation.
The Minister conceded that there was some merit in the argument advanced by the British Medical Association. It is deeply worried, as it said in its document, that, following the changes in April, some health authorities will dispense with their responsibilities by saying that they are matters for local authorities. Some local authorities will say that 900 they cannot cope. In the middle will be the elderly people who expect community care and who will find that it is not there. In response to that, the Minister said that if such a situation arises the Government will step in because it would imply that joint planning was breaking down. That is exactly what it would imply.
In many parts of the United Kingdom, especially in Scotland, joint planning has never operated. There have been no agreements, discussions or policy formulation involving the health authorities and the local authorities, with input from voluntary organisations and users. That is essential if community care is to have any meaning. Hundreds of thousands of elderly people are not receiving the democratic support embracing their rights that any approach to the provision of proper social services seems to suggest.
The hon. Members for Woodspring (Dr. Fox) and for Aylesbury (Mr. Lidington) were anxious to know more about advocacy, and I am anxious to encourage them in their search for knowledge. They missed the speech of my hon. Friend the Member for Birmingham, Perry Barr (Mr. Rooker), who suggested some further reading for them. It would do them no harm to study the Disabled Persons (Services, Consultation and Representation) Act 1986, which clearly defines advocacy, assessment and representation. Perhaps they have the imagination to extend that Act's provisions to the elderly.
The hon. Member for Tiverton (Mrs. Browning) made a constructive intervention, and she should be encouraged to make a speech. She seemed to invite the House to become involved in an argument about Devon. I would not pretend to know much about Devon, but what if one multiplied her example and applied the argument elsewhere in Great Britain?
The one element missing from our arguments is the view that elderly people take of the services that are or are not provided for them. The elderly and their advocates ought to contribute to any debate leading to decisions that are of enormous importance, for good or for ill, to elderly people.
The Bill's origins are to be found in a report published by the Public Accounts Committee five or six years ago —which is recent history in terms of community care— saying that community care was in chaos. As a consequence of that and other strong representations, the former Prime Minister, Baroness Thatcher, invited Sir Roy Griffiths to prepare a report. Given his previous report on the health service and the then Prime Minister's belief in market forces, she did so with some confidence. However, after close examination, Sir Roy found that allegations made by my hon. Friend the Member for Wakefield (Mr. Hinchliffe) and others of my right hon. and hon. Friends were staring him in the face in reality.
My hon. Friend spoke of people being discharged from institutions and channelled into some other form of health care without proper assessment or any evidence of advocacy. Sir Roy was confronted with instances of that happening on a day-to-day basis, in a domestic sense.
Sir Roy's report stated that there had been decades of rhetoric but no action, and that Government declarations had not been matched by resources. He said that there ought to be a community care strategy so that if elderly people, for example, were discharged from long-stay psychiatric hospitals into the community, proper assessments and arrangements could be made and genuine care in the community delivered.
901 Sir Roy said also that the problem of the boom in the number of elderly people was not being addressed. Even if the Bill is enacted, many elderly people will remain in the community. There is a strong case still for supporting local authorities in delivering services such as home help, so that the elderly can live independently and enjoy an improved quality of life.
§ Madam Deputy Speaker
Order. Although I have no objection to passing references to matters of general and wider import, I hope that the hon. Member does not intend to go into great detail. He should bear in mind that the House is considering an amendment to one clause, not the genesis of the whole Bill.
§ Mr. Clarke
Your perspicacity, Madam Deputy Speaker, never ceases to amaze me. You called me to order at exactly the point at which I intended to turn to the relevance of advocacy. Our objectives cannot be achieved unless more progress is made with advocacy.
I will conclude in the generous terms with which the Opposition have approached the Bill. Although the Minister has not delivered, at least he acknowledges the problem. Because we have made at least that progress with him, if not with certain Conservative Back Benchers, I beg to ask leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ Mr. Gunnell
I beg to move amendment No. 3, in page 2, line 34, at end insert—'(IC) Arrangements shall be made by virtue of this section only where the staff of any voluntary organisation or any other person providing the accommodation have undertaken a course of training recognised by the Secretary of State.'.
§ Madam Deputy Speaker
With this, it will be convenient to consider amendment No. 4, in page 2, line 34, at end insert—'(ID) Arrangements shall be made by virtue of this section only where the establishment providing accommodation has a staff training plan, available for inspection by the authority, providing for appropriate training for all grades of staff.'.
§ Mr. Gunnell
When one visits a residential home for elderly people—and I am sure that many of the hon. Members present for this debate have done so—one quickly gains an impression of one kind or another. I refer not only to the home's physical appearance, but to its smell. Some homes immediately announce the nature of their residents—particularly if they suffer from dementia.
That sense of the atmosphere is enlarged when one witnesses the interaction between the staff and residents. One learns a great deal about the nature of the home and whether its residents are settled and happy. I recently visited a home for the elderly in my constituency that I had previously visited two years ago. The moment that I went through the door, I sensed a difference. Whereas before I had found it riot at all a lively place, I became aware of a changed relationship between the staff and the residents.
I discovered that about a year and a half previously, someone new had been put in charge of that home—and her attitudes had filtered down to the staff. She attempted to motivate her staff as a team, to meet more effectively the needs of the residents. She has ensured that her staff have an opportunity to develop their skills, and they enjoy greater job satisfaction because they have a better sense of career development.
902 That is not to say that things are perfect at that home. I was shown all sorts of examples of where greater resources are needed. Much has to be done, and I left with a list of the actions that ought to be taken to improve the residents' physical well-being and facilities.
In relation to training, which is covered by amendments Nos. 3 and 4. There is much written evidence emphasising the importance of staff training in ensuring the quality of residential care establishments. I have quoted previously from the Howe report, which is the most recent to be published on residential care, and to which the Government are prepared to attach credibility. The Howe inquiry examined residential care for the elderly in the local authority sector in particular. The report concluded that training and staff development were a key element, affecting the quality of service and the status of residential care as a profession.
That links two vital aspects of residential care. Training is, indeed, a vital part of any home. It not only determines what skills can be used in ministering to clients, but affects people's perception of their jobs and their future in residential care, and tells them whether it involves a career —a progression. That is important if a home is to give satisfaction.
The amendment requires training issues to be spelt out and to become a statutory requirement. The major issue today relates not to the sense of the amendments, but to whether it is valuable for them to be incorporated in legislation. We are simply asking for the recommendations of inquiries that the Government have backed to be adopted in practice. The Griffiths report, which has been referred to several times today, recognised the crucial importance of training: indeed, all reports on community care have emphasised that. A report from the Audit Commission is due to be published tomorrow and I am sure that training will feature in it. Training is vital to the changes that we all want.
The Bill aims to ensure that private and voluntary sector homes are covered by legislation, that they are used by local authorities and that residents are given a wide choice. It is important in that connection to spell out training requirements. According to the independent report on residential care produced by Gillian Wagner in 1988, published by the National Institute for Social Work—a body which the Government clearly respect—The facts speak for themselves. The 1986 survey by the Local Government Training Board states that, of residential and day care staff only 7.5 per cent. working with adults … have a social work qualification.The proportion increased to 24 per cent. if a non-social work qualification such as teaching or nursing was included.
That tells us that a quarter of staff have some training. In local authority field work, 67 per cent. have a social work qualification; the figure rises to 71.5 per cent. when other qualifications are included. The residental figures were, of course, produced in 1988, and we should like to think that they had improved since. The Utting report, however, does not suggest that any great improvement in residential care training has taken place. It suggests that only 30 per cent. of staff have some qualification.
Our amendment focuses on the person who would be in charge of a home. I shall not go into all that the Wagner report says about the complexity of the work and the knowledge and skills that would be required, but it makes it clear that managerial and senior staff in residential work 903 require a full social work qualification. It also makes it clear that the inquiry team wanted a measure such as amendment No. 4 to be introduced as long ago as 1988, stating:We recommend, that every establishment—in statutory, voluntary and private sectors—should be required to draw up a staff training plan which should be subject to inspection procedures. The plan should be closely related to the aims and objectives of the establishment, and to its specific functions and tasks.The report says that the training plans should have a common basis. There should be induction training for those who join the staff and continuing core training for those who become permanent staff members. There should be team development and a regular appraisal of each individual's training needs. People with non-social work qualifications who move into residential work should receive conversion training and those appointed to senior posts should be expected to undertake qualifying training in social work as early as possible. Part of the training should be internal. Regular staff meetings should be held and used to assist the development of staff as individuals and groups.
The strong emphasis that the Wagner report places on training is understandable in view of the evidence that it cites. According to the written evidence that the inquiry received:Training is the major preoccupation of contributors, being mentioned in their … Recommendations almost twice as often as any other subject. The reasons for this are many. Implicit is a feeling that lack of facilities for training reflects lack of appreciation of residential skills and consequently low status for residential workers in comparison with field workers.Giving people a sense of professional status is important in how they regard their jobs, and hence to how they are likely to perform their tasks.
The personal evidence presented to the inquiry made similar points. The report states:The personal evidence places the same emphasis on training, and for the same reasons, as the formal evidence, but it does add a vivid sense of the difficulty and frustration suffered by those who attempted to go on courses … The … overwhelming impression about training given by this evidence is how few correspondents have received it.A total of 116 individual staff from residential homes wrote to the committee, but only 13 appeared to have been given even rudimentary training. Seven of those 13 were working in child care.
Again, I should like to think that the position had improved since the recommendations, but there has clearly been no dramatic improvement. That is why we believe that a training requirement shold be enshrined in legislation. If it is left to private homes, voluntary homes and even to local authority homes to decide on the level of training, progress will be slow towards the realisation of what the Wagner committee saw as the goal by means of which satisfactory residential care would be provided.
Almost exactly the same views are expressed in the recent Howe report:Training plans are of great importance in assisting with the delivery of quality care.The inquiry therefore recommends that local authorities require the production of training plans, which contain minimum standards, within the inspection procedures for their own homes and those of the private and voluntary sectors and demonstrate their implementation.904 Our amendment can, therefore, be seen to be absolutely in line with both the 1988 and the 1992 reports.
Sir William Utting, from his position as permanent secretary, stated that the Howe committee should look into residential care. It did so and it concluded that training was essential and that there should be training plans that affected all members of staff in private homes, voluntary homes and local authority homes.
The Howe inquiry elaborated on that point and said thata major aspect of residential care is the need for teamwork and consistency of practice, regardless of who is on duty. The provision of training programmes for complete staff teams is therefore of the utmost importance. New ideas cannot be reliably introduced to a home by training one or two staff outside the home and sending them back to influence the others; if new approaches are to be adopted or attitudes changed, it is necessary for the complete staff team to be involved and identify with the new thinking …The Inquiry therefore recommends that in every home a senior manager should have specific responsibility for (a) developing the staff training programme for the home, (b) ensuring that new staff have induction training, and (c) acting as a link with others responsible for training, such as the authority's training section or local colleges placing students, concerning matters such as training programmes about the authority's policies, secondment planning and placements for students.The report makes it clear that this is a very important aspect of improving the quality of care in care homes.
The question, therefore, is whether provision should be made for this in legislation. We say yes. Only by including it in legislation are we likely to obtain the improvements for which we look.
Reference has already been made to contracts for residential care. The Consumers Association has recently published a report on this question. The association states that a facilities document should accompany the contract. That would provide assurance, as part of the contract, of the care available. The number of staff and their qualifications would have to be stated. Those details would provide evidence that the staff had been trained and that they had the skills available to meet the needs of the clients.
That could be written into the contract. Progress will be slow, however, if we have to rely on the contractual method alone for the introduction of training. We cannot afford to wait. In the absence of training, we have to pay particular attention to the avoidance of abuse.
An article on abuse and its avoidance has been published by Patricia Riley. It is entitled "Professional Dilemmas in Elder Abuse" and it was written when she was a member of the directorate of Kent county council. In terms of institutional abuse she makes it very clear that the successful avoidance and detection of institutional abuserequires quality assurance programmes to be a focus for all staff groups from all agencies … and requires staffing of establishments at a level allowing more than 'warehousing' care.In parenthesis she states:have you ever heard the T.V. referred to as 'third member of staff, and seen rows of elderly people sitting round the walls staring into space while the T.V. blares away to break the silence?Yes, we have seen institutions such as that. It is not just a question of the number of staff; it is a question of the attention to staff training. That is referred to as an essential part of avoiding institutional abuse.
905 Staff development meetings and training lead to people being aware of what is going on in homes. Some of the abuse that has led in the past to public scandals could thereby be prevented.
Large numbers of people may be encouraged by this measure to set up care homes. We must therefore provide safeguards. I intend to refer to the reports of two cases that were looked into by the registered homes tribunal. Under the heading "No Place Like Home", my hon. Friend the Member for Peckham (Ms. Harman) published those cases. One is a residential care home in Burnley. According to registered homes tribunal decision No. 129 of June 1990, an examination of that home showed thatcare staff were not sufficiently skilled, experienced or qualified to provide adequate care for the residents … this led to serious consequences in the treatment of and attention to seriously ill residents.The proprietor of the homehad instructed residents to leave their beds and rooms when they were not fit to do so … residents were left with dirty clothing and bed linen and without proper incontinence pads. They were often smelly and damp.A series of other unfortunate practices was referred to, but the lady proprietor was described asthe only qualified or senior member of staff and was hardly in attendance, and she insisted that members of staff should tell untruths to cover up her absence.The second case involved the Harrogate health authority. Regarding a home run by a Dr. Crammer, the tribunal referred to the fact that the quality and quantity of staff required to run and maintain the nursing home on a daily basis was simply not there. It stated:There was a high turnover of staff in charge and a persistent failure to meet the minimum staffing requirements of the Health Authority.The tribunal found in favour of the health authority, which said that the ownershows a cynical disregard of social and statutory obligations which arise as a consequence of ownership of a Nursing Home.The crucial reason for the inclusion of our amendment is shown there.
Dr. Crammersees ownership as an exercise in business matters … Much of his evidence went to his concern as to the reduction of costs in the Nursing home. Whilst financial efficiency is to be applauded, that does not mean standards should be reduced below acceptable levels.It is our contention that if our amendments on training were included in the legislation, there would be a greater
guarantee of the level of care that we regard as important for our elderly people.
One of those who spoke to the Wagner inquiry said:Training is extremely important, especially for young people, but they must have within themselves a nature that is caring and courteous, to be able to relate to a person's integrity, not just to humour them … The dignity of the person is what matters most.Because that is what matters to us, it is important to provide for homes encouragement, by way of statute, that will ensure training and guarantee acceptable standards of care.
§ Mr. Peter Griffiths (Portsmouth, North)
I want to say a few words on the amendments. [Interruption.] The frequency and length of interventions are no measure of sincerity.
The issue of training is vital. The spirit in which the amendment was moved reflects the general view held by anyone who has any knowledge or understanding of the needs of those in residential accommodation. However, 906 the hon. Member for Morley and Leeds, South (Mr. Gunnell) does not seem to have thought through the clear distinction that exists between the attainment of qualifications and training. They are not the same thing in any sense. It may be that certain qualifications are necessary for some of the staff in residential accommodation. Certainly, in nursing homes, nursing qualifications must be part of the procedure. However, in many residential homes the qualification that is most necessary is not a certificate or diploma, but a genuine concern to assist those who require personal help and support.
Not everyone who works in a residential home is there to further his or her career. It may be that a woman—it is sometimes a man—who takes on the job of care assistant develops an interest and wishes to develop her knowledge and understanding through training courses to which she could be seconded. For many middle-aged care assistants, the main qualification is that they are concerned. The hon. Member for Morley and Leeds, South referred to protection from abuse. The most potent protection from abuse is the motherly care assistant who would not consider falsifying reports or records at the behest of someone with a paper qualification.
I am not suggesting that we should belittle regular training; it is important for those who hold senior management positions. Our task should be to reinforce best practice. I was interested to learn only last week of an example of best practice in my constituency. Senior managers have been meeting with a highly qualified psychologist and have been putting themselves in the position of residents in individual circumstances. That is the sort of high-level training that is extremely valuable for people in managerial positions.
At the other end of the scale, there is the essential need for basic training for those who work in residential homes.
§ Mr. Griffiths
I shall give way when I finish this point.
Obviously, staff need to be trained to lift patients properly and to care for their intimate needs in a proper manner. However, that does not require legislation. No sensible owner of a residential home would allow staff to lift patients in an inefficient way because if, patients were injured, there might be challenges in the courts.
§ Mr. Hinchliffe
The hon. Gentleman has clarified his comments. He seemed to be saying that he did not think that any form of basic training was relevant to the role of care assistant. Clearly, he concedes that lifting and handling skills and first aid—basic caring skills—are essential. My concern is that he is giving the impression that Opposition Members are talking about degrees in sociology. We are not. We are talking about basic skills. From 1980 to 1987, I was involved in teaching courses on caring skills. During that time, I saw several hundred students, but there was not one from a private care home. The private care sector did not seem to recognise the need for or the importance of training. Does the hon. Gentleman accept that that is worrying? That is why my hon. Friend the Member for Morley and Leeds, South (Mr. Gunnell) moved the amendment.
§ Mr. Griffiths
I did not give way to the hon. Gentleman immediately because I wanted to finish my point. I do recognise the need for qualifications for some members of 907 staff and the need for basic training for all members of staff. I am prepared to accept that there are probably examples of failure to provide adequate training. However, the hon. Member for Morley and Leeds, South was giving statistics about the number of people who hold qualifications. He was using that to suggest that the fact that only a tiny minority of those working in residential accommodation have qualifications means that staff are untrained. I was seeking to show that that is not necessarily so.
We want to ensure that training follows best practice, but we need not do that by legislation. The hon. Member for Morley and Leeds, South said that we should encourage the development of training by legislation. That is an odd choice of words. Legislation should be used when encouragement has failed. We should seek to encourage best practice by making sure that it is widely publicised and well-known. Also, we should encourage best practice through the contract. The amendments deal with that, but the hon. Member for Morley and Leeds, South did not. When any sensible local authority awards contracts, it will take into consideration the way in which staff are trained.
§ Mr. Griffiths
The hon. Gentleman asks me from a sedentary position why we should not require training. The answer is that to require training of all staff, as amendment No. 4 seeks, would mean a massive bureaucratic training programme for thousands of care assistants who would be required to go through forms of training which were beyond the training that they had already and which they were unlikely to want. If they are simply told that they must be trained, some of them will leave.
Not only the motherly ladies would leave. In my constituency, sixth formers work in residential homes at weekends. They take part in the life of the home and bring a spirit of youth and vitality which could not be trained into them. They cannot do training courses when they are in the sixth form at school and they will soon leave for their own education and training.
§ Ms. Coffey
The hon. Gentleman seems to distinguish between care and training. He seems to say that we need people who care and that care is enough. The problem is that caring is often not enough. I shall draw an analogy with residential child care. There may be homes in which people care about the children, while they also abuse them. There can be abuse by someone who is caring. I am sure that the hon. Gentleman agrees that caring is not sufficient.
Surely the hon. Gentleman agrees that there should be an objective measure of the balance between caring and the ability to transmit that into skills. If he accepts that, he must arrive at the conclusion that there must be training, in whatever way he cares to put it, for everyone involved in personal and close relationships with another individual which involve care. I am sure that there is not a division between caring and training.
§ Mr. Griffiths
I am grateful for the hon. Lady's comments, because we are basically in agreement. I believe that care is the first and primary component that anyone should bring to the job, but I agree that care is not enough.
908 It must be skilful care and it must go beyond simple emotional commitment to the person who is being cared for. It must be recognised that people have needs, which requires a wider vision. I am sure that the hon. Lady and I do not disagree on that point.
We may disagree, however, on the question of including such a provision in the Bill. It would be nonsense if it were included in the Bill, which applies to only a narrow range of institutions. Even if such a provision applied to all institutions, it would, first, discourage those who were pioneering best practice; secondly, discourage those who did not wish to go beyond basic training in the giving of care; and thirdly, mean that there was a marked increase in costs in homes.
I assure Opposition Members that the idea that running a residential home is a licence to print money is certainly not true today, if it ever was. There is heavy competition, and there are homes that are not full and do not have waiting lists. The idea that there would have to be extra staff on duty while others were on training courses would lead to additional costs. If we want carers to have adequate training and adequate qualifications where necessary, the best way to achieve that would be through encouragement.
§ Mr. Hinchliffe
I have listened carefully to the hon. Gentleman's interesting contribution. I commend the fact that he, as a Conservative Member, has made a contribution and it is helpful that he has put forward his views.
The hon. Gentleman makes a point about the private sector's difficulty in financing training. Does he accept that, with the Government's requirement for increasing numbers of individuals who work in care in the private sector to be qualified, the logic of his argument is that the expense falls on the public sector?
The time for the private sector to take training seriously is long overdue. The simple fact is that the private sector relies on people being trained entirely at public expense. It is becoming increasingly difficult for local authorities, because of the pressure on expenditure on personal social services, to train people, who subsequently move into the private sector.
§ Mr. Griffiths
There has always been a movement from training in the public sector into the private sector, whether it has involved people trained at the royal naval dockyard in Portsmouth in years gone by going into private industry or people trained in medical and nursing schools going overseas. That is not new and strange; it is reasonable and it is part of the normal career process in a free society that people should move.
I have not suggested that the burden should fall entirely on the public sector. I have said that the burden placed on the private sector should be a burden that the private sector is capable of bearing. There should be a requirement that will encourage best practice and not simply impose a rigid straitjacket to which the existing residential accommodation units cannot conform between now and next April.
The amendment would lead to a rushed and botched scheme which would not be to the advantage of those in residential care. I welcome the spirit of the amendment, but I hope that Opposition Members will not press it because to do so would be simply to go beyond the point 909 at which they would be most likely to help the residents in the homes, which is the task that all of us have set ourselves.
§ Ms. Liz Lynne (Rochdale)
I support the amendment. The hon. Member for Morley and Leeds, South (Mr. Gunnell) made a terrific contribution to our debate.
The Royal College of Nursing report "A Scandal Waiting To Happen", which has been mentioned in the debate, states that a shortage of properly qualified nursing staff will not be solved by the present proposals due to take effect in April 1992. The Howe report, stemming from the residential staff inquiry, says that staff in residential and nursing homes must have proper qualifications and appropriate training. It is essential for people in residential and nursing homes to have a proper training.
There is a need for the training of the complete staff team. We cannot have one person being sent off for training while others in the nursing home are not trained. What would happen when the trained staff were off sick? It is difficult for residential home owners and nursing home owners when staff are off sick and they have no one who is trained to bring in to take over the responsibilities. There should be a proper staff training plan so that everyone in a home has some training before becoming involved with the patients or residents.
I take the point about the need for someone who is caring. It is essential that staff are caring, but it is also essential that they have some modicum of training before they are let loose on the residents or patients.
One can see for oneself whether or not a home is well run. I have been to many homes in Rochdale and elsewhere. Some are light and a happy. The residents seem to be enjoying themselves and there is a lot of laughter. In others, everyone seems a little depressed—perhaps not greatly upset but a little depressed none the less. As soon as one enters such a home, one thinks, "There is something not quite right here." Ultimately, that comes from the top —from the person in charge of the home—and is reflected in the training of the staff.
We must ensure that staff are trained. I have referred before to the 90-year-old lady in my constituency who came to see me. She had been in three different homes, both in my constituency and outside it, and was very dissatisfied with the standard of treatment that she had received. For a start, she had seen one elderly lady being bathed by a male member of staff who had no training whatever. Had he had medical qualifications or been trained as a nurse, it would have been different: no doubt the elderly person would not have minded being bathed by him. But an untrained new member of staff had been given the responsibility for bathing all the elderly ladies. Elderly people who have protected their modesty for many years may suddenly find, when they go into a residential home, that they have to take off all their clothes in front of a young man who has no training or qualifications. The young man in question went on to gain nursing qualifications in the end, but that is not the point.
§ Dame Jill Knight (Birmingham, Edgbaston)
We are all following the hon. Lady's speech with great care, but can she tell us whether the home to which she refers was a private residential care home or a council-run home? Many of us have visited many of both in our time
§ Ms. Lynne
All three were private. The problem exists in all homes—local authority homes, private nursing homes and private residential homes. The need for proper staff training applies equally to them all.
There are incidents in homes throughout the country. I am sure that every hon. Member could cite examples of inadequate staff coverage and training. Sometimes people want to go to the loo but are kept in their place for a long time because there are not enough staff around to take them there. Through training, we must ensure that staff realise that it is wrong for elderly people to have to stop going to the loo, because it is bad for their bladder control and can lead to great problems. That element of training is vital. Young care assistants need to be told that that is not good medical practice.
The Howe report on residential staff says that the majority of care staff have taken short courses organised by a local authority but that, although they are effective in the transfer into residential work, little in the way of staff development and training is monitored. Training should be monitored by local authorities.
Paragraph 21.1 of the report says:The inquiry therefore recommends that local authorities require the production of training plans which contain minimum standards with an inspection procedure for their own homes and those of the private and voluntary sectors, and demonstrate their implementation.In its entirety, the Howe report makes the case for proper training. I agree with the hon. Member for Portsmouth, North (Mr. Griffiths) that care assistants have to be caring, but I maintain that training, too, is essential.
§ Mr. Kevin Hughes
Amendments Nos. 3 and 4 would provide for the staff in the homes mentioned in the Bill to be appropriately trained. The case for the amendments was eloquently made by my hon. Friend the Member for Morley and Leeds, South (Mr. Gunnell), who went into a great deal of depth and showed his knowledge of the subject.
Training is generally acknowledged to be the key ingredient in achieving high-quality care for those requiring residential accommodation. In spite of that, there is evidence to suggest that a large number of staff in the residential care sector receive little or no training. Some lack any knowledge of even the most basic health care techniques, such as first aid and techniques for lifting and handling.
The needs of those in residential care have changed greatly in the past decade. The incidence of dementia among elderly people has increased, and the figure is likely to continue to escalate given the current demographic trend, which suggests that the increase in the over-75 population will continue into the next century. Elderly people suffering from dementia may eventually lose their individual pesonality. That is the spectacle with which they confront care staff, who are thus required to provide high-quality care for residents from whom they receive little or no recognition or communication, let alone appreciation or gratitude. Appropriate training recognises the great demands placed on all staff who care for the most vulnerable in our society.
911 No one would dispute the fact that the overwhelming majority of staff working in residential care are conscientious and dedicated individuals, in spite of poor pay and working conditions.
In her report, published in 1988, Lady Wagner referred to residential care services as being in a demoralised state, with the staff concerned being held in low esteem. There is little evidence to suggest that there has been any significant improvement in recent years. Lessons have unfortunately had to be learned from the results of inquiries into serious incidents in the residential care sector.
There can be no doubt that, in some instances, the lack of staff training has led to a vicious circle of low morale and poor-quality care. That creates a dangerous environment, in which the potential for abuse, neglect or exploitation exists. Despite the lack of willingness to address the issue throughout the 1980s, the abuse of vulnerable adults, especially older people, is now on the agenda, and several hon. Members have mentioned it. I have no desire to be alarmist or to denigrate the work of the vast majority of highly motivated care staff, many of whom recognise that such abuse exists and would welcome the opportunity to express their anxieties about the situation. Appropriate training that recognises the high levels of skill and commitment required by residential care staff is generally accepted as an essential element in prevention.
Training costs money, however, and many proprietors of residential care homes give such expenditure the lowest priority and do not regard it as desirable. In fairness, I must say that a few homes in the private sector do spend money on training. When I was chair of social services in Doncaster, the metropolitan authority offered facilities for the training of staff in private residential homes. A few proprietors took those opportunities, and their staff were trained alongside the local authority staff. Many certificates were presented to people from the private residential care centre in Doncaster.
I believe that legislation is essential to ensure that training is made available to all staff. The development of the national vocational qualification in care provides an excellent framework, and it is to be hoped that accreditation will soon be given to higher levels. Management training is also essential for those who are responsible for running and managing residential homes.
Age Concern and other voluntary organisations have provided excellent charters in recent years for adoption by those who provide residential care. Those documents recognise the rights of residents to receive care in an environment which affords them the same rights as they would expect to have if they lived in their own home. Those rights include the right to privacy and the right to have their dignity and individuality respected at all times. The documents state that all care offered should start from the basis of promoting independence and choice. If those objectives are to become more than pious sentiments, a rigorous training programme is absolutely essential.
The latest report, entitled "The Quality of Care", has been mentioned more than once in the debate. The committee was chaired by Lady Howe. The report made some 30 recommendations, some of which were referred to by my hon. Friend the Member for Morley and Leeds, 912 South (Mr. Gunnell). Half of the recommendations make specific reference to the need for training to ensure the provision of high-quality care.
The Minister may be aware of my early-day motion 175, which has already been signed by 188 Members of Parliament, and which welcomes the publication of Lady Howe's report. I hope that the Minister and the Government will support its call for increased funding to facilitate improvements in training, pay and conditions. I ask the Minister to support the amendments and in so doing to accept the need for legislation for training.
§ Mr. Yeo
When the hon. Member for Morley and Leeds, South (Mr. Gunnell) moved the amendment he rightly drew attention to the enormous effect that a change of management can have on the way in which an establishment is run. The whole atmosphere of the place can change. We all agree with him on that. He quoted figures to demonstrate that the proportion of trained workers was lower in residential homes than in some other areas of personal social services activity. That is true, but one of the reasons is that trained workers move out of residential work into other areas of social services.
§ Mr. Yeo
The reason is that the status of residential work is not as high as some other forms of social services work. One of the issues that I discussed recently with Lady Howe following the publication of her helpful report was finding ways of making it attractive to people, in terms of career development, to work in residential care and stay in it for a reasonable proportion of their career.
§ Ms. Coffey
Does the Minister agree that one of the main reasons why residential workers leave residential work is that it is almost impossible to support a family on the pay that they receive and that little opportunity for training is given to them and they receive little reward for what training they have? Does he agree that experienced residential staff will continue to leave simply because of pay?
§ Mr. Yeo
People may decide to leave residential work for a variety of reasons. However, raising people's perception of the importance of that work would be a valuable contribution to ensuring that trained staff stay in residential work for longer than they do at present.
My hon. Friend the Member for Portsmouth, North (Mr. Griffiths) made a constructive and perceptive speech with which I entirely agreed. He drew an important distinction between training and qualifications. I shall refer to other remarks that he made.
The hon. Member for Rochdale (Ms. Lynne) and others referred to the Howe report. Most of the recommendations in that report are for the local authorities to follow up, but the Government are considering the actions which the report suggests that we should take and how we might take them forward. As I said, I have recently discussed the report with Lady Howe.
All hon. Members will have sympathy with the aim of the amendments, which is basically to ensure that the highest possible standards of care are provided in all types of accommodation. However, I dare say that it will not 913 come as a complete surprise to Opposition Members to hear that I intend to resist the amendments. I do so on the grounds of both practicality and appropriateness.
If the amendments were accepted, local authorities would find initially that they could use only a few establishments, because only a few met the requirements. The consequence of that would be that a substantial number of people who currently go into residential care would have to remain in hospital. The amendments would undermine the progress that we are making towards community care and the reforms that the caring for people policy is designed to achieve. Hospital beds would be blocked and a great many people would have to remain at home in conditions with which they might find it difficult to cope.
§ Dame Jill Knight
Will my hon. Friend take this opportunity to place on the record the undoubted fact that without the residential home care provided by private sector homes we could not possibly cope with the growing number of elderly people who need such care? Will he make it plain that the House cannot take action that would lead to the closure of large numbers of such homes, because we need them so much?
§ Mr. Yeo
I am glad to have the opportunity to assure my hon. Friend that that is indeed the case. It would be not merely a setback but a major crisis if the independent sector were forced to withdraw to any significant extent from the provision that it currently makes. The private sector houses a large and increasing number of elderly people. So my hon. Friend is right. Indeed, we are determined to ensure that the independent sector continues to make a growing contribution to residential care provision.
Our most recent survey of the statutory sector dates from 1986. It showed that only a quarter of the staff in residential care for adults held a social work or other relevant qualification. It is estimated that as at September 1990, 18,921 care staff and a further 50,556 other staff would need to take a training course, only some of whom have been trained so far. To train all of them would be a massive task, as my hon. Friend the Member for Portsmouth, North said.
We have begun to tackle the training agenda with several initiatives, including the training support pro-gramme, which has increased in volume year on year to its current level of £29 million, which supports at least £41 million of expenditure by social services departments.
The hon. Member for Wakefield suggested in an intervention that the independent sector lagged behind the statutory sector on training. We do not hold centrally statistics on the numbers of staff in the private or voluntary sectors or on the qualifications that they hold. There is certainly no evidence to suggest that more staff are qualified in the independent sector than in the statutory sector.
We have addressed the need for better work force data by funding the local government board to develop and disseminate advice to social services departments on work force analysis. The board has published the "Social Services Work Force Analysis Handbook" and is holding seminars in various parts of the country.
§ Mr. Hinchliffe
The Minister implicitly criticised the lack of qualified staff in the public sector of residential care, but, by his own admission, the Department of Health 914 does not have any similar information about the number of staff who are qualified in the private residential care sector. Why is that the case? I find it rather surprising.
§ Mr. Yeo
I did not intend to criticise either the statutory or the independent sector. I am merely trying to set out the present position to demonstrate the effect of accepting the amendment.
I recognise that data are inadequate. That is why we have begun to tackle the problem in the way that I described. It would be helpful to everyone if we knew what the situation was. Amendment No. 3 does not take into account the changes that we are introducing in vocational and professional training and education. As the House knows, the Government have supported the development of national vocational qualifications, NVQs, in the care sector. NVQs levels 2 and 3 for residential care staff became available only late in 1990. Their introduction makes a substantial change in vocational education and training. Whereas, previously, completion of a training course, which led to a qualification, was seen as indicative of quality of performance, with NVQs, performance has to be demonstrated in the workplace. Only when that performance has been assessed as competent is a person awarded an NVQ.
As regards amendment No. 4, the Government fully support the development of training plans in appropriate circumstances, as a way to achieve improvements in the quality of service provision. The amendment would require the provision of training plans and training in some circumstances where that would be inappropriate —for example, in the case of a person or a couple who are simply providing homely accommodation. The consequences of accepting the amendment would be that some viable and highly valued establishments might need to close because local authorities would not be able to place people in them.
Finally, the responsibility for training staff within the private and voluntary sectors rests with them as employers, but training is only a part of a complete quality assurance system. One of the great merits of the new framework, which will exist after April next year, is that it will be possible for the underlying aim of both the amendments to be achieved, if local authorities assess whether appropriate quality assurance systems are in place when they are setting contracts. That would include, as a minimum, examining the extent of training provision within a home, and the existence of a training plan. Against that background, I urge the House to reject both the amendments.
§ Mr. Rooker
I am astonished at the contributions from the two Conservative Members who spoke in this debate. they were not what I would call constructive; they were extremely one-sided and were not part of the main flow of the debate around the Bill. We have not really been debating the Bill. From day one we made our position clear—we did not want to debate the Bill, as we agree with it, but we have used it as a vehicle for raising other issues.
On training, I shall not use the quotes from the reports by Lady Wagner and Lady Howe that other hon. Members used. They are all relevant and repetition would serve no purpose. However, one argument from the original Wagner report that should be reinforced is the idea that we should treat all staff as officers and professionals, whatever they do. We should not argue that 915 because people are simply care assistants they do not deserve training. All staff who care for our fellow citizens have to be trained and to be treated as equals as regards their professionalism, whatever level of care they offer. I think that that was argued in the Wagner report, but it has not been taken on board. It is reinforced by the conclusions and recommendations of the Howe report, but has not been introduced in practice.
As stated in the Wagner report, it is not merely a question of training. I am prepared to recognise the distinction that the hon. Member for Portsmouth, North (Mr. Griffiths) made between training and qualifications. Recognition and registration are also issues. I do not wish to mention Maastricht in this debate, but come next year and the free movement of labour in 1993, they will become issues. In some of our European partner countries, one cannot work as a care assistant in residential care unless one is trained, qualified and registered. Therefore, people from this country will not be able to share in that movement of labour.
If it is good enough for our partners in Europe to have a more regimented training system, we should consider it. By and large they beat us on training hands down, in all sectors of industry, which is why their economies are more successful than ours. I am not saying that everyone must be registered to be a care worker, but, as night follows day, that will have to come.
Also, that should not merely affect care workers in residential care. Many care workers give domicilary care. People in their own homes or in group homes will be on the receiving end of the complex care packages that we discussed in Committee and will be taken care of by workers who may not be trained. They ought to be trained. Training should cover that area of care as well as workers in residential care.
The hon. Member for Portsmouth, North, said something that was self-evident, but the way that he said it was interesting. Opposition Members accept that it is a fact of life that public sector industries train and private sector industries get the benefit. That is true. However, one cannot accept that and argue in the next breath, as many Tories do, that there should be competition between the two sectors and that costs in the public sector are higher and so the private sector is more efficient.
§ Mr. Rooker
The hon. Member for Birmingham, Edgbaston (Dame J. Knight) wishes to intervene and I shall make her the same offer as I made to the hon. Member for Tiverton (Mrs. Browning). If I give way, will she make a speech later to show that she is committed to debating community care and is not passing through on the way from one dinner to another to make an aside?
§ Dame Jill Knight
The hon. Gentleman can be as rude as he likes, but there are such things as Select Committees which one has to attend, as I have been doing this evening. It has not been my fault that I have been unable to be here because of other duties. I can assure the hon. Gentleman that I have not been to one dinner, let alone two.
Is the hon. Gentleman saying that people who go to private residential care homes, paid for by the taxpayer 916 —as many thousands do—have no right to benefit from people who have been trained by the public sector? That is certainly what it sounded like. Is he saying that people who go to residential care homes have no right to ask for help from people who have been trained elsewhere?
§ Mr. Rooker
I offer the hon. Lady a fulsome apology as she has been in the Select Committee dealing with accommodation, but her second point was ridiculous. I am not saying anything of the kind. The hon. Lady has an obsession, and she has proved it because she has only mentioned one sector of provision in her interventions. We are not saying that. We want everyone involved in care to be trained and qualified—within the public, voluntary and private sectors. However, funding for that training ought not to be an impost on one sector, when the three sectors are in competition. That is unfair and that is what causes chaos in the financial arrangements for residential care.
§ Mr. Rooker
The hon. Lady may shake her head all she likes, but I am right and I know it. She wants training and qualifications, but she is not prepared to will the financial means to take it into account. It is as simple as that.
The public sector is more than happy to train, but in that case it is no good having multi-sector provision. We want multi-sector provision and choice born out of competition. We agree with that, but the hon. Lady does not. She wishes to snuff out the public sector and to establish a monopoly of private sector care. Opposition Members do not agree with monopoly provision of care, whether in the public, the private or the voluntary sector. Therefore, we want a level playing field of costings, although I hate that term, and it is unfair that the training impost falls on one sector.
I mentioned care outside residential homes, and it is important that training takes place in that sector, too. As a society, we are entrusting our fellow citizens to the care system.
The level of care or where it is delivered does not matter. When someone is placed in the care of another it means that society is duty bound to ensure that the quality of care is supreme. The quality of that care cannot be guaranteed unless one knows that the carer, at whatever level, is trained for the job.
The test of quality of care has underlined all our debates. It is the only test that counts. Throughout the passage of the Bill the Minister has been extremely co-operative and we have had extremely interesting debates. In fact, the Bill would have gone through on the nod on a Friday in February were it not for a slight error in the mechanics of this place. However, the Bill had its Second Reading and was considered in Committee in four sittings.
The short debate on the amendment has concentrated on training and I am afraid that the Minister's response has been so unreasonable that we must divide the House.
§ Question put, That the amendment be made—
§ The House divided: Ayes 68, Noes 155.918
|Division No. 48]||[8.30 pm|
|Ashdown, Rt Hon Paddy||Callaghan, Jim|
|Ashton, Joe||Campbell, Menzies (Fife NE)|
|Barnes, Harry||Campbell-Savours, D. N.|
|Bayley, Hugh||Carlile, Alexander (Montgomry)|
|Beggs, Roy||Clwyd, Mrs Ann|
|Coffey, Ms Ann||Marshall, Jim (Leicester, S)|
|Connarty, Michael||Martin, Michael J. (Springburn)|
|Dafis, Cynog||Maxton, John|
|Dalyell, Tam||Michael, Alun|
|Davidson, Ian||Michie, Mrs Ray (Argyll Bute)|
|Davis, Terry (B'ham, H'dge H'l)||Milburn, Alan|
|Dixon, Don||Miller, Andrew|
|Donohoe, Brian||Morgan, Rhodri|
|Eastham, Ken||Morley, Elliot|
|Flynn, Paul||Morris, Rt Hon J. (Aberavon)|
|Forsythe, Clifford (Antrim S)||Olner, William|
|Foster, Derek (B'p Auckland)||Pike, Peter L.|
|Galloway, George||Powell, Ray (Ogmore)|
|George, Bruce||Radice, Giles|
|Gerrard, Neil||Redmond, Martin|
|Godman, Dr Norman A.||Roche, Ms Barbara|
|Gunnell, John||Rooker, Jeff|
|Hall, Mike||Short, Clare|
|Harvey, Nick||Simpson, Alan|
|Hinchliffe, David||Skinner, Dennis|
|Hughes, Kevin (Doncaster N)||Smith, C. (Isl'ton S & F'sbury)|
|Jackson, Ms Helen (Shef'ld, H)||Taylor, Matthew (Truro)|
|Jones, Barry (Alyn and D'side)||Tyler, Paul|
|Jowell, Ms Tessa||Wallace, James|
|Kennedy, Charles (Ross, C & S)||Watson, Mike|
|Kirkwood, Archy||Wigley, Dafydd|
|Livingstone, Ken||Wise, Audrey|
|Loyden, Eddie||Tellers for the Ayes:|
|Lynne, Ms Liz||Mr. Alan Meale and|
|Mahon, Alice||Mr. Thomas McAvoy.|
|Adley, Robert||Evans, Jonathan (Brecon)|
|Ainsworth, Peter (East Surrey)||Evans, Nigel (Ribble Valley)|
|Aitken, Jonathan||Evans, Roger (Monmouth)|
|Alexander, Richard||Faber, David|
|Alison, Rt Hon Michael (Selby)||Fabricant, Michael|
|Arbuthnot, James||Fenner, Dame Peggy|
|Arnold, Jacques (Gravesham)||Fishburn, John Dudley|
|Atkins, Robert||Forsyth, Michael (Stirling)|
|Atkinson, David (Bour'mouth E)||Fox, Dr Liam (Woodspring)|
|Atkinson, Peter (Hexham)||Freeman, Roger|
|Baker, Rt Hon K. (Mole Valley)||French, Douglas|
|Baker, Nicholas (Dorset North)||Fry, Peter|
|Banks, Matthew (Southport)||Gillan, Ms Cheryl|
|Bates, Michael||Greenway, John (Ryedale)|
|Beresford, Sir Paul||Griffiths, Peter (Portsmouth, N)|
|Blackburn, Dr John G.||Hague, William|
|Booth, Hartley||Hargreaves, Andrew|
|Bowden, Andrew||Harris, David|
|Bowis, John||Haselhurst, Alan|
|Brandreth, Gyles||Hawkins, Nicholas|
|Brazier, Julian||Hawksley, Warren|
|Brown, M. (Brigg & Cl'thorpes)||Heald, Oliver|
|Browning, Mrs. Angela||Heathcoat-Amory, David|
|Burns, Simon||Hendry, Charles|
|Burt, Alistair||Heseltine, Rt Hon Michael|
|Butcher, John||Hicks, Robert|
|Butterfill, John||Hill, James (Southampton Test)|
|Carttiss, Michael||Horam, John|
|Channon, Rt Hon Paul||Hunt, Rt Hon David (Wirral W)|
|Chaplin, Mrs Judith||Hunter, Andrew|
|Chapman, Sydney||Jack, Michael|
|Clappison, James||Jackson, Robert (Wantage)|
|Clark, Dr Michael (Rochford)||Johnson Smith, Sir Geoffrey|
|Clifton-Brown, Geoffrey||Jones, Gwilym (Cardiff N)|
|Coe, Sebastian||Jones, Robert B. (W H'f'rdshire)|
|Coombs, Simon (Swindon)||Kilfedder, Sir James|
|Cope, Rt Hon Sir John||King, Rt Hon Tom|
|Couchman, James||Kirkhope, Timothy|
|Currie, Mrs Edwina (S D'by'ire)||Knapman, Roger|
|Davis, David (Boothferry)||Knight, Mrs Angela (Erewash)|
|Day, Stephen||Knight, Greg (Derby N)|
|Deva, Nirj Joseph||Knight, Dame Jill (Bir'm E'st'n)|
|Dorrell, Stephen||Knox, David|
|Dover, Den||Legg, Barry|
|Duncan, Alan||Leigh, Edward|
|Duncan-Smith, Iain||Lester, Jim (Broxtowe)|
|Elletson, Harold||Lidington, David|
|Lightbown, David||Stanley, Rt Hon Sir John|
|Lilley, Rt Hon Peter||Stephen, Michael|
|Luff, Peter||Stern, Michael|
|McLoughlin, Patrick||Streeter, Gary|
|Malone, Gerald||Sweeney, Walter|
|Mans, Keith||Sykes, John|
|Martin, David (Portsmouth S)||Taylor, Ian (Esher)|
|Merchant, Piers||Taylor, John M. (Solihull)|
|Mills, Iain||Thomason, Roy|
|Mitchell, Andrew (Gedling)||Thompson, Patrick (Norwich N)|
|Moate, Roger||Thornton, Sir Malcolm|
|Moss, Malcolm||Tredinnick, David|
|Neubert, Sir Michael||Trend, Michael|
|Nicholls, Patrick||Walden, George|
|Nicholson, David (Taunton)||Walker, Bill (N Tayside)|
|Paice, James||Waller, Gary|
|Patnick, Irvine||Wardle, Charles (Bexhill)|
|Peacock, Mrs Elizabeth||Watts, John|
|Porter, David (Waveney)||Wells, Bowen|
|Richards, Rod||Wheeler, Sir John|
|Riddick, Graham||Whitney, Ray|
|Robertson, Raymond (Ab'd'n S)||Whittingdale, John|
|Robinson, Mark (Somerton)||Widdecombe, Ann|
|Rowe, Andrew (Mid Kent)||Willetts, David|
|Ryder, Rt Hon Richard||Winterton, Mrs Ann (Congleton)|
|Shaw, David (Dover)||Winterton, Nicholas (Macc'f'ld)|
|Shaw, Sir Giles (Pudsey)||Wood, Timothy|
|Shepherd, Colin (Hereford)||Yeo, Tim|
|Speed, Sir Keith||Tellers for the Noes:|
|Spencer, Sir Derek||Mr. Robert G. Hughes and|
|Spink, Dr Robert||Mr. Tim Boswell.|
§ Question accordingly negatived.8.45 pm
§ Ms. Coffey
I beg to move amendment No. 5, in page 2, line 34, at end insert—`(IE) Arrangements under this section shall only he made with small homes which register with the registration authority under the terms of the Registered Homes (Amendment) Act 1991.'.The Registered Homes (Amendment) Act 1991, which is not yet implemented, provides for the compulsory registration of residential homes with fewer than four residents. The requirements placed on the small homes that become registered under the Act are less onerous than the existing provision in respect of larger homes. For example, the only reason for which registration of a small home may be refused is that the owner or other person concerned with running the home is not a fit person. On the other hand, the registration of larger homes may be refused on one of the following additional grounds: that, for reasons connected with their situation, construction, state of repair, accommodation, staffing or equipment, the premises used or intended to be used for the purpose of the home, or any other premises used or intended to be used in connection with it, are not fit to be used; or that the way in which it is intended to carry on the home is such as not to provide services or facilities reasonably required.
The approach to the differentation between smaller homes—those with three or fewer people—is characterised by a general attitude referred to as the lighter touch. The differentation in respect of registration and conditions attached to registration and deregistration is fundamentally illogical and inconsistent. A smaller home will have only to submit an annual return. The person running the home will be required to state briefly his name and address, the number of residents cared for and their category, the names of other persons living at the same address, any criminal convictions since the last annual return and the position with regard to charges made since the last return.
919 As can be seen, the information in the return is very sparse. There is no obligation on the local authority to inspect the home. Larger homes have to be inspected twice a year, but smaller homes have only to submit an annual return. The local authority can, of course send an officer to visit and inspect if a complaint is received, but there is no obligation to inspect.
This raises many questions. Let me give some examples. How will the registering authority know if the person running a home leaves or ceases to operate the service during the 12 months after registration or submission of an annual return? What precaution will be taken to safeguard residents from eviction as a result of the eviction of the owner himself? A person might have obtained a number of homes on a rented basis and might be unable to pay the rent or be found guilty of multi-mortgage fraud. In that situation, a small home would cease to operate, and presumably the residents would face eviction. The annual return that a home submits does not require the owner to reveal his financial situation. There is therefore no indication of the stability of the home. The eviction of an elderly person is, of course, a very serious matter for that person and his or her relatives. There is much evidence to suggest that the stress resulting from a move can be terminal for an elderly person. It is very important that elderly people are protected and given stability and protection in the homes in which they reside.
I wonder why there are different registration requirements, particularly with regard to facilities and services. For example, it is proposed that, under section 10(1) of the Registered Homes Act 1984, the provisions concerning fire precautions and drills, precautions against accidents, first-aid requirements, consultations with environmental health officers, training and details about residents should not apply to small homes. It is difficult to see why those regulations should not apply to small homes, as the danger of fire in a small home is as great as in a large home if the premises are not safe, and the risk of accident in a small home is just as great as in a large home. The legislation in respect of homes quite rightly pays attention to this important matter.
Elderly people tend to be very frail. Falls that in a younger person would not cause much injury can fracture the bones of an elderly person or cause other serious injury. The safety of a home is therefore important. Why should this be seen to be sufficiently important in the case of larger homes as to require regulation, but not in the case of smaller homes? There is no evidence that smaller homes are safer than larger homes. Safety is secured only to the extent to which precautions are taken. One can satisfy oneself only by requiring that those precautions are taken. It cannot be assumed that a home with three or fewer residents is safe, but that appears to be what the legislation says. It is therefore totally illogical.
I strongly suggest that the registration for small homes should be the same as for larger homes. The same regulations should apply. If the Minister is unwilling to accept that, the information given on the annual returns that a home submits should be much more extensive. For example, greater attention should be paid to criminal convictions occurring after the registration process. There 920 should be an obligation to declare criminal convictions on the annual return, rather than waiting until the next annual return.
More personal details should be given of the sex, category and number of residents cared for in the home. A copy of the assessment for each person admitted should be given. After all, elderly people's needs are the same whether the person is admitted to a large or to a small home. With that copy of the assessment in the annual return, details should be given about how the care provided has met the assessment of the person's needs, because that is a way of measuring the care that the home has given.
Also included should be the full names, dates of birth, qualifications and experience of persons other than residents not living in the home but employed or working in a voluntary capacity. Details should be given of anybody who helps out in the home or has contact with it.
I am sure that people will say that the amendment is unnecessarily prescriptive.
§ Ms. Coffey
Yes; but if it is a bureaucratic nightmare for small homes, why is it not for large ones? That is what the regulations demand of large homes. It is either right or it is not. There is no difference in the age, frailty or needs of the elderly people admitted, so there should be no differentiation in the standards and quality of care demanded, or how that quality of care is measured and inspected. If it is right for one, it should be right for the other.
Another aspect that the Minister should take into consideration is what the term "registered" implies to the public. If a home has a plaque that says "Registered by the social services department", that implies that the home has a stamp of approval. If the Government are to continue to apply different regulations to small and to large homes, they should make it clear to potential residents that small homes do not offer the same protection as large homes, or residents will not know of the differentiation and will be misled.
In examining why the differentiation is made and reading the introductions to parts of the Bill, it is clear that people think that because a home is small it provides a homely atmosphere and is therefore safer. However, at this very moment, incidents of horrendous abuse of one family member by another are probably happening throughout the country in small homes with a nice homely atmosphere. We should have learnt from past inquiries into incidents of abuse that homes do not protect the people within them. We have taken that seriously on board with children and should do so with elderly people. It is a fundamental mistake to assume that because a home has three residents or fewer, those people are protected by the homely atmosphere and that that home should therefore not be open to inspection or monitoring or be required to have the same fire precaution arrangements or standards of first aid.
Abuse is more likely to happen in a small home because often that is the place where there will be kind, personal relationships that exist within a family, which can become distorted and abusive. Within a small home, elderly people have little ability to complain, because it is difficult to complain to somebody who cares for them every day that 921 they do not like what that person is doing to them, particularly if, from one year to another, they see no one from outside because there is no inspection requirement.
I think that in a year's time a scandalous incident of abuse will take place in a small home and there will be a public outcry and a public inquiry. Thereafter, the regulations and rules will be tightened up but, in the meantime, before the scandal breaks, the person who is subject to abuse will continue to be abused without protection. Who knows, he or she might even die a victim of that abuse before the public outcry catches up and demands tighter regulations.
In almost every incident of child abuse or abuse within a residential setting, the reaction has been to tighten up the inspection and monitoring process. I hope that we have learnt from all those public inquiries and that we will not set up a system that is open to abuse. We should ensure that the inspection and monitoring process that applies to larger homes is applied also to smaller homes to protect residents.
§ 9 pm
§ Mr. Yeo
The hon. Member for Stockport (Ms. Coffey) was not present in the last Parliament when the Registered Homes (Amendment) Act 1991 was debated. The measure received all-party support and many of the issues that she has raised contradict, in some respects, that happy spirit of co-operation.
Taken on face value, the amendment would undermine the purpose of the Bill because it would limit the extent to which local authorities could arrange residential accom-modation in small homes for those registered under the 1991 Act.
The Bill's intention is to ensure that local authorities continue to have as wide a scope as possible to make arrangements for residential accommodation for people in need of care. We do not believe that residential accommodation should be restricted to residential care homes and nursing homes. It must go much wider than that and include housing provision where there is an element of care—for example, group homes or sheltered housing. Such accommodation has to be included in the provisions of the National Health Service and Community Care Act 1991 if local authorities are to ensure that a full range of options is provided to meet the needs of the wide variety of people whom they seek to serve.
A person in sheltered housing may have self-contained accommodation which is similar to that of someone living in the community. Separate but sheltered premises are homes for frail or disabled people, and it would be inappropriate to require such homes or similar premises such as group homes to be subject to registration under the Registered Homes Act 1984.
I have no hesitation in defending the single criterion —the fitness of the person running the home—as the one on which the registration of small homes should be decided. It tackles the principle concern—which led to the introduction of the amending legislation—that some of those running small homes had criminal records or were otherwise unfit to care for vulnerable people. However, it does so in a way that will not deter carers by placing unreasonable regulatory burdens on them.
We must bear in mind the fact that we are dealing mainly with homes that are not run on commercial lines but are run by individuals or families who take in and care 922 for one or two people, perhaps in their own homes. Some people will provide such care under adult placement schemes. It would not be right to deter carers by imposing on them additional demands or costs, which could result in them deciding that it was not worth their while to offer such care, which is just what many people prefer to receive.
I am sorry that the hon. Member for Stockport will not accept that it is wrong not to draw a distinction—we believe that it is a big distinction—between small homes and larger ones in terms of the requirements imposed on them. I recognise the concern about the intention not to impose a duty of regular inspection on small homes, while local authorities must inspect larger, independent homes at least twice a year. However, local authorities are not precluded from inspecting small homes. They have the powers to do so when they feel that that is necessary—for example, on receipt of a complaint.
We wish to keep the annual return, to which the hon. Lady referred, as simple as possible. However, it must be sufficient to enable authorities to keep track of changes in homes that might affect the standards of care provided and alert them to anything that might require further investigation. We do not want to make the completion of the return an excessive burden.
There will be a duty on those who run small homes to report major changes as they occur. Regulations already place that requirement on people running larger homes and we shall extend the requirement downward when the Registered Homes (Amendment) Act 1991 comes into force. The changes that must be reported include changes in the number or category of residents for which the home is registered and any changes in the people running the home. It will become an offence for someone to take over the running of a home if they have not been approved as suitable by the local authority.
We have had to strike a balance between competing considerations. I recognise the anxieties to which the hon. Lady referred, but I do not believe that it would be possible for any legislation, however tightly drawn, completely to eliminate the risk of abuse occurring. It would be impossible to introduce a system that allowed a variety of providers to fulfil their duties while acting as a guarantor against the risk of occasional abuse.
We have brought small homes under regulatory control in a way that addresses the principle concern by providing an opportunity for local authorities to keep in touch with significant changes in those homes and giving registration authorities the power to close unsatisfactory homes. We have achieved that without imposing undue burdens or costs on local authorities. Therefore, I believe that we have struck the right balance and I invite the House to reject the amendment.
§ Ms. Coffey
I do not think that it will come as any great surprise to the Minister when I say that I do not think that the Government have struck the right balance. The Minister said that he believed that the homes to which I referred would not be commercial enterprises. I can see no reason for him to make such an assumption, as it would be possible for many commercial enterprises to grow up around the care of three people. It is wrong to assume that small homes will not be commercial enterprises. That is why I am worried that there are not to be regular inspections.
I welcome the fact that, acccording to the Minister, there are to be changes in the annual returns to cover some 923 of the issues that I raised. I understand the argument that we should not place unnecessary burdens on carers, but we should consider the matter from the view of those who are cared for. The protection of elderly people and those who are cared for should be our paramount consideration.
I spent 20 years of my life enacting foster care legislation to stop children being abused, so I know very well that legislation does not stop abuse. But it does provide a climate of opinion in which local authorities and social services departments become aware of their obligation to inspect. Once a local authority has been asked to carry out inspections, it becomes responsible for ensuring that such inspections are adequate, knowing that if they are not it will be the subject of an inquiry. If we remove the obligation to inspect, that climate of opinion changes and authorities do not feel responsible. Such a climate of opinion will lead to a gap in care, and in that gap abuse may take place.
The amendments that we moved in Committee were designed to deal with certain subjects. For instance, we mentioned the illogicality and the inconsistency in the Government's approach to larger and smaller residential homes. Be that as it may, I beg to ask leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ Mr. Rooker
I beg to move amendment No. 7, in page 2, line 34 at end insert—'(1G) Arrangements shall only be made by virtue of this section where the voluntary organisation or other person providing the accommodation makes a contract with the local authority as to the charges they will impose, the frequency of increase, the criteria to be used in raising charges and details of any supplementary changes to residents including a statement of policy regarding any differentiation between residents in accommodation at public expense and other residents.'.The amendment allows us to discuss once again the charge levied in residential and other homes. We mentioned them in Committee and we had hoped that the Minister would go away and think about them a little more. We were struck by the boldness of his approach in Committee; he thought that it was fine to levy extra charges for second helpings at dinner. He said that that was part and parcel of the system.
We are pleased to see the Secretary of State present for the debate on this important amendment. I presume that she left her ring fence outside—we have been looking for it all day.
§ Mr. Rooker
That is quite possible. In any case, we are pleased to see her here.
I am not attacking any particular sector. Some residential and nursing homes in this country provide top-quality care without extra charges for second helpings of food, single rooms, newspapers, hairdressing, trips, breakfast in bed, alcoholic drinks, incontinence pads or toothpaste. Such homes are, however, few and far between. Many homes do charge for these services. We should like to know whether the Minister has thought about the subject again.
Before local authorities take out contracts with homes covered by this Bill, they ought at least to know what they 924 are paying for. They ought to know in advance what the supplementary charges are and how often charges are increased.
In passing, I should like to mention the immoral funding arrangements brought about by the Government's practices. I refer particularly to the nursing home sector. All residents in such homes receive exactly the same service—there are no supplementary charges for different services—but residents pay different fees depending on whether they are staying at public expense with DSS income support or at their own expense, perhaps by spending the assets from a family home.
I do not object to their being regarded as disposable assets. I cannot, however, see the morality of allowing home owners to charge some people more for the same services of the same quality. The differences are enormous and range from £70 to £90 a week for exactly the same services. Home owners have to ensure that a third or perhaps half of their residents are self-funded.
The first question one is asked when seeking a nursing home for a friend or a relative is, "Do they have their own home?" I was asked that three times last year. In the case of single people, a residence for disposal immediately signals, that, for a while, such people can pay more. Residential home owners would go bankrupt if they did not charge some people more than others.
Why should some residents subsidise the Government who are not paying the full whack in income support? There is a degree of immorality about that. No Minister has ever addressed that problem in correspondence, in written answers, in Committee or in a public speech. In Committee, the Minister spoke about supplementary charges for extras, and when one of my hon. Friends spoke about an extra charge for dumplings the Minister seemed to think that that was okay. I emphasise that differing charges apply for the same level of service and I am not discussing charges for single or double rooms.
§ Mr. Rooker
If differential charges were abolished overnight, many homes would go out of business, people would be thrown on the street and on the public purse. It is never fully explained to relatives or to the people immediately concerned that they will have to pay more if they have their own resources. The House should not remain silent on the issue, and the amendment provides an opportunity to raise the matter.
§ Mr. Bayley
Money is the key to care: with it people can enter care: without it, they are locked out. That was brought home to me today when I received a letter about a constituent of mine from the trade union branch of which he was a member about 20 years ago. I shall read two short extracts:Mr. Rogers is 88 years old, and until his wife died in April of this year they were both residents of the Fulford Nursing Home in York … for the last two years the annual increase in his payments have been immediately absorbed by increased residential fees … Mr. Rogers finds he can no longer afford to stay in the Home and has been obliged to seek temporary accommodation with his son. He does not know where he will go next, and fears that he will not be able to afford the cost of residential care in the future. He tells me that many elderly and frail people now live in daily fear of losing their homes. It seems to me that it is intolerable that the elderly are being 925 put in this situation, and f would be obliged if you draw attention to the plight of Mr. Rogers and other elderly people in residential care.The plight of Mr. Rogers is not isolated. An article in my local paper, the Yorkshire Evening Press, describes the case of two elderly women, Mrs. Lily Lupton aged 83, and Mrs. Mary Brennan aged 79. They had to leave the Riverside Lodge nursing home when it increased its charges to them by £35 a week. Ironically, the home's motto is "Where friendliness abounds". I was a member of York health authority at the time that those two elderly ladies were evicted from their home. The cost of caring for them fell immediately on the public sector.
Earlier this year, the Social Services Policy Forum—a consortium comprising the Association of Directors of Social Services, British Association of Social Workers, National Institute for Social Work, the Joseph Rowntree Foundation in York, and other bodies—published a report on social services financing. It stated that the Government's community care reforms raised expectations, and added:These expectations are likely to be dashed unless there is an informed public debate about the level of services that should be available and the resources required to provide them.
§ Mr. Deputy Speaker (Mr. Michael Morris)
Order. I have listened attentively to the hon. Member, but the amendment specifically relates to charges, not to the overall provision of community care. I hope that the hon. Member will return to the subject matter of the amendment.
§ Mr. Bayley
I take your point, Mr. Deputy Speaker.
It is necessary for public provision to be made, to ensure that residents whose charges are met at public expense will obtain the care that they need. That is extremely hard for social services departments to plan, until such time as they are aware of the Government's budgetary allocation for the social services reforms.
I hope that the Secretary of State will take account of four matters. The current distribution of funding from the social security budget relates not to local care needs but to the local distribution of private residential care homes. That pattern should not necessarily be reflected in the long-term allocation of funds.
There is a care gap—vividly illustrated by the two cases that I cited—between the level of support available In the form of social security payments and the cost of residential care. Unless that gap is closed, those requiring care will lose the accommodation that they need. Where such a gap exists, who picks up the tab? It is usually the resident's relatives, but often they are themselves elderly and on low incomes. Their ability to top up fees is limited, and they may be caused considerable hardship.
In other cases, no one is available to top up the fees, and in those circumstances the resident will suffer the fate that befell my constituent, Mr. Rogers.
I also ask the Secretary of State to take note of the existing strain on social services departments' budgets. They are under enormous pressure—
§ Mr. Deputy Speaker
Order. The hon. Member for York (Mr. Bayley) is relatively new to the House, but he must address the amendment, which concerns charges and negotiations between local authorities and residential homes. I am sure that the hon. Member can be creative 926 and constructive in speaking to the amendment, but he is not doing that. He must either speak to the amendment or sit down.
§ Mr. Bayley
As my hon. Friend the Member for Birmingham, Perry Barr (Mr. Rooker) suggested, there should be no gap between the quality and range of care provided for those who are in homes at public expense, and provision for those who are able to pay for their care. Many people in private homes are required to pay additional charges on top of the basic fee, which will presumably be paid by the social services authority after April next year. I fear that, unless the Government clarify the level of funding of local authorities now, nine months from today, when the reforms come into operation, authorities will have had no time to negotiate contracts with the care providers to ensure that a comprehensive package of care is available.
§ Mr. Skinner
My hon. Friend has identified a cornerstone of community care provision. His point—which, let me add, relates to the amendment—is that the amendment refers to the differentiation that may or may not exist between private and local authority care. I hope that you are listening carefully, Mr. Deputy Speaker, because this is very important. My hon. Friend is pointing out that, if local authority funding is reduced or is not provided in the necessary proportion, there will be a difference between public and private care. I cannot for the life of me see how he can speak to the amendment without referring to public funding, and I hope that he will continue. I am listening carefully.
§ Mr. Deputy Speaker
We are all listening carefully; that is why, when the hon. Member for York was out of order, I drew the fact to his attention. His most recent remarks, however, were in order.
§ Mr. Deputy Speaker
Order. I want to listen to the hon. Member for York, not to the hon. Member for Bolsover (Mr. Skinner).
§ Mr. Bayley
Many studies show that a wide range of services for elderly people demand extra payment on top of the basic fee. They include physiotherapy, occupational therapy, chiropody in almost all homes, personal laundry in a few homes, medicines, hairdressing, incontinence pads —which were mentioned by my hon. Friend the Member for Perry Barr—and, in some instances, entertainment. Unless local authorities are prepared to pay a comprehensive fee to cover all those services, we shall not secure the classless society that the Government wish to introduce. There will be two classes of resident: one class will enjoy the rewarding quality of life that old age deserves, while the other will be faced with a lesser quality of life. That is indefensible.
§ Ms. Lynne
I wish to pursue the question of supplementary charges, to which the hon. Member for York (Mr. Bayley) briefly referred. I understand that community health workers are not allowed into residential homes and, in particular, nursing homes, and I fear that nursing homes will start to charge for physiotherapy and other back-up facilities.
At present, a general practitioner can be called in and recommend physiotherapy, but the physiotherapist cannot 927 enter the nursing home. I am worried about the fact that patients will face charges because nursing and hack-up facilities are not allowed to come in.
§ Ms. Jowell
Great uncertainty surrounds the implementation of the legislation. The Minister has provided us today with welcome assurances that the plans will proceed as intended, but I have one or two points to make about the funding of residential care which, if not properly addressed, will further compound the difficulties referred to in the amendment regarding the charges levied by individual residential care homes and nursing homes.
If I may identify one source of uncertainty, according to a letter sent by Mr. Laming, of the inspectorate of the social services and Mr. Foster of the management executive to all directors of social services:The current broad patten of funding through social security support should be regarded as an implied commitment for 1993–94 … in respect of new clients requiring residential or nursing home care.Otherwise interpreted, that means that about the same number of nursing home beds should be taken up after April 1993 as would have been taken up under the old system before 1993.
There is a discrepancy between the estimates offered by the Department of Health and the Local Authority Associations as to how many new beds there will be. The Department of Health estimates that there will be between 20,000 and 25,000. However, the present rate of growth, at 8 per cent. per annum, suggests something more like 35,000 to 40,000 beds. That creates uncertainty not just for local authorities but for those homes that are directly affected. It has a direct bearing on their financial calculations and therefore on the additional income that they are likely to have to raise by levying charges to close the gap.
I am particularly concerned about the responsibilities that will be placed upon local authorities after 1993. They will have to underwrite the full cost of a place in a residential or nursing home. If the funding level is not right and local authorities do not have enough money to cover the cost of all the people who have been placed in homes, or if, in particular, the manner of distribution is not right, local authorities will be engaged in searching for cheaper and less effective solutions. We must also assume that nursing homes and residential care homes will be looking at new ways to levy supplementary charges to make up for the money that is not available from the local authorities in order to meet the full cost of the care that they provide.
In the early stages of the national health service reforms, the Government found it possible to provide contingency funds so that some trusts, for instance, could avert their looming financial crises. I ask the Minister to announce similar contingency funding in order to provide protection for elderly and vulnerable people throughout what is likely to be a pretty choppy transitional period.
§ Mr. Yeo
I am glad to be able to advise the hon. Member for Birmingham, Perry Barr (Mr. Rooker) that I have had another think about the line that I took in Committee, in particular on the question of additional charges. I know that he will be pleased about it. I recognise that I was wrong in Committee to take the line that I did. I did not express myself anything like robustly enough.
928 I have no hesitation in saying that the Government see absolutely no reason to intervene in the negotiations between home owners and individual residents who are paying their own fees. We do not wish to dictate what are freely negotiated terms between two private parties. We see no reason to impose our judgment on what those parties should agree to.
§ Mr. Hinchliffe
We are talking not about companies in the City but about vulnerable elderly people. I am astonished to hear the Minister's language. Will he listen to what Opposition Members have said?
§ Mr. Michael
Will the Minister accept that many people are in difficult circumstances when decisions of this sort are being made? Often, not only the individual, but the carers who share in those decisions, do not have professional advice. I am sure that he is aware of the document that has been produced by the Carers National Organisation which shows that 33 per cent. of carers have no access to professional services or support. Therefore, does he accept that we should be making sure that there is protection along the lines urged by my hon. Friends?
§ Mr. Yeo
Opposition Members are suggesting that people should be denied the right to use their savings in the way they choose. No Conservative Member will support a measure that compels people to limit their charge for a particular service to a level that has been set arbitrarily and centrally and which prevents people from legitimately devoting resources to obtaining a service if they are able to do so. That would be an absurd imposition. It would be east European in its nightmarish consequences.
It is for local authorities to negotiate the best possible terms for the residents they sponsor and we will expect them to negotiate toughly in order to secure the best value for money. If the analysis given by the hon. Member for Perry Barr is correct, the effect of preventing home owners from setting their own charges would be directly to raise the cost to the public sector of keeping other residents in those homes.
§ Mr. Rooker
That is exactly the point. The public sector —the Government through the Department of Social Security—can bulk-buy by using income support. Therefore, it gets the same service at a lower cost than my individual constituents who cannot bulk buy because they have an asset. In effect, such individuals are institutionally ripped off. That is indefensible.
§ Mr. Yeo
I have already explained to the House why I do not think that the Government or the House should seek to impose terms between two private parties that are free to negotiate. As I have said, the consequence of accepting the analysis of the hon. Member for Perry Barr would be substantially to increase the cost to the taxpayer of keeping the residents in residential homes and private nursing homes.
I must correct the impression that the hon. Member for Perry Barr gave about the view that I expressed in Committee on the issue of extra payments. I do not think 929 that any of my remarks in Committee could be construed as meaning that basic services could be subject to any additional charge. Part of the contracting process, in which local authorities will be engaged after April next year. is to ensure that home owners provide a proper and adequate standard of service for all residents, including all publicly funded residents. I must make it clear to the hon. Member for York (Mr. Bayley) that I see no reason why those same residents should not purchase additional items or services out of their own resources or the resources of their families.
The hon. Member for Rochdale (Ms. Lynne) asked about entitlement to NHS services. Those who live in residential homes have the same rights and access to NHS facilities without payment of any charge as they would if they were living in their own home.
§ Mr. Yeo
It is part of the contract that the services provided by the nursing home will include some that would be health services if someone was not living in the nursing home. The price charged by the nursing home includes those services. For that reason, they will not also be available free under the national health service.
§ Mr. Skinner
When the Minister was banging the Dispatch Box, he said that the Government had no intention of interfering between bodies that make charges or otherwise. He took a strongly purist line. Why do the Government interfere with dental charges, and charges for specs and teeth? Why do they force local authorities to put rents up? The Government cannot have it all ways. The Minister cannot say that the Government do not interfere and, then, when they want to hammer the people at the bottom of the pile by shoving rents up and having health service charges, give a different set of criteria. If the Minister does not intend to interfere with people who negotiate will he, as a member of the Government, vote for the 30 per cent. for the top people's salaries, or will the Government interfere?
§ Mr. Yeo
I welcome rather belated arrival of the hon. Member for Bolsover (Mr. Skinner) in the proceedings on the Bill. We had half a day on Second Reading and 10 hours in Committee. I have been on the Bench since 3.40 pm, whereas the hon. Gentleman has just drifted in after what must have been a pretty good dinner.
§ Mr. Skinner
Unlike the Minister's hon. Friends sitting behind him and unlike those who are missing, I do not come in here half drunk because I do not go to the bars. So—
§ Mr. Yeo
I was doing my best to be charitable to the hon. Member for Bolsover because he was talking such indescribable claptrap that I thought that there was only one possible explanation. Naturally, I accept his assurance that he has not been anywhere near the bars.
930 I will explain to the hon. Member for Bolsover a distinction which, I hope, is not beyond even his understanding of these matters. My concern is that there should be no interference by Government or by Parliament between two freely contracting parties when both are in the private sector. It is quite another matter to say that the same principle should apply when individuals are contracting with the state, whether for the renting of a council house or for the purchase of dental services or eye tests. There is no point of comparison between the delivery of those services, the price at which they are charged and the way in which that charge is set, and the situation between the private owner of a private residential or nursing home and a private individual who has the resources to pay his own way into it. There is no point of contact between the two cases.
The hon. Member for Dulwich (Ms. Jowell) raised a point about the shortfall in funding. After next April, local authorities will be increasingly important purchasers of services from the independent sector. After a year or two, they will be by far the largest purchasers. As a result, they will be able to obtain good value for money from the providers. We should expect them to negotiate extremely toughly to ensure that the present gap between the charges levelled by residential homes and nursing homes in some areas and income support limits—there is no concealment of that fact, which we acknowledge—should be narrowed by the negotiating position that the local authorities will then be in. To the extent that there is still a gap, we will consider it when settling the funding arrangements for the policy.
The amendment would represent a gross intrusion on people's ability to decide the level at which fees should be set for residential homes. It also implies that the local authorities will not build into their own contracts arrangements that govern the basis on which fees will be increased in future. For those reasons, it would be in the interests of all those who will benefit in the long term from our community care policies if the House rejected the amendment.
§ Mr. Rooker
With the leave of the House, Mr. Deputy Speaker, I shall reply. I became more and more angry as the Minister spoke. You or I would hardly expect to walk into a shop in Whitehall or Victoria tomorrow and be asked to pay a different price for a commodity on the shelf depending on whether we got our money from the DSS, from investments or as salary. The Minister now accepts that that is what will happen. Frankly, that is just not on. The Minister says that, from next April, local authorities will be in a position to bulk-buy at a lower cost residential care places, but such deals will not be forthcoming in respect of people who fund themselves.
Some 68 per cent. of dwellings in England are owner-occupied and there will he a substantial increase in the number of people who will be releasing their disposable assets as the first call in respect of their care costs. I make no complaint about that, but I cannot see the morality of charging people more than their neighbours on a daily and weekly basis for the same service in the same home just because their neighbours are funded by the local authority, as it will be in April, or the DSS, as it is at present. We want equality of treatment—the same charge for the same service, and I find it unbelievable that the Minister should regard that concept as in some way east European.
931 It would be a wholly different matter if this were a question of taxation, although I suppose that, in a round-about way, that is what it is. The nursing home owners do not like having to do what they do; they have to do it to stay in business, but they are apologetic about it. They have told me that they have never heard a Minister address the issue in public. Now, we have the Minister's remarks on record and I suppose that we must be grateful for that.
If there were a price commission in this country, we should be the first to complain that our constituents were being charged different prices for the same service. That position cannot be tenable and I do not see how we can possibly accept it. It is as though Sainsbury's were charging people different prices for the same goods because their income came from different sources. The Minister must know that there is no foundation for his argument and that he could not sustain it before an independent body.
The practice has been allowed to grow like Topsy. The Government intend to allow it to continue and to shift the blame to local authorities from next April.
We did not intend to vote on any of the amendments and we are not complaining about the Bill, but the Minister has made me so angry that I shall be happy to hear whether my hon. Friends wish me to withdraw or press the amendment. [HON. MEMBERS: "Vote."] In that case, I shall press it.
§ Question put, That the amendment be made:—
§ The House divided: Ayes 53, Noes 154.932
|Division No. 49]||[9.43 pm|
|Ainsworth. Robert fCov try NE)||Jones, Barry (Alyn and D side)|
|Ashdown, Rt Hon Paddy||Jowell, Ms Tessa|
|Ashton, Joe||Kennedy, Charles (Ross, C & S)|
|Barnes, Harry||Kirkwood, Archy|
|Bayley, Hugh||Livingstone, Ken|
|Beggs, Roy||Llwyd, Elfyn|
|Boyce, Jimmy||Loyden, Eddie|
|Callaghan, Jim||Lynne, Ms Liz|
|Campbell, Menzies (Fife NE)||Mahon, Alice|
|Campbell-Savours, D. N.||Martin, Michael J. (Springburn)|
|Clwyd, Mrs Ann||Meale, Alan|
|Coffey, Ms Ann||Michael, Alun|
|Connarty, Michael||Morgan, Rhodri|
|Dalyell, Tam||Morley, Elliot|
|Davidson, Ian||Pike, Peter L.|
|Davis, Terry (B'ham, H'dge H'l)||Powell, Ray (Ogmore)|
|Dixon, Don||Rooker, Jeff|
|Donohoe, Brian||Taylor, Rt Hon John D. (Str'gf'd)|
|Eastham, Ken||Taylor, Matthew (Truro)|
|Flynn, Paul||Tyler, Paul|
|Forsythe, Clifford (Antrim S)||Wallace, James|
|Foster, Derek (B'p Auckland)||Watson, Mike|
|George, Bruce||Wigley, Dafydd|
|Godman, Dr Norman A.||Wise, Audrey|
|Hall, Mike||Tellers for the Ayes:|
|Hinchliffe, David||Mr. Dennis Skinner and|
|Hoyle, Doug||Mr. Thomas McAvoy.|
|Hughes, Kevin (Doncaster N)|
|Adley, Robert||Atkinson, Peter (Hexham)|
|Ainsworth, Peter (East Surrey)||Baker, Rt Hon K. (Mole Valley)|
|Aitken, Jonathan||Baker, Nicholas (Dorset North)|
|Alexander, Richard||Banks, Matthew (Southport)|
|Alison, Rt Hon Michael (Selby)||Bates, Michael|
|Arnold, Jacques (Gravesham)||Beresford, Sir Paul|
|Atkinson, David (Bour'mouth E)||Blackburn, Dr John G.|
|Booth, Hartley||Knight, Mrs Angela (Erewash)|
|Bottomley, Peter (Eltham)||Knight, Greg (Derby N)|
|Bowden, Andrew||Knight, Dame Jill (Bir'm E'st'n)|
|Bowis, John||Knox, David|
|Brandreth, Gyles||Kynoch, George (Kincardine)|
|Brazier, Julian||Legg, Barry|
|Brown, M. (Brigg & Cl'thorpes)||Leigh, Edward|
|Browning, Mrs. Angela||Lidington, David|
|Burns, Simon||Lightbown, David|
|Burt, Alistair||Luff, Peter|
|Butcher, John||MacKay, Andrew|
|Butterfill, John||McLoughlin, Patrick|
|Carttiss, Michael||Malone, Gerald|
|Cash, William||Martin, David (Portsmouth S)|
|Channon, Rt Hon Paul||Mawhinney, Dr Brian|
|Chaplin, Mrs Judith||Merchant, Piers|
|Chapman, Sydney||Mills, Iain|
|Clappison, James||Mitchell, Andrew (Gedling)|
|Clark, Dr Michael (Rochford)||Moate, Roger|
|Clifton-Brown, Geoffrey||Moss, Malcolm|
|Coe, Sebastian||Neubert, Sir Michael|
|Coombs, Simon (Swindon)||Nicholls, Patrick|
|Cope, Rt Hon Sir John||Nicholson, David (Taunton)|
|Couchman, James||Paice, James|
|Cran, James||Patnick, Irvine|
|Currie, Mrs Edwina (S D'by'ire)||Peacock, Mrs Elizabeth|
|Davis, David (Boothferry)||Porter, David (Waveney)|
|Day, Stephen||Richards, Rod|
|Deva, Nirj Joseph||Riddick, Graham|
|Dover, Den||Robertson, Raymond (Ab'd'n S)|
|Duncan, Alan||Robinson, Mark (Somerton)|
|Duncan-Smith, Iain||Rowe, Andrew (Mid Kent)|
|Elletson, Harold||Shaw, David (Dover)|
|Evans, Jonathan (Brecon)||Shaw, Sir Giles (Pudsey)|
|Evans, Nigel (Ribble Valley)||Shepherd, Colin (Hereford)|
|Evans, Roger (Monmouth)||Sims, Roger|
|Faber, David||Speed, Sir Keith|
|Fabricant, Michael||Spencer, Sir Derek|
|Fenner, Dame Peggy||Spink, Dr Robert|
|Fishburn, John Dudley||Sproat, Iain|
|Forsyth, Michael (Stirling)||Stanley, Rt Hon Sir John|
|Fox, Dr Liam (Woodspring)||Steen, Anthony|
|Freeman, Roger||Stephen, Michael|
|French, Douglas||Stern, Michael|
|Fry, Peter||Streeter, Gary|
|Gallie, Phil||Sweeney, Walter|
|Gillan, Ms Cheryl||Sykes, John|
|Greenway, John (Ryedale)||Taylor, Ian (Esher)|
|Griffiths, Peter (Portsmouth, N)||Taylor, John M. (Solihull)|
|Hague, William||Thomason, Roy|
|Hampson, Dr Keith||Thompson, Patrick (Norwich N)|
|Hargreaves, Andrew||Thornton, Sir Malcolm|
|Harris, David||Tredinnick, David|
|Haselhurst, Alan||Trend, Michael|
|Hawkins, Nicholas||Walden, George|
|Hawksley, Warren||Waller, Gary|
|Heald, Oliver||Wardle, Charles (Bexhill)|
|Heathcoat-Amory, David||Watts, John|
|Hicks, Robert||Wells, Bowen|
|Hill, James (Southampton Test)||Wheeler, Sir John|
|Horam, John||Whitney, Ray|
|Hughes Robert G. (Harrow W)||Whirtingdale, John|
|Hunt, Rt Hon David (Wirral W)||Widdecombe, Ann|
|Hunter, Andrew||Willetts, David|
|Jack, Michael||Winterton, Mrs Ann (Congleton)|
|Jackson, Robert (Wantage)||Winterton, Nicholas (Macc'f'ld)|
|Jones, Gwilym (Cardiff N)||Wood, Timothy|
|Jones, Robert B. (W H'f'rdshire)||Yeo, Tim|
|Kilfedder, Sir James|
|King, Rt Hon Tom||Tellers for the Noes:|
|Kirkhope, Timothy||Mr. Timothy Boswell and|
|Knapman, Roger||Mr. James Arbuthnot.|
§ Question accordingly negatived.
§ Mr. Michael
I beg to move amendment No. 9, in page 2, line 34, at end insert—(1I) The making of an arrangement by virtue of this section shall not preclude the making of any other 933 arrangement or payment under any other enactment in respect of any other occupant whereby the same accommoda-tion is treated as sheltered accommodation.'.I am grateful for the opportunity to move the amendment briefly—I hope without further provocation from the Minister. We get the impression that he has decided that his reputation for being reasonable was voiced too generously by the Opposition. Perhaps that is why he reacted so fiercely to the sensible amendment moved by my hon. Friend the Member for Birmingham, Perry Barr (Mr. Rooker) a short time ago. That is our explanation. I now invite the hon. Gentleman to balance his response to the previous amendment with a measured and constructive response to amendment No. 9, because that is the way in which he responded in Committee.
The amendment will give the Minister the opportunity to do what he promised—to examine the matter and, if necessary, to amend the Bill on Report. The point is a simple one. Where premises are used for the type of arrangement for which the Bill allows and are, therefore, defined as residential accommodation, and not as sheltered accommodation, it would be possible to introduce flexibility on one side of the line and reduce it on the other.
We seek an assurance from the Minister that where the type of accommodation for which arrangements can be made under the Bill can appropriately be dealt with as sheltered accommodation that will be possible under appropriate legislation. I hope that the Minister can assure us that such flexibility can continue to operate. I look forward to his response.
§ Mr. Yeo
After 10 hours in Committee and six hours on Report, I think that it was inevitable that the constructive mood would have to come to an end. I was glad of the chance to find some issue on which there was not complete harmony between the two sides of the House. Unfortunately, I cannot maintain my disagreeable mood.
We debated this issue in Committee and since then I have reconsidered the need for the safeguard that the amendment would introduce. I can confirm that it is our intention, as I said in Committee, that local authorities should have the widest possible flexibility to identify the most suitable type of accommodation to meet the needs of each individual who comes forward for assessment. That package of care will sometimes include sheltered housing.
It is worth pointing out the significance of that type of accommodation. The work done by the Office of Population Censuses and Surveys in 1990 showed that, on average, out of every 100 people aged 65 and over, 89 were in ordinary housing, just over five were in various kinds of communal care and 56 per cent. were in sheltered housing. That is an important component of the total range of options available to local authorities. That accommoda-tion is making a significant contribution to meeting the needs of elderly people. We do not intend that the Bill should jeopardise that contribution.
I believe that the assurances that I gave in Committee, and which I have re-examined, still hold good. For that reason I hope that the hon. Member for Cardiff, South and Penarth (Mr. Michael) will be able to withdraw his amendment.
§ Mr. Michael
I am pleased that the Minister has returned to sweetness and light. I can understand his sense of frustration in the course of a long debate, but I can only commend the example of my hon. Friend the Member for 934 Birmingham, Perry Barr (Mr. Rooker) and my colleagues who have remained constructive and positive throughout our consideration of the Bill.
In view of the assurances that the Minister has given, which I am pleased to welcome, I beg to ask leave to withdraw the amendment.
§ Amendment, by leave, withdrawn.
§ Motion made, and Question proposed, That the Bill be now read the Third time.9.57 pm
§ Mr. Sims
I do not wish to detain the House, but I understand why the Opposition wanted to debate community care, which is an extremely important issue that merits such debate. However, it is a pity that they chose to stage the debate in the way that they did.
The Bill is a small, technical one and I believe that it would have been helpful to allow it to go through swiftly. We could then have devoted a day by some other means to debate the range of issues covered by community care. Alternatively, we could have had a longer Third Reading. I should have liked to emphasise a number of issues raised in our various debates and I suspect that my views would have commended themselves to the Opposition. I intend to forgo making such a speech, however, as I do not want to be out of favour with the Whips or, in particular, my parliamentary colleagues.
However, I want to take the opportunity to correct the impression given by the hon. Member for Wakefield (Mr. Hinchliffe) in Committee last Thursday. As can be seen at column 116 of the report of the Committee's meeting, the hon. Gentleman was very critical of the home help provision of the London borough of Bromley. It is true that that borough has separated personal care services and domestic cleaning services, and it is true that the latter were put out to tender. All the tenders that were offered were rejected, on the ground either of cost or of quality, so the cleaning service remains in house. Bromley has drawn a clear distinction between people living in their own homes who need a degree of personal care—bathing, perhaps cooking, and so on—
§ It being Ten o'clock, the debate stood adjourned.
§ That, at this day's sitting, the Community Cure (Residential Accommodation) Bill [Lords] may be proceeded with, though opposed, until any hour.—[Mr. Robert G. Hughes.]
§ Question again proposed.
§ Mr. Sims
I was saying that Bromley has drawn a clear distinction between those who need a degree of skilled help and those who can look after themselves perfectly well, but may have difficulty with, for example, Hoovering and cleaning the bath and the loo. I suggest that it is a sensible use of limited human resources to use for cleaning those who can help in that sort of way, as distinct from those who are able to give more personal care. There is no question of neglecting people who use just the cleaning service. If help is needed, it is available at the end of a phone line. There are neighbours, friends, possibly the cleaning person, and in many cases the care link system, by which, at the press of a button, the person in need is put straight in touch with the help centre.
I hope the hon. Member for Wakefield will accept that if he did not misinterpret the schemes that Bromley runs, 935 he misunderstood them and that they are an example that other boroughs could follow, with a view to achieving greater flexibility of home care services.
§ Mr. Hinchliffe
My central point concerns how a home care organiser determines on any Monday morning whether Mrs. Smith needs a carer or a cleaner. The hon. Gentleman has not addressed that point.
§ Madam Deputy Speaker (Dame Janet Fookes)
Order. The hon. Gentleman must not intervene from a sedentary position.
§ Mr. Sims
If a person is coping perfectly well, but needs someone once a week or once a fortnight to help with cleaning, it is not sensible to provide him or her with more skilled help. As I have said, however, there should be easy access to a higher degree of help if circumstances change.
I hope that the House will not divide on the Third Reading, as I am sure that we should all like to see the legislation go through. There are many questions yet to be cleared up, and there are many understandable concerns about community care, but the sooner local authorities can learn more about how they will have to operate the system, particularly with respect to the resources available to them, the better.
§ Question put and agreed to.
§ Bill accordingly read the Third time, and passed.