HC Deb 18 March 1998 vol 308 cc1222-44

11 am

Mr. Paul Burstow (Sutton and Cheam)

The fifth anniversary of the introduction of community care is on 1 April, so today is a good time for us to debate the subject. I know that several hon. Members want to speak about some of the issues that come under this wide topic. My intention is to concentrate primarily on services for older people, whereas others may want to talk about matters such as mental health and children's services.

What stands out for me in all the writing on community care is the overwhelming weight of anecdotal evidence supporting the need fundamentally to rebalance our health and social care system. At present, the economics of health and social care has the unintended effect of driving people into high-dependency, high-cost institutional care rather than supporting them at home. I want to illustrate what that means in practice, and to make some suggestions about the way forward.

Few would argue with the aims of community care, but the evidence gathered by the National Association of Citizens Advice Bureaux and others—reflected, I am sure, in the mailbags and surgeries of many hon. Members—shows that community care has failed to deliver, and is better described as crisis management than as care management.

I want to make the case for complementary national and local strategies that involve older people and carers in their conception, implementation and evaluation, are genuinely cross-departmental and multi-agency, and promote improvements in public services through learning and local experimentation.

In its report "The Coming of Age", the Audit Commission illustrated the vicious circle of crisis management that health and social care are locked into because of bed blocking, cost shunting and buck passing. The consequence is that elderly people are funnelled into inappropriate institutionalised care. The report said: The pressure on expensive hospital beds and the use of nursing and residential homes is making it hard to free up resources for alternative services that might start to ease the situation. The number of older people being admitted to hospital is growing. Pressures on hospital beds are increasing. People are being discharged sooner, and more people are receiving expensive residential and nursing-home care. As a result, there is less money for preventive and for recuperative and rehabilitation services.

The number of people using acute services and the speed of their discharge are increasing, and so is the number of people being readmitted. Figures obtained last March by my hon. Friend the Member for Southwark, North and Bermondsey (Mr. Hughes) reveal that as many as 100,000 people a year aged 75 or over become emergency readmissions to hospital within 28 days of discharge.

For far too many older people, admission to hospital is simply the first step to their premature loss of independence. Eight out of 10 new residents of care and nursing homes come directly from hospital. Increasing hospital throughput has, in turn, increased pressure on older people and their carers—often the elderly husband or wife—to make snap decisions about where they are to live out their remaining years.

Nearly two thirds of social services gross expenditure on the care of older people in England is spent on residential care, but only one in 20 people aged 65 or over currently need long-term care other than in their own homes. The emphasis on residential care is hardly surprising, given the perverse financial incentives. The Audit Commission found that in almost every case, it is cheaper for social services departments to use residential care in preference to devising a care package to support independent living.

The net cost of domiciliary care in 1996 was about £197 a week, which was considerably more than the net cost of a place in an independent residential care home, at £94 a week. The differences are caused by the interplay of a nationally applied means test for residential care, and locally determined eligibility criteria for domiciliary care.

Evidence gathered by NACAB demonstrates how the original objectives of community care have been distorted. Targeting of support is a clear aim of community care, but the reality for far too many people is of care rationing, with longer waits for assessments and care provision, tightening eligibility criteria and more and increasing charges. The consequences represent a false economy for society.

The NACAB report "Rationing Community Care", said: Excessive targeting of scarce resources on those in greatest need is leading to inadequate preventative measures in terms of support services in the community for both carers and care users, which may result in more costly institutional remedies becoming necessary. NACAB has drawn to my attention some cases that illustrate the point. A woman on income support was told that help was available at £7 an hour, and social services suggested that she take out a loan to pay for it. In January, a woman in Wales was told that, under a revised scheme, her charges would double, from £21 to £42 a week, because she was not in receipt of income support. She cannot afford the new charge, as she has high living costs, including the cost of constant heating and of electricity to power her stair lift and other aids. She is refusing to pay the increased charge, and is prepared to go to court if necessary.

Funding for services that promote independence will remain vulnerable to cuts as long as health and social care remain locked in a vicious circle of acute medical intervention and high-dependency institutional care. Two services illustrate the point, and the Minister may be familiar with them, as I have tabled quite a few written questions on them: continence care and chiropody.

Currently, 3 million people in the United Kingdom—5 per cent. of the adult population—are affected by incontinence, which increases the risk of hospitalisation by 30 per cent. for women and 50 per cent. for men. It has been estimated that the cost of health care for incontinence stands at £1.4 billion annually, not including the costs of informal care and of the inappropriate use of long-stay beds for people for whom incontinence is the prevailing condition.

Incontinence is one of the key triggers of admission to residential care, as it places great strain on carers. It makes no sense at all—least of all for the taxpayer—to place such a burden on carers, but Age Concern has found that, increasingly, continence products are being rationed in absolute numbers per month rather than on the basis of medical need.

The same false economies beset chiropody services. A joint study by the Joseph Rowntree Foundation and Age Concern found that foot troubles constituted the commonest physical health problem associated with chronic difficulties in daily living. Nearly seven out of 10 over-85-year-olds cannot cut their own toenails, and rely on chiropody services.

It is hardly surprising, then, that 70 per cent. of the case load of national health service chiropodists is made up of older people; but it is very depressing to learn that 40 per cent. of NHS chiropodist managers report budget cuts this year. Investment in chiropody services represents value for money, preventing the need for costly emergency admissions to acute beds.

Where do we go from here? The Secretary of State often refers to the need to remove the "Berlin wall" between social and health care services. He is right to some extent, but it is not as simple as that, because there is also a need to address the relationships between Departments.

Changes need to be made in the way in which community care operates. In particular, there need to be clear guidelines and minimum standards for community care provision. For example, guidance on standards, inspection and charging for domiciliary care is long overdue.

The choices about eligibility and charging that are currently made at local level are, in fact, national issues, as they ultimately turn on the question of funding. There is no excuse for this Government to pass the buck, as the previous Government did. The Labour party came to power with a clear commitment to take action on the issue of what people have a right to expect from social services.

The Labour manifesto stated: We will introduce a long-term care charter' defining the standard of services which people are entitled to expect from health, housing and social services"— a laudable aim that we look forward to being delivered. Clear national minimum standards for the provision of continence and chiropody services need to be high on that list to be studied.

It is also clear that structural change at the local level is again on the national agenda. The Select Committee on Health has been looking into it and the Government's Berlin wall rhetoric points to it. It is far too easy to assume that changes to structure will solve everything. Some politicians—I do not exclude my party from this—have an unhealthy interest in structure. Simply aligning health and social care misses the point—it merely moves the interface.

The fact is that many of the services that need to co-operate to meet the needs of older people are already covered by local government. In particular, the aligning of health and social care would leave out the housing dimension, which the Health Select Committee rightly drew attention to before the general election as the neglected part of the community care framework". The problem, both nationally and locally, is departmentalism and a lack of co-operation within, let alone between, agencies. It is a question of culture and accountability, not structure. The debate about structure should not be allowed to divert attention away from the simple truth. Even if it proves possible to make all the different cogs in the welfare system fit smoothly one with another, the level of resources is inadequate to oil the wheels.

Indeed, the Audit Commission's director of health and social service studies, David Browning, is reported in Community Care magazine as giving short shrift to those who argue for major structural changes, such as setting up a single or joint agency between health and social services. An experimental programme is necessary, trying out different approaches and mixes of multi-agency working—for example, initiatives such as those in Somerset, south-west Hampshire and Wiltshire, where district nurses have started to take on social care management functions and in some cases have direct access to social services funds, following a comprehensive needs assessment. In south Bedfordshire, health visitors can set up meals on wheels for clients via a phone call to social services, and social workers can arrange for elderly people to be visited by one of the trust's district nurses.

I said that a fundamental re-balance between health and social care was necessary. I want the balance to be tilted back towards home-based care, such as occupational therapy, physiotherapy, and rehabilitation. The results can be startling. In a scheme developed in Devon, three quarters of those thought to require residential care on admission to a rehabilitation centre needed no continuing social care support on their return home. When compared to the cost of discharging directly into residential care, the savings were as much as £2,000 per person.

Unnecessary admissions, bed blocking and readmission rates can be reduced, but breaking out of the vicious circle into a virtuous one is a high-risk strategy in a public service where failures are rightly condemned, but successes rarely celebrated. The social services inspectorate and the Audit Commission are working in Devon to try to establish what the crucial success factors of such projects could be. However, the Devon experience is based on a long period of operation, which predates the introduction of community care. Social services departments coming late to such schemes may struggle to find the start-up and running costs of such ventures.

The development of such services lends itself to an experimental approach because it is out of diversity that examples of good practice can become universal. In that respect, the winter pressures initiative is a good example. Imaginative approaches have been tried, particularly around prevention of admissions and rehabilitation, but with the funding due to run out on 31 March, the scope for innovation has been constrained. Furthermore, given the one-off nature of the initiative, some positive schemes may soon have to stop. Simply imposing new conditions on the use of the coming year's special transitional grant is unlikely to sustain existing best practice, let alone spread it more widely.

Government must foster the conditions for innovation. In a recent report entitled "Community Health Care for Elderly People", the Clinical Standards Advisory Group highlighted four barriers to collaborative working. The first is different professional and organisational cultures, and I hope that in that respect, the legal and accounting restrictions that often get in the way of inter-agency working will be removed as that would do much to realise common goals between different agencies.

The second barrier is the fact that the geographical boundaries of health and local authorities are not coterminous. I hope that the Minister may be able to say something about what mechanisms he plans to use to realise the national health service White Paper's exhortation to GP consortiums to use boundaries conterminous with social services.

The third barrier is the financial constraints on social care and I hope that the Minister will be able to tell us the Government's intention for special transitional grant in 1999–2000. Will SSA and revenue support grant be adjusted upwards, or will ring fencing continue? I also hope that the Government will consider establishing an innovation fund to pump-prime, for periods of two to three years, joint projects between housing, social and health services and the voluntary sector to test out different approaches to delivering preventive services, which must involve carers and older people right from the outset.

Such an experimental programme should involve the SSI and the Audit Commission in monitoring and evaluation to ensure that the lessons learned and the good practice that emerges are widely shared and understood by managers and practitioners, and should draw on the work of the recently established preventive task group. Perhaps the opportunity could also be taken to pilot the extension of direct payments to those over-65s who want them. That would put them in the driving seat in determining the right care package to meet their individual needs.

The fourth barrier is the lack of shared compatibility of information systems, which is apposite given the previous debate. The decision to withdraw supplementary credit approvals for capital investment in information systems to underpin community care is undoubtedly inhibiting progress in that area. Again, I would welcome an indication from the Minister as to the intentions in that area.

I would add a fifth barrier, which is planning overload. While partnership is undoubtedly the key to achieving both health and social care objectives, the current plethora of planning requirements, ranging from community care plans and health improvement programmes to joint investment plans, can prove a distraction from delivering service outcomes. I hope that the social services White Paper will dovetail with the joint health and social care agenda in the NHS White Paper and rationalise the situation.

The overwhelming weight of anecdotal evidence supports the case for a fundamental re-balancing of priorities between health, housing and social care. The approach should be experimental and should involve older people and their carers. Help the Aged recently published a report called "A Life Worth Living: The Independence and Inclusion of Older People", which contained a sentence that summed up the challenge: We are in danger of needing more and more ambulances downstream to fish people out of the river for want of fences upstream to stop them falling in. Unless we find ways in which to break the vicious circle of crisis management, we shall continue to condemn older people to a life of dependency, when community care should deliver independence and dignity.

11.16 am
Mr. David Hinchliffe (Wakefield)

First, I pay tribute to the hon. Member for Sutton and Cheam (Mr. Burstow) for obtaining this debate. In general, I agree broadly with virtually everything that he said. It is a great pity that we have precious few debates on such a fundamentally important area as community care. During my time in the House, with the exception of the 1993 legislation, every debate on community care has been initiated by Back-Bench Members, which is a great pity when one considers the crucial impact that such provisions have on our constituents.

I must inform the House that I spoke to the hon. Member for Sutton and Cheam yesterday to establish what area of community care he intended to approach. I did so for a particular reason. In 1995, I was surprised to receive from the Minister's predecessor a parliamentary answer indicating that the Department of Health had established a difference between the formal definitions of community care and care in the community. Having been around community care for a long time because of my work background, I regarded the two terms as meaning the same, but under the previous Government, a new definition arose. Care in the community came to refer to mental health and provision for people who had been in psychiatric hospitals. Community care meant the areas to which the hon. Gentleman referred—elderly and disabled people.

This morning, I will stick to the same area as the hon. Gentleman, but I must place on record my belief that it is important in the near future to debate mental health and provisions for the elderly and the learning disabled. I am conscious that both areas require much attention, and I am aware that the Minister may want to discuss policy initiatives with the House.

The Government face a series of key challenges on community care as a direct consequence of the way in which the previous Government, over 18 years, effectively privatised community care provision in a manner that has directly affected service levels and the nature of provision. The hon. Member for Sutton and Cheam mentioned that in describing the inappropriate care models into which people may be pushed. I want to consider the history of why we are where we are now and why the Government face tough challenges in re-establishing some coherence in community care instead of leaving the job lot to the private market, which was the essence of the previous Government's policy.

I await with interest the shadow Minister's contribution, because he normally gives a robust performance in such debates, and especially his defence of the previous Government's record on care of the elderly. They were responsible for some fundamental changes that were very much for the worse. The policy change over their 18 years stemmed largely from a little-publicised decision in 1981 to allow the use of supplementary benefit to supplement the costs of home provision of private or voluntary care. That later became income support. The decision profoundly affected the nature of community care provision, especially for elderly people. That point was picked up by the hon. Member for Sutton and Cheam.

The direct consequence of the previous Government's decision—I believe that this was deliberate—was, from 1981 onwards, a huge explosion in the provision of private nursing home and residential care in a way that distorted the nature of community care provision, especially for the elderly and disabled. The matter has still to be addressed by the new Government. It will take many years to skew provision away from the emphasis on institutional care that was mentioned by the hon. Member for Sutton and Cheam.

I have established from the Library that £3 billion was used for the scheme between 1981 and 1993, when the community care changes occurred. Anyone considering that logically would realise that the money would have been far better invested in the community services that the hon. Member for Sutton and Cheam mentioned rather than in a huge expansion of institutional care, which was on the way out even in the 1970s. We have gone in the opposite direction to most other European countries because of the dogma of the Conservative party, which believes in private medicine, private medical care and private provision. That has been detrimental to properly planned community care which enables people to remain in their own homes. I shall expand later on what we should do about that.

I take issue with one point made by the hon. Member for Sutton and Cheam. He said community care was introduced on 1 April 1993. He understands the point that I am going to make. Community care was not introduced then; there was a change in its administration. It existed in a variety of ways long before institutional care, or even the workhouse, was invented. It has generally been the province of a carer in a family, usually a female relative. He will accept that all that happened in 1993 was an attempt to unravel the shambles that followed the 1981 decision. The National Health Service and Community Care Act 1990 was Treasury-driven because of alarm about how the income support budget had shot through the roof as a result of the 1981 decision.

The 1981 decision had several policy consequences that the Minister understands and will no doubt address later. An outdated model of provision that was on the way out, in cross-party policy terms, as far back as the 1970s has been resurrected by the privatisation of community care. Institutional provision for elderly people is now everywhere. I am not knocking such provision because there are some very good care and nursing homes in the private and voluntary sector. Some are less good, as the Minister will accept. His current review and the White Paper may tackle that in due course.

What concerns me about the privatisation of community care and the development of institutional models is the way in which public perceptions of what elderly people need were narrowed down to focus on such provision. That was unhelpful. For people of a certain age—we all hope that we shall reach such an age—there is now a perception that the appropriate care may be institutional. We should ask serious questions about that, as other countries are doing, and consider how we can use available resources to develop alternatives to give people a proper choice so that they do not have to go into institutional care. I accept the point of the hon. Member for Sutton and Cheam that some resources invested in institutional care could be better used to ensure that people have the choice of remaining in their own homes.

I fear that a consequence of privatisation has been the development of a huge market in private care, both residential and nursing, and in private insurance to encourage the view that we all need to insure ourselves privately so that, when we are gaga, we can be looked after through some institutional provision. It worries me that that perception has been allowed to float around this place without being challenged.

The hon. Member for Sutton and Cheam mentioned the third report of the Health Select Committee in the 1995–96 Session. Interestingly, his predecessor was a member of the Committee. She was usually—in fact, always—totally uncritical of the Conservative party's performance in government. However, this report exposed a good deal of what that Government did, and stated: We are very disappointed with the Government's response, which attempts to shuffle off responsibility and does nothing to meet the needs of some of the most vulnerable members of society. His predecessor said that, or at least subscribed to it in the report. That shows the extent to which people were concerned about what had happened.

The report also made some profound comments about the idea that there is a great demographic crisis. The first paragraph of its of summary of conclusions said that that belief was based on "unsound evidence" and was "downright alarmist". That alarm has been whipped up by private business interests who want to create the view that we must build more and more institutions for the elderly and pay more and more to insurance companies to ensure that we are looked after in old age. I accept that the royal commission on long-term care for the elderly will examine those issues, but I make a plea for us to move away from such narrow thinking and to broaden our views of care of the elderly in the way, in many respects, in which the hon. Member for Sutton and Cheam mentioned.

The second direct consequence of the changes of the 18 years of Conservative rule was a double whammy for the elderly in that people in their 60s, 70s, 80s and 90s in my constituency have endlessly raised with me their anxiety. that, throughout their working lives, they have paid national insurance and taxation on the assumption that, on reaching old age, free care would be available. They were paying for a national health service that offered them free care.

When they reached that stage, the NHS gradually, with a nod and a wink from the Department of Health, withdrew from free care. Such people were means-tested and found that they had to pay for the care they had already paid for. People are deeply unhappy about that, because they have been misled. People who fought in the second world war and who are still around deserve our consideration. That is a grievance affecting thousands or even millions of people who feel that they have been badly let down.

Mr. Nicholas Winterton (Macclesfield)

I apologise for not having been here for the whole of the debate. The hon. Member for Wakefield (Mr. Hinchliffe), who is currently Chairman of the Select Committee on Health and whom I hold in high regard, has drawn attention to the fundamental injustice of what has happened. Does he agree that at no stage has the House voted for the change that took place by deceit, which is that services that had hitherto been provided within the health service were ultimately taken out of the health service, so that people who believed that they would be looked after in their retirement now have to pay for their care and perhaps utilise all the savings that they have accumulated during their working life?

Mr. Hinchliffe

I am grateful for that intervention from the hon. Gentleman, for whom I have the greatest respect and under whose chairmanship of the Select Committee I served for several years. If I can do half as good a job as he did as Chairman of the Select Committee, I shall be a happy man, because he did a first-class job, to the extent of being removed from that position by his own Government. At this point, I should put down a marker and hope that my hon. Friend the Minister listens when I say that I hope that that does not happen to me.

The hon. Member for Macclesfield (Mr. Winterton) is absolutely right: the changes took place without any statutory change or debate in the House. That brings me to my third major point about the consequences, which is that there has been what I believe is a deliberate blurring of the boundaries between the national health service and local authority social services, which was formalised by the community care changes that took place in 1993. That blurring has taken place in the way described by the hon. Gentleman and I believe that the previous Government and the Department of Health actively encouraged the shunting of costs from the NHS to local authorities, because it meant that local authorities, which were largely Labour-controlled, could be blamed for making a mess of functions that had previously been carried out quite successfully by the NHS.

The key issue in the contemporary policy debate is that, without any debate in the House or serious thought being given to the results, we now have two separate systems impacting on the care of elderly people and disabled people in the community; they often offer exactly the same services, but one—the local authority provision—is means-tested and the other is free. That is absolute nonsense. I would encourage my hon. Friend the Minister to look at some of the evidence taken in the Select Committee in recent weeks. We have asked every witness, including Department of Health officials, to define the boundaries between the NHS and local authority social services. So far, nobody has managed to do it, but that is what faces our constituents daily when they require community care in their own homes and they frequently have to do battle to determine which agency has responsibility.

The best example examined by the Committee in recent weeks is that of a person requiring a bath within the community—a bath within his or her own home. Is it a nursing bath or a care bath? That person wants a bath but, depending on whose argument is strongest, that bath might be a means-tested bath or a free bath. In Yorkshire, we take such matters seriously, because people do not like paying for things that they do not have to pay for. The serious point is that it is absolute nonsense that that is the policy consequence of the previous Government's 18 years of blurring boundaries and shunting the provision of care toward the private sector. We now do not know who is responsible for what at local level.

Last week, the hon. Member for Isle of Wight (Dr. Brand) offered a good suggestion which came the closest yet to defining the difference between a medical bath and a social bath. He says that it depends on whether you have medical oil in the bath or a little yellow duck. That is a pretty good stab, given the nonsensical situation, and I should like to hear the Minister's thoughts on how he intends to unravel the consequences of 18 years of nonsense from the Conservative party.

There are several other areas I should like the Government to address and, knowing the Minister, I am sure that he will respond to these points. He will be familiar with them already, given that the social services White Paper is expected shortly. First, there is the question of resources. I sincerely welcome and congratulate my hon. Friend and his colleagues on what was announced in the Budget yesterday and what has been done since 1 May last year. In a sense, it makes my job as Chairman of the Select Committee on Health harder, because I would far rather have the sort of relationship with Ministers that the hon. Member for Macclesfield had with the Conservative Secretary of State and Ministers when he was Chairman. The current Labour team are doing an excellent job in terms of the resources that they have won for the NHS.

I qualify that welcome by making the point that, when we consider community care, we are not dealing only with the NHS, but with the ability of local authorities to provide care. In my area, social services are making cuts of about £5 million this year in addition to £6 million last year and that is happening across the country. My hon. Friend the Minister knows that and what its impact will be on people's ability to obtain services within their own home. Therefore, it is not only my hon. Friend, but his colleagues in other Departments and the Treasury, who ought to be aware of the implications of the current spending restrictions. The needs of carers in particular are directly affected by problems at local authority level.

I make a plea that we should look radically at introducing different models of care. We should do what other countries have done and have a fundamental shift away from the emphasis on institutional care for elderly people. I do not want to end up in wall-to-wall geriatrica in my old age; there should be something different to look forward to, even if I need care. There are models on offer that are preferable to that sort of approach to care of the elderly. For example, Denmark made the provision of care homes illegal in the 1980s because putting people into institutional care is deemed a diminution of human rights. Following the point made by the hon. Member for Sutton and Cheam, let us look at housing models of care provision, because that is surely the way forward, even for people who need a substantial amount of nursing care.

I hope that the long-term care commission will be looking at that issue, but I ask my hon. Friend the Minister to study the possibility of introducing sheltered and very sheltered housing models where, instead of people paying huge care costs from their capital, which uses it up, they can invest their capital in assisting with care provision, so that, when they move on or die, there is some capital left apart from that which has been used to benefit themselves and others during their time in those sheltered establishments.

Finally, there is the question of boundaries. Without pre-empting the Select Committee's conclusions on the boundaries between the NHS and social services, I have to say that the current arrangements are unsustainable, wasteful and extremely expensive. When I look at my local social services departments and community health trust, I, as the local Member of Parliament and as someone who worked in social services for donkey's years, cannot tell my constituents the differences between what they do because they cover the same functions. I cannot understand the reason for having two separate bureaucracies doing the same job, and I hope that the Minister will look radically at those issues and challenges.

I urge hon. Members to view the care of elderly people in policy terms through our own vision of what we would like to be available for ourselves when we reach the stage of requiring care. I would not want for myself what is currently on offer, so I hope that, over the next 10, 20 or 30 years, my hon. Friend the Minister and his colleagues and successors can achieve a radical transformation that humanises the care of elderly people along the lines that I and the hon. Member for Sutton and Cheam have suggested.

11.39 am
Dr. Evan Harris (Oxford, West and Abingdon)

I also congratulate my hon. Friend the Member for Sutton and Cheam (Mr. Burstow) on securing this debate. I am pleased to see that the Minister is in his place. I think that everyone recognises that he has made an energetic start to his portfolio responsibilities. He has visited my constituency and the city of Oxford on several occasions, and was well received. The fact that we may cross swords on policy and funding matters from time to time does not mean that I doubt his ability or the high levels of energy that he expends. I also commend the hon. Member for Wakefield (Mr. Hinchliffe), the Chairman of the Health Committee. We hope that he will do such a good job as Chairman that the Government may indeed be tempted to try to move him on.

I am particularly pleased to speak in this debate as I have tried, without success, to secure my own Adjournment debates on social services in my local authority of Oxfordshire and on community hospitals. Oxfordshire county council received a very bad settlement in terms of grant, standard spending assessment for social services and capping limit. Oxfordshire also faces the closure of community hospitals, including the loss of beds at Abingdon community hospital in my constituency. My cup runneth over today, as I have just heard about cuts of up to £12 million to Oxford university funding. That falls outside the scope of this debate, but it seems to me that such bad news stories happen all at once and usually in groups of three.

I shall examine the funding problems of Oxfordshire county council as it is a good model for the conflict and tension between the provision of satisfactory local authority social services care for the elderly and its impact on the health service, particularly in the form of pressure on acute beds. All authorities have stories to tell about the false economies that underfunding of local-authority-provided social services care can cause in the acute sector.

The cuts facing Oxfordshire county council in social services alone amount to £5.55 million—or 7 per cent—this year. Those cuts will effectively mean reduced services in family centres, which support families with young children. They are important preventive measures that help to avoid children being at risk. There will also be cuts to respite centres that offer the carers of multiply disabled children a much-needed break, allowing them to spend time with their other children or simply to have time to themselves.

Cuts in the number of social workers for children and families and for disabled or elderly people across the county will mean delays in assessment, and therefore delays in finding placements and delivering care. Elderly people in residential homes in Oxfordshire will no longer be entitled to a reduced charge for their first four weeks. The charge for transport, meals and service for those attending day centres will increase to a flat rate of £5. Charges for relief for carers will be increased—Oxfordshire is no longer able to offer even a few hours relief per month free of charge.

Charges are being introduced for day care for clients with learning disabilities who live at home. The mental health budget, which is already small and overstretched—as it is in many parts of the country, in our shires and inner cities alike—will be cut by 9 per cent. That will mean more cuts in day care for a group of people who desperately need somewhere to go during the day. The food subsidy for meals on wheels will be discontinued, leading to a price increase from £1.40 to £2.10 per meal. Charges for domiciliary laundry will also be introduced.

I shall deal in a moment with the financial causes of what has happened, but we must ask whether the changes are the result of a political decision or whether the county council was forced by circumstances to introduce them. I can inform the House that the cuts were agreed by the Liberal Democrat and Labour groups on the council. The Conservative group disagreed because it wanted to take yet another £1 million from social services for political reasons.

We must recognise—as the Liberal Democrat and Labour groups did—that those people who use social services are less well able to organise campaigns of the kind that are launched in an attempt to save local libraries or museums or to prevent teacher sackings. There is great concern that the most vulnerable people in areas such as Oxfordshire will have to pay the price of the Government's adoption of flawed and insufficient Conservative spending plans for this year and next.

The funding increase for the county council, at 3.1 per cent., is inadequate even to cover inflation and added duties. It takes no account of the demographic changes that have resulted in rising cost pressures. The number of elderly people in the area is increasing. In discussions such as these, we often regret the fact that there are more elderly people needing domiciliary care. However, we should welcome that fact: it is a sign that the health service is succeeding, that public health measures are improving, and that people are living longer in retirement. We hope that people's retirement will be happy, but it will not be if they fail to share in the country's increased wealth and the growth in the economy. The welfare state and social services support should grow accordingly: people should not suffer cuts to services affecting them and their loved ones who may be ill.

The increase in funding for Oxfordshire—I know that this applies to many other county councils—was not sufficient to cover the increase in the number of children, particularly children with special needs, in the area. Cutting children's services and support for at-risk children will have repercussions in the form of disruption in class, for example. The county simply will not be able to achieve the education results that the Government and the Liberal Democrats wish to see in our schools.

Unfortunately, despite every councillor being elected on a platform of not cutting services and raising local taxes, it was not possible for the county council to increase resources and thus avoid cutting social services for local council tax payers. I have received many letters criticising the fact that the county council is still capped and so must cut social services support and care in the community. I have received as many letters from people who are distressed that, under the new Government, cuts in social services provision are the same as before—if not worse.

In many care areas, it is not good enough for the Government to have said, "Things can only get better." It is not right to deprive democratically elected local authorities—which in Oxfordshire received a 100 per cent. mandate on the day of the general election for this—of the ability to raise the funds necessary to preserve existing services when the Labour party stood on a platform of seeking to protect and enhance such services.

Mr. Nicholas Winterton

Does the hon. Gentleman believe, from a professional point of view, that there was an adequate transfer of resources from the national health service to social services? The hon. Member for Wakefield (Mr. Hinchliffe) made the point that social services had to assume huge additional responsibilities for functions that were previously provided by the NHS. Does the hon. Gentleman believe that there was an adequate transfer of resources to enable local authority social services departments to undertake those important responsibilities?

Dr. Harris

No, I do not think so. We are now entering the sixth year of the special transitional grant. However, the scale of funding is not enough. I had intended to address that point later, but I shall tackle it now, as the hon. Member for Macclesfield (Mr. Winterton) has helpfully introduced it.

It is not acceptable for the Secretary of State, in an article in The Daily Telegraph, or for anyone else, to claim that community care has failed when many hon. Members feel that it has never been tried—because it was never funded adequately by the previous Government. It was unfair to expect social services to cope, particularly with elderly people leaving NHS care and long-stay hospitals and the mentally ill leaving asylums.

Mr. Hinchliffe

It is important to clarify the Secretary of State's comments in the article, which I read. He was talking specifically about the perception, in relation to mental health, that there were people within the community who were a danger to themselves and to others. The Secretary of State said not that community care had failed but that serious questions remained as to whether, in order to secure the safety, health and well-being of those people and the community, they should have the option of acute psychiatric provision locally.

Dr. Harris

I am grateful to the hon. Gentleman for explaining the Secretary of State's comments. The Department of Health also issued clarification following the publication of the interview, explaining that the emphasis should be on those few tragic cases—which I fear may always occur—involving assaults and occasionally murders in the community.

Since my election, a community care patient has murdered a family in Abingdon in my constituency by burning down a house. There was also the well-known Newby case in Oxford. I have read the reports at length. Although they raise questions about adequate communication between the multiple agencies involved—particularly with regard to housing in the Abingdon case—there was a clear problem of underfunding, including in the acute sector. People are pushed out of care extremely quickly in order to free up beds because occupancy levels in the acute sector are well over 100 per cent. in many mental health wards. Hon. Members will recognise that figure.

There are also inadequate resources in the community to keep an eye on people and give them support. The Government will soon have to decide whether community enforcement orders, under which people are supervised and forced to take medication, are the only way out of the problem. I express no view on that, as this is not the appropriate time at which to do so. But no one wants to go back to the days of asylums. Where the changes have worked and have been adequately funded, they have been welcomed.

In the case of Oxfordshire and many other counties, the root cause of the funding pressures facing the county council this year and next has been an inadequate settlement and an inadequate standard spending assessment for social services, which increased nationally by only £91 million, even before inflation and demographic changes were taken into account.

The blame for that does not lie entirely with the Government, because they were wedded—wrongly, the Liberal Democrats believe—to Conservative spending plans, which were a catastrophe for social services. The Government suggested that things would get better after the election, but in Oxfordshire we shall have to wait until the year after next—if then—for things to start being turned round.

That, sadly, will be too late for many people, who will suffer now. When we speak about cuts in care for elderly and vulnerable people, we ought to remember that those people may well die, and will certainly have a reduced quality of life, if they do not get adequate care.

It is difficult for people in my constituency to understand why, in order to fund the commitment not to increase taxes on the wealthy, the most vulnerable—the users of social services—must pay. The two pledges—to improve services and save the NHS, and not to raise taxes—are incompatible. It cannot be done.

I shall deal now with the interaction between care in the community and the health service. There are two problems. The first is the media's concentration on the acute sector in hospital care. Politicians of all parties may be to blame, as the best proxy that we have for measuring how the health service is performing are waiting list figures.

Those figures are flawed, because they do not take account of the time spent waiting for the initial out-patient appointment, the time taken for investigations and then the time taken to see a surgeon, perhaps, to get on the waiting list. They are also flawed because, for many operations that used to be offered, such as those on uncomplicated varicose veins, which used to have a long waiting list, the waiting time is now infinite because the operation is not available. The result is a fiddling of the figures, not necessarily deliberately, by health services that are reducing the number of operations offered.

Waiting list figures are nevertheless a useful proxy for measuring the health service. Because of that, we tend to concentrate on them—certainly, the media do—at the expense of everything else. Extra effort is put into reducing waiting lists—I understand that there is to be a statement this afternoon expanding on that, as we heard on the radio this morning—but we must ask whether additional resources might be better spent in community care, perhaps to free up beds in the acute sector so that waiting lists can be tackled.

The second problem is the concentration on crisis management in the health service. Money announced in July last year is allocated in November last year to be spent by April this year on avoiding a winter crisis. As any business person or any good public service budget manager knows, money can be spent far more efficiently and to far greater good if notice is given that it is coming and the time constraints are not so tight.

However, we recognise that many innovative schemes were produced by the winter pressures money. Anglia and Oxford health region got a good share of that funding and, by working with the social services departments of all the local authorities in the area, put in place some excellent schemes, such as the hospital at home, step-down care and increased support to stop people being admitted in the first place.

The question is what will happen next winter. Will that funding be continued? I should be grateful if the Minister could tell us whether it will be recurrent or whether there will be a similar exercise next winter, which will not be as efficient as allowing social services some extra funding to pick up the costs of people who have been moved into their budgets in the residential care sector with the winter pressures money.

The pressure on emergency admissions is no longer just a winter phenomenon; it exists all year round, because social services are failing to cope all year round. When we do not offer support for carers, there is an increase in emergency admissions. In hospital parlance those are called social admissions. That is a poor term. In my experience as a hospital doctor, those are people who desperately need to be seen and desperately need treatment, but they are there because they cannot cope with their home circumstances.

Delayed discharge is another aspect of the problem. The figures show increases in delayed discharges, despite the extra money for winter crises.

Liberal Democrats propose a lifting of the cap in local authorities to allow local people democratically to elect authorities to spend money on social services and care for the most vulnerable. We also propose that some health service money should be spent directly on community care, to relieve the pressure on the health service and improve community care.

In a spirit of co-operation, I offer the Minister some ideas about how the welcome extra money allocated in the Budget might be devoted to community care, not only to improve services there, but to save money and create space in the acute sector by tackling the waiting list problems that were inherited from the previous Conservative Government and exacerbated by the adoption of that party's spending plans.

Unlike other Opposition parties, the Liberal Democrats always present an alternative Budget. Over and above the sum that the Government have allocated this year, we allocated additional money from cyclical surpluses to the NHS, so that an extra £250 million would be spent on three areas.

The money should be used to save community hospitals that are currently under threat in Oxfordshire, Essex, Cornwall and other parts of the country, as the Minister knows from previous Adjournment debates. Those community hospitals can work with social services to provide good community care through the three Rs of community care: recuperation, rehabilitation and respite care.

People who have had their operation can be moved out of busy, noisy, intensively nursed acute wards into more appropriate local care near their families to recuperate before going home. If they need rehabilitation, they can receive physiotherapy or occupational therapy and their houses can be modified while they are in a cheaper bed in a community hospital. Respite care can be given for one in four, six or 10 weeks, according to need, to enable carers to cope more easily and to reduce emergency admissions.

We want more money to be allocated to community care for mental health to take the pressure off the acute sector in mental health, and we want more care for carers, perhaps through specific targeted funding and by implementing the recommendations for the assessment of carers' needs, as laid down in the Carers (Recognition and Services) Act 1995, which has never been properly funded.

By giving more resources to social services departments in local authorities and to the NHS for spending in the community to release money in the acute sector, we can give the elderly and vulnerable people in Oxfordshire and elsewhere the care that they deserve.

11.57 am
Dr. Julian Lewis (New Forest, East)

As a new Member, it has been a privilege for me to hear for the first time the hon. Member for Wakefield (Mr. Hinchliffe) speaking on a subject on which he has a fine reputation in all parts of the House. If I understood his argument correctly, he said that we should move more in the direction of community care in the long-term treatment of the elderly, much as we have already done in the long-term treatment of the mentally ill.

As some hon. Members present will know, I was fortunate enough to introduce a Mental Health (Amendment) Bill when I was drawn second in the private Member's Bill ballot. I shall refer briefly to three categories of people who are affected by community care for the mentally ill: people who may kill; people who need what might be termed "a periodic MOT"; and people who need a place of refuge.

On his thoughtful speech, the hon. Member for Oxford, West and Abingdon (Dr. Harris) was a little too glib when he attributed to shortage of resources the problem of homicides committed by people released from psychiatric institutions into care in the community. I am sure that he does not mean that generally, because it is certainly not true. It is a little strange that people are prepared to take chances with the lives of citizens by releasing people into the community, knowing that there is a significant risk that they may harm others—often members of their own families. By contrast, if one applies the same argument to the capital punishment debate, it is often said that one must not risk accidentally executing one innocent person, even if it means that 99 guilty people escape the gallows.

That shows a slightly different sense of values. There seems to be a complacency about taking the risk of releasing potentially lethal people into the community, but none about taking the risk of accidentally executing someone who is innocent. I am sure that the families of those who have been killed by people who were wrongly released into the community would have a lot more to say on that subject.

One must not throw the baby out with the bath water as one moves in the direction of community care for people who need a periodic MOT. There are people who suffer acute suicidal depression which cannot be coped with through care in the community alone.

There used to be a system which I understand—I am not an expert in this field—was known as "the revolving door." The idea was that people would be encouraged to live their lives normally in the community as far as possible; but, when they felt a crisis coming on, there would be an institutional facility available for them—to give them an MOT, to give them a service, to get them back on track. Then, perhaps, they would not require any more in-patient treatment for another three or four years. That process could continue steadily for the rest of their lives.

I am concerned that the shift towards community care and away from institutional treatment for people who are mentally ill, creditable though it is in general, has deprived such people of the facilities they need from time to time to keep themselves on the straight and narrow.

I refer now to the people about whom I was concerned when I introduced my private Member's Bill, which, sadly, was talked out in five and a half hours of precious parliamentary time, perhaps to little avail, on 12 December last year—people who need a place of refuge. It is often said that there are insufficient beds for people who suffer acute psychiatric breakdowns. That is not necessarily the case.

The problem is that, as a result of the mass closure of institutions, such beds as remain are not sufficiently compartmentalised between different people with different mental illnesses. Even where a bed is available in a psychiatric unit for someone who is suffering from an acute psychiatric, potentially suicidal, breakdown, the GP, or other medical officer in charge, will not want to recommend that that person takes it if he or she will thus be placed in an environment with seriously disturbed people, which could only harm rather than help his or her condition.

I hope that the Government will think again about blocking the Bill that has been reintroduced in another place by Lord Rowallan. I am pleased to say that it has been given the Second Reading there that it was denied in this House. I hope that the Government will think ahead a bit more about creating a strategy whereby those who, from time to time, need admission to a psychiatric unit can have a bed there to enhance their condition, not to make it worse.

12.3 pm

Mr. Patrick Nicholls (Teignbridge)

I congratulate the hon. Member for Sutton and Cheam (Mr. Burstow) on his choice of subject for debate. He and I might have slight differences about solutions in given circumstances, but nobody could criticise him for having introduced the debate or the manner in which he did so.

The debate so far has been characterised by an understanding—I hope that it will continue in the time remaining—that, although we may disagree from time to time on how to achieve a given end, it is, as the hon. Member for Wakefield (Mr. Hinchliffe) said, ultimately about ensuring that our elderly people receive the care that we expect and hope for. That aspiration is shared by hon. Members on both sides of the House.

When I was preparing for the debate, I recalled having seen many years ago a rather dramatic advertising poster in the maternity unit of a hospital in Exeter. It struck me as rather apposite. It said, "The first seven days are the most dangerous in your life", and some wag had written underneath, "And the last seven are not devoid of hazard." In a sense, that is where I am coming from.

The hon. Gentleman made it clear that, although this is a wide-ranging debate, he wanted to talk about care of the elderly. I shall say a word or two about that as well. We are, after all, living in a greying population. The figures are dramatic. Between 1951 and 1996, the proportion of the population aged 65 or over increased by 66 per cent. The number who are 75 and over has increased by a dramatic 136 per cent.

At present, there are some 10 million pensioners in the UK. Eighteen per cent. of the general population are over pensionable age. Two thirds of those who are over 75 are women and more than three quarters of them are aged 85 and more. In 1993, a man of 60 could expect to live for another 17.8 years and, inevitably, a woman 21.9 years. Old people account for some £20 billion of spending in health and social services every year. Nobody need be in any doubt that we have a greying population, which imposes obligations and concerns on us that were not foreseeable in 1950.

I was particularly pleased to hear the hon. Member for Oxford, West and Abingdon (Dr. Harris) pinch one of my lines. One often hears about this, and it is often presented as a problem, but it is not. Not so long ago—certainly in our grandparents' generation—if someone was 50, their time was virtually up. These days that is not the case. If it were, several hon. Members in the House at the moment would feel more than nervous. It is good news that people are living so long. We are in the business of trying to ensure that they live for as long as possible and that they have a good quality of life for as long as possible—one that we would enjoy.

What people want when they consider care in their old age is affordable, quality health care. They do not want their hard-earned savings, for which they may have worked all their lives, to be gobbled up in their last two or three years. After a life in which they may feel that they have achieved some modest material success, they do not want to have nothing to leave to their children. There cannot be an hon. Member who has not had experience of difficult cases about where the money is going. Sometimes the concern is felt every bit as much by those who will not be able to leave something as it is by those who think that it is not right that they will not inherit. Those are the two principal considerations that must be dealt with.

To some extent, community care for the elderly has grown like Topsy; we have not had a firm policy, it has just occurred. We have heard about the way in which community care has developed and about the changing role of local authorities. The Government are to be complimented—I say this quite straightforwardly—on having set up in December the royal commission to examine the short and long-term options for sustainable funding for long-term care for elderly people in the UK, both in their own homes and in other settings, and within 12 months to recommend how and in what circumstances the cost of care should be apportioned between public funds and individuals. That is a succinct statement of what the commission will examine.

The commission has yet to report, so it is early days, but has the Minister had any preliminary thoughts on the matter? He shakes his head slightly, but he must have had, because he has announced a number of other initiatives, for which I commend him. I hope that he will say something about the composition of the commission, under Sir Stewart Sutherland, which represents a roll call of the good and the great. The Minister will know that certain groups, such as care providers, charities and lobbying groups, are anxious because they are not represented on the commission.

Private sector providers of residential and nursing home care are worried that their voice may not be heard in the commission. Barry Hartley, chairman of the National Care Homes Association, said: We are extremely disappointed that there is no representation from the private care sector on the Commission or of care practitioners. The private care sector has a wide ranging knowledge of how the current system works and it also has experience and expertise of the funding of long term care which may well not be available elsewhere. We must take that on board, because it addresses head on the worries of the hon. Member for Wakefield about trends under the previous Government.

I thought for a moment that he had not realised that the Conservative party was no longer in government. I share his confusion, because it takes a while for such things to sink in. I do not intend to attack the Minister yet, because he has not been in post for long enough, but he must say how he sees the future. I understand where the hon. Gentleman was coming from, but do not entirely agree with him. However, I agree with him on some issues.

We would all like to stay in our own homes and among our families for as long as possible in old age, but that will not be an option for everyone. The hon. Gentleman used the word dogma. We should not be dogmatic and say that local authorities should provide care because it is wrong for the private sector to make a profit from it. I do not have the slightest interest in who provides care; I want to ensure that the best care is provided.

Mr. Hinchliffe

The hon. Gentleman misunderstands my point, which is that privatisation of care has led to people taking a limited view of the models available. The private sector has shown a lack of imagination, which is not to say that all private care homes and nursing homes are bad. They offer extremely backward models, and I am surprised at the lack of exciting policy development, given that the sector is desperate for challenges such as I have proposed.

Mr. Nicholls

I am grateful for the hon. Gentleman's clarification, which shows that our views are not so far apart. I accept that people should stay in their own homes for as long as possible. Some people, wrongly but sincerely, feel uneasy about transferring community care from the local authority sector to the private sector.

Mr. Burstow

Does the hon. Gentleman think that the bias in the market is a problem? Community care in the home—domiciliary services—costs more than residential care. Surely there should be a level playing field.

Mr. Nicholls

It costs what it costs. Community care is not cheap, but people will demand it if it is the right option. The Government of the day are responsible for its delivery, or for explaining why it is not being provided. Some people think that private sector provision of residential accommodation is wrong.

My mother was a matron for Devon county council, so I have probably spent more time in part III residential accommodation than any hon. Member. Her last appointment was to a purpose-built state-of-the-art old-people's home. I lived there for a time and have no criticism of the standard of care provided. We could compare private sector and local government sector facilities, but it is quality of care that is important. There would be more money to go round if care could be provided more cheaply, and I would not object if it was increasingly provided by the private sector. How does the Minister view the development of private sector care?

Mr. Ivan Lewis (Bury, South)

I seek clarification. We all agree that quality of care, not who provides it, is the most important issue. A number of local authority homes closed when the Conservative party was in government, not because they provided care that was not equal to that provided by private sector establishments, but because financial arrangements for community and residential care were deliberately skewed in favour of the private sector so as to stimulate that sector and to disadvantage the local authority sector. Does the hon. Gentleman accept that decisions should have been made on the basis of quality, not on the basis of ideology?

Mr. Nicholls

I would agree if I accepted the premise—but I do not. Once local authority care was properly priced, we could find out what it cost. There are exceptions, but my experience in Devon is that private sector residential care is less expensive than local authority care. Some people are more comfortable in traditional part III residential accommodation, but they must have a choice. I think that I am at one with Devon social services department on that.

I was impressed by the remarks of the hon. Member for Wakefield about people finding it increasingly difficult to understand whether they or the state is responsible for their care. The Minister will correct me if I am wrong, but I understand that the problem stems from the inception of the welfare state. Now, however, more people are more prosperous and are living for longer, so they are more likely to need care, but might lose their money by paying for it. Such people tell me and every other hon. Member, "I've paid my dues, I'm entitled to care."

The problem is that the national insurance system gives people the moral right to be looked after in their twilight years but does not provide the funds to pay for it. The Minister's petty brutalisms about not wanting lectures from Conservative Members are an engaging part of his speeches, but how will he deal with that problem?

A Labour Whip said to me the other day, "We are all Tories now." I am not sure whether that is entirely true. I am not referring to the hon. Member for Liverpool, Wavertree (Jane Kennedy). The aura of Toryism sits ill on a number of Labour Members but, ignoring his radical youth, it sits well on the Minister. I have invited the hon. Gentleman to visit my constituency and a hospital there. If he felt able to do so, he would see a number of things that might be relevant to today's debate and he would thoroughly enjoy that, but now we all want to hear—once we have heard the ritual petty brutalisms—how he sees the future.

12.19 pm
The Parliamentary Under-Secretary of State for Health (Mr. Paul Boateng)

I have never been accused of delivering brutalisms that are petty, and I do not intend to begin today.

The less said about the speech of the hon. Member for Teignbridge (Mr. Nicholls) the better, but I certainly look forward to visiting his constituency. I shall arrange for a suitably equipped person to ride shotgun as I enter the heartlands of true Toryism.

The hon. Gentleman mentioned the lady Government Whip who had said, "We are all Tories now." I am assured by my hon. Friend the Member for Liverpool, Wavertree (Jane Kennedy)—who is sitting next to me, but who must of course be silent during the debate—that it was not her. I am asked to make that clear, and I do so, being one always to take the advice of my Whips—particularly that of my hon. Friend.

This has been a good debate. In many ways, it has been characteristic of what is meant to happen on Wednesday mornings. On Wednesday mornings, hard-working and committed Back Benchers are supposed to talk about the subjects that they know best, rooting their speeches in experience gained from their constituencies and their lives. All Back Benchers who spoke today did that, and the House owes them—especially the hon. Member for Sutton and Cheam (Mr. Burstow)—a debt of gratitude. The hon. Gentleman brought to the debate a depth of experience and commitment that was especially welcome.

I always look forward to the hon. Gentleman's many questions about incontinence and chiropody. Not only does considering those questions and reflecting on the answers—which I am required to do—pass the time during my journey between the House and my home; they highlight two critical aspects of continuing care, not least the care of the elderly. This Government are committed to opposing and combating social exclusion. In that context, issues relating to incontinence and chiropody are very important in practical terms. If there is no toenail-clipping service enabling an elderly person to go to the local newsagent, that person is being marginalised.

The Government are concerned about the distinctions between a health bath and a social care bath. I know that those distinctions also concern my hon. Friend the Member for Wakefield (Mr. Hinchliffe), who performs his role as Chairman of the Health Committee in such a distinguished way. We have spent much time considering the matter, but it is not at the forefront of the mind of the person who is waiting for a bath and who wants his or her dignity to be protected. We must ensure that the interface between health and social care is more efficient. We are determined that the boundary should be managed properly and, later in the year, we shall produce a White Paper setting out our thinking.

Such boundaries will inevitably exist. That is the central aspect of reconfiguration: if, by the wave of a magic wand, we were to reconfigure health and social care tomorrow, a boundary somewhere would still have to be negotiated. We want to ensure that we manage the boundary better than we have in the past: that is why it is so important that the White Paper holds out the prospect of pooled budgets. When health and social care can be managed better by that means, it is one way forward—but only one way; of itself, it does not answer all the questions.

The effective pooling of budgets will be helpful and I know that many local authorities and people in the health care sector look forward to the time when they will be able to underpin their joint planning in that way.

Mr. Burstow

The Minister may be about to deal with the issue of conterminosity between GP consortiums and social services departments. What mechanisms will he introduce to provide incentives for coterminosity?

Mr. Boateng

We have made clear in the White Paper that we expect social care boundaries to be taken into account in the formation of primary care groupings, and we have no doubt that they will be. It should be recognised, however, that some of the good practice highlighted by the hon. Gentleman and others in any event involves social workers—whether in the statutory or the voluntary sector—working ever more closely with the primary care team.

I was interested by what my hon. Friend the Member for Wakefield—backed up by the hon. Members for Sutton and Cheam and for Oxford, West and Abingdon (Dr. Harris)—said about the capacity of health visitors and GPs working in the primary care team to gain access to meals on wheels and other aspects of social care. We want that to be made easier. We need a structure that is patient-focused, empowering people to maintain their independence and giving them choice. We should be keen to provide better care and better outcomes for individuals. We need to be better at measuring what we do in terms of outcomes and the value that we add to the lives of vulnerable people.

In the few minutes that remain, I want to make a couple of points which, I fear, cannot do justice to the breadth and quality of the debate. We have made new resources available. For health alone, in addition to the £500 million announced in yesterday's Budget statement, £1.2 billion has been provided, including an additional £0.3 billion to deal with winter pressures. The hon. Member for Oxford, West and Abingdon should note that Oxford has done particularly well out of that. The good news is that much of the money that has been channelled through the NHS has gone to social services departments, which have used it to build on existing good practice. We are talking about establishing better systems for rehabilitation and recuperation and taking more care with multi-disciplinary assessments in terms of both admission and discharge.

I have mentioned the care of the elderly. This morning I attended a seminar, or conference, organised by the Alzheimers Disease Society. We examined the way in which we could, through joint working, better meet the needs of that particularly vulnerable group. I pay tribute to the ADS for its pioneering work in that sector. There is new money and local authorities and health authorities are learning to use it better, but we cannot be complacent—we must be constantly vigilant.

On mental health, of course, much needs to be done. My right hon. Friend the Secretary of State for Health has made it clear that he regards that as a priority. His remarks on care in the community and its failures were well received.

Mr. Deputy Speaker (Mr. Michael Lord)

Order. We must now move on to the next debate.

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