§ [Relevant documents: With Respect to Old Age: A Report by the Royal Commission on Long-Term Care (Cm. 4192-I); Modernising Social Services (Cm. 4169); Long-Term Care: The Government's Response to the Health Committee's Report on Long-Term Care (Cm. 4414).]
§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Clelland]1.14 pm
§ The Secretary of State for Health (Mr. Alan Milburn)
First, I apologise to the House for the fact that I shall not be here for the winding-up speeches due to a prior engagement. I have informed you, Madam Speaker, and the spokesmen of both the main Opposition parties.
We live in an ageing society. For too long, old age has been seen as a problem. People talk of the burden of an ageing population; some even say that changes in the ratio of working to retired households in our country are unsustainable. That is not the view of the Government. A growing elderly population is a success, not a failure; it should be celebrated, not denigrated. Older people are valuable in our society, not a burden on it. That is why we have taken action throughout Government to improve the health, well-being and security of older people: restoring free eye tests, introducing winter fuel payments, cutting VAT on fuel, the introduction of the minimum income guarantee for poorer pensioners, free TV licences for older pensioners—all of that a recognition of the importance of older people to our society.
Underlying each of these approaches is a recognition that, far from there being a demographic time bomb that will overwhelm society as we have known it, the rate of growth in the numbers of older people in the next 50 years will be about half that of the last 50 years. It is true, however, that there will be more very old people, aged 85 years or more, during the next few decades. That, too, is something to be celebrated, but it means that the way that we care for people in old age must change.
Today's debate gives the House the opportunity to consider these issues in what I hope will be a calm and considered fashion. The future of long-term care is an issue that concerns each of our constituents in each of our communities. Long-term care is not just about caring for older people. It is about younger, disabled people too. The need for changes to the system of long-term care is therefore not just the product of demographic change. Change is needed for other reasons. For too long, standards of care have been too variable. Standards of care have been a matter of local discretion. About 150 local authorities and about 100 health authorities regulate care homes, often to very differing standards. Some services, such as home-based care, are not currently regulated. The regulation system has not been properly independent.
There are very real concerns about the funding of long-term care. Although only one in five old people need long-term care, as they approach old age many more become anxious about how well they will be looked after, who will look after them, how much it will cost and who will pay. The current system has failed to be explicit about these issues, not least because it has developed in such an ad hoc way in recent decades. Under the previous Government alone, there were six major changes to the benefits and rules governing long-term care.
445 The current system of care is confused and confusing. It provides too many incentives to care for old people in care homes and too few incentives to care for them in their own homes. Arguably, the current system is premised upon the idea that older people do not want what most of the rest of us want—the chance to live a fulfilling life in as independent a way as possible. All the evidence suggests that, all things being equal, older people want to remain as independent as possible for as long as possible.
It is right, therefore, that we re-examine all the issues to do with long-term care in the round. In our election manifesto, we said that we would set up a royal commission to examine the funding issues. In December 1997, we established a royal commission chaired by Sir Stewart Sutherland. The commission took oral evidence, conducted public hearings and received more than 2,000 written submissions. We published its report in March 1999, and I want to place on the record my thanks to the royal commission for all its work.
When the report was published, my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson) said that he hoped that it would stimulate debate to help find a way of ensuring that people could have access to high quality long-term care that was fair for individuals and the taxpayer. Indeed, the royal commission explicitly called for such a debate. Today the House has an opportunity to take part in that debate.
In the past, there have been too many short-term solutions for long-term care. What is needed instead is a properly considered solution that should be capable of standing the test of time. Today's generation of older people, and the generations to follow, deserve no less.
As the royal commission said, there is no obvious answer. That was reflected in its conclusions; it published a majority and a minority report. Since March, there has been an active debate on the commission's approach and its 23 recommendations. A wide range of ideas and views has been expressed. My Department has received more than 800 responses to the commission's recommendations.
§ Mr. Archy Kirkwood (Roxburgh and Berwickshire)
It is very interesting that the Department has received 800 responses as a result of Sir Stewart Sutherland's excellent piece of work. Does the Minister know off-hand how many that he received were in favour of the minority recommendation of the royal commission?
§ Mr. Milburn
I do not know the answer. I know from my discussions with Sir Stewart that he, too, has been receiving a fairly weighty postbag. I guess that many right hon. and hon. Members have as well. We need to consider extremely carefully the range of views that have been put forward by a full range of organisations and individuals. We need also to consider the royal commission's recommendations.
§ Miss Julie Kirkbride (Bromsgrove)
Can the Secretary of State tell us how many of the responses that he has received support the recommendations set out in the majority report? Perhaps he could give us a guide rather than an absolute number. Is it 50, 60 or 70 per cent. Can the right hon. Gentleman give us an idea or a clue?
§ Mr. Milburn
It is so tempting to guess from the Dispatch Box. On balance, however, that is a temptation 446 that I shall probably avoid. [Interruption.] I know that Liberal Democrats often guess about policy issues but it is probably wiser that the Government continue to take a considered view of these issues.
Since March, the Government have been taking action to improve long-term care. We are improving services by allocating £140 million over three years to help fund respite care as part of our new national carers strategy. We are providing local authorities with special grants totalling almost £300 million this year to encourage them to help older people return to independent living and prevent their unnecessary admission to institutional care. We are extending direct payments to people aged 65 and over as well as to the parent carers of disabled children.
Our approach recognises that any system for funding long-term care must be part of a wider policy of support for older people. Over the next year we shall extend this programme of support for older people still further. For too long older people have found the care system a bewildering maze full of differing rules and confusing criteria for access to services. There has been a lottery in long-term care just as there has been one for health care. The Government are determined to tackle both.
§ Rev. Martin Smyth (Belfast, South)
Has an assessment been made of the pressure upon both the independent and voluntary systems at this stage when we are emphasising community care? So many statutory homes throughout the country have been closed and people are puzzled about what the future holds for them.
§ Mr. Milburn
I understand the concerns of the residential care sector. I shall be coming to that. However, I do not accept that there is a wholesale crisis in that industry. The hon. Gentleman should remember that over the course of this year, next year and the following year, social services budgets are being increased by more than 3 per cent. in real terms, with an extra £3 billion going to them.
§ Mr. Milburn
The hon. Lady says that she wants more for Worcestershire. She should have a word with the Conservative Treasury spokesmen. They are always telling us that our spending plans are reckless, madness and irresponsible. The Conservatives, Back Benchers and Front Benchers, cannot have their cake and eat it on these spending issues.
We will be taking four important steps to ensure greater fairness and transparency in the care system. First, today we are honouring another manifesto commitment by publishing a new charter for long-term care. [Interruption.] The hon. Member for Sutton and Cheam (Mr. Burstow) scoffs. I think that it is an important idea to honour manifesto commitments. Does the hon. Gentleman not agree? "Better Care, Higher Standards" will for the first time give people who need long-term care the information that they need to know what they can expect from their local health and housing authorities as well as social services.
The charter will require local health, housing and social care agencies to implement local charters by June 2000. In that way everybody will know what to expect, 447 how they will be treated and where to go to get effective help and advice. Annual public satisfaction surveys of services covered by the charter will be published.
As we know from our postbags and surgeries, many people going into long-term care, and their relatives, are naturally anxious and worried about their future. I hope that the new approach to setting standards will ease some of these worries and ensure that people receive a higher quality service at this crucial time in their lives.
§ Mr. Edward Leigh (Gainsborough)
It is all very well talking about charters, but the Prime Minister spoke about these issues in the most inflammatory terms during the general election. He said that we, the Conservatives, wereforcing pensioners to sell their homesand that pensioners deserved better than that. There is a royal commission report, and the Secretary of State passed over it in about four minutes. It was allowed to gather dust for six months. Is it true that the report will never get out of the long grass because its recommendations will be too expensive?
§ Mr. Milburn
I would be extremely cautious if I were the hon. Gentleman. As I remember it, he served as a Minister in the previous Government. They established a royal commission on criminal justice. It was set up in June 1991 and the final Government response was made in June 1996—five years later. If the hon. Gentleman will wait a moment or two, I shall set out very clearly the timetable for our response. It will be far shorter than the previous Government managed with their royal commission.
§ Mr. Paul Burstow (Sutton and Cheam)
Will the Secretary of State confirm that the announcement he has just made about a long-term care charter is about providing guidance to local authorities to draw up their own local charters? Will he confirm that that was a policy of the previous Government, when they required local authorities to produce community care charters? Is his announcement not just a relabelling and recycling of old policies?
§ Mr. Milburn
No, that is not true. We want to ensure that there are clear national standards in all areas—in the national health service and in social services, too. The hon. Gentleman will be aware that, last week, the Minister of State, Department of Health, my hon. Friend the Member for Barrow and Furness (Mr. Hutton), published new information about the performance of individual social services authorities. I take a fairly fundamentalist view on this issue. I believe that the people who pay for and receive such services have the right to know how well they operate or, in some cases, how poorly they operate. We shall continue the drive to make such information available, not just locally but nationally.
§ Mr. Field
If we publish information about how well local authorities do, is it not important that it is accurate 448 and up to date? Is it not true that the information recently published on Wirral social services was grossly inaccurate on the improvements that Wirral has made not only during the period of the inspection, but, much more importantly, since the inspection?
§ Mr. Milburn
I am reliably informed by my hon. Friend the Minister of State, Department of Health that the Wirral local authority not only provided the information that was published, but that it was invited to comment on the draft publication. My right hon. Friend's point is not quite accurate.
§ Mr. Milburn
We shall look into that issue, but I am now determined to move on to my important second point; it is only the second out of four.
Secondly, early in the new year, we shall consult on new guidance to give everyone fairer access to social services. We want to iron out the unacceptable variations that exist at present and to create a fair set of rules and procedures that everyone can follow and understand. The aim will be to achieve greater consistency between local authorities in the way that they apply eligibility criteria for accessing all adult social services, including long-term residential care. Importantly, the guidance will stress the need to align social services criteria with NHS continuing health care criteria. It will also stress the need to agree eligibility criteria with housing agencies to ensure a properly co-ordinated response to people's needs.
Thirdly, we also want the care provided to older people by the health service to be of a higher standard in future. Older people are entitled to be treated with dignity and respect wherever they use the NHS. They are entitled to have fair access to health care; age discrimination has no place in the modern national health service that we seek to establish. That is why next year we shall publish a new national service framework for older people. For the first time, we shall lay down clear national standards, defining the treatment and care that older people can expect in all settings—whether in hospital, general practitioners' surgeries or from social services—as they move from hospital into care or back home.
The national service framework will be ready next year for implementation by April 2001. In the meantime, we are making good progress in eliminating mixed-sex accommodation in the NHS, which many old people feel—I agree with them—threatens their dignity and self-respect.
Fourthly—[Interruption.] The hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) is having difficulty counting, but this is my fourth point. Fourthly, we want to ensure higher quality in all aspects of care. We are currently consulting on draft national minimum standards for residential and nursing homes. Final standards will be published next year. The quality of care provided in people's own homes, however, is not currently regulated at all, so in the new year we shall launch a consultation exercise on possible new standards in that area.
The setting and enforcement of standards of home care providers will be central to our drive for higher quality social care services. Other elements will include the first 449 ever quality strategy for social care, together with improvements in the training, qualifications and regulation of the social care work force, far too many of whom remain unqualified.
§ Mr. Milburn
I want to make a little progress. I have given way many times, and I know that many hon. Members want to speak.
Together, those four steps will help to deliver a fairer and better integrated system of care for older and disabled people. They will improve user and carer choice, as well as the consistency and quality of the long-term care system. All those initiatives were either called for by the royal commission, or go significantly beyond its recommendations. In total, we are already actioning 11 of the royal commission's 23 recommendations, so we are making good progress.
§ Mr. Letwin
I thank the right hon. Gentleman for giving way, and I rise on a genuine point of information. Has he just said that he will establish a new police force to oversee how people are, in their own homes, looking after elderly people?
§ Mr. Milburn
No. The hon. Gentleman should try to put aside his ideological convictions and think about the type and quality of care that people receive. We are contemplating, for the first time, means of ensuring that standards among home care providers are as high as possible. That sector has never been regulated, and as a consequence, as we are all too aware—or should be aware—from our constituency experience, standards have not always been as high as they should be, and in some cases abuse has taken place. We are determined to avoid that.
§ Mrs. Humble
Does my right hon. Friend recognise that the many frail, elderly people who are cared for in their own homes by a single carer are more at risk and more vulnerable than elderly people being cared for in a residential setting, where they are surrounded by many more people and have regular visitors? That is one reason why it is vital to consider regulating home care.
§ Mr. Milburn
I am grateful for my hon. Friend's support. I know that she comes from an active background in social services and that she understands the issues. 450 Social services authorities are all too aware of some of the problems that occur precisely when the system of domiciliary care services is improperly regulated.
Many of the royal commission's suggestions for changes to the funding system for long-term care have substantial cost implications, both now and for the future. Those costs range from over £1 billion a year to over £6 billion a year. As a Government, we are committed to a prudent, disciplined approach to public spending, so we have already set out our spending plans for the three years to March 2002.
Looking to the future, the 2000 spending review will agree new spending plans for a further two years. We intend to complete the review by next summer. It will aim to find out how best our spending programmes can contribute to achieving the Government's overall objectives. In particular, we want to create a fair, inclusive society where communities are secure and healthy. Improving the care of older people will be an important element of the Department of Health's input into the spending review. The review will consider long-term care funding, alongside changes to improve the quality and delivery of care. Our proposals on financing long-term care will be completed next summer when funding decisions will be announced. We aim to publish a White Paper around that time.
We shall base any future reforms in this area on three key principles: choice, fairness and quality. Similarly, just as elsewhere in our welfare reform programme, our policy will be that people should provide for themselves where they are able to do so. In particular, people prefer and should have the opportunity to remain at home for as long as possible. There will, of course, be situations where a person needs to be admitted to a residential care or a nursing home, and that choice should be available, but any reforms to the system of long-term care must reflect and reinforce the crucial policy objective of encouraging independence through choice.
We know that we need to find a fairer way of funding long-term care for the future. There are around 375,000 older people in residential care and nursing homes in England. The taxpayer already helps to fund the care costs of about three quarters of them, fully or in part. Of those people in residential care and nursing homes, about 100,000 with assets over the present capital limit of £16,000 fund their own care. We established the royal commission because of widespread criticisms of the current arrangements.
The means test for residential care is hard on those with only modest amounts of capital, usually their family home, and lower retirement incomes. It also leads to a widespread fear that people will be forced to sell their homes in order to fund their long-term care requirements. There can be pressure for the immediate sale of the home when people enter care. Sometimes, of course, selling an empty house makes sense, but premature sale can rule out the possibility of people returning home after some support and rehabilitation. Many older people are anxious about a decision to sell, and the move into care can itself be extremely stressful.
§ Mr. Geoffrey Clifton-Brown (Cotswold)
I am grateful to the right hon. Gentleman for giving way. Does he agree that long-term care requires long-term solutions? Is he aware that the average worker, over a 40-year 451 working life, pays more than £100,000 in national insurance? Would it not be better to move towards a system whereby a properly funded pension was built up, which could be put towards the funding of proper long-term care?
§ Mr. Milburn
As the hon. Gentleman rightly says, we must consider these highly complex issues. They are issues not just for the Department of Health. They cut across the entire Government—the Department of Social Security, the Department of the Environment, Transport and the Regions, the Treasury and other Departments are all involved in the discussions. It is extremely unlikely that there is one simple big-bang solution, but it is important that we understand the nature of the problem in order that we can begin to posit where we could move in the future.
§ Mr. Milburn
No, I will not give way. I have already taken too much time and I must move on.
There are insufficient incentives for authorities to rehabilitate and support people in their own homes. The charges that people pay for care at home vary too much between different parts of the country. Private financial products for long-term care, as they are currently structured, do not deliver attractive options for most people who have to pay for their own care. Finally, the system as a whole needs better ways of assuring and improving the quality of care.
§ Mr. John MacGregor (South Norfolk)
The Secretary of State said that one of his principles was fairness. As he develops his proposals, will he bear in mind that what many people regard as one of the most unfair elements of the present system is having to sell the family home, particularly a modest family home, in order to qualify for state assistance, whereas others who have not struggled to build up a home of their own are in a better position?
§ Mr. Milburn
I understand that. I understand both the unfairness and the very real fear that that causes among people who are growing old, their relatives and carers.
§ Mr. Milburn
I shall give way to the hon. Gentleman because he is so persistent, but that will be the last time.
§ Mr. Burstow
I am grateful to the Secretary of State for recognising my persistence. Will he ensure that when he returns to the House after the review, he can justify the present situation in which a dementia sufferer must pay for nursing care? How can that be fair? Will it be addressed in the review?
§ Mr. Milburn
I shall come on to these important issues in a moment. They were raised explicitly by the royal commission and in the commission's consultation, and I am sure that they are reflected in the postbag that the Department of Health has received since the royal commission produced its report.
452 It is now time to explore practical ways of addressing these fundamental failings in the current long-term care system, and I shall set out for the House how we intend to do just that.
Many of the possible changes to the funding system raise complex practical issues. As part of the 2000 spending review process, we shall be exploring some of those issues and the commission's recommendations in detail. The royal commission raised six issues in both the minority and majority reports which we are examining in particular detail.
First, the royal commission recommended that consideration should be given to providing nursing care free, whether delivered in the NHS or in private nursing homes. Even within the royal commission, there were different approaches to the definition of nursing care. We will be working with interested parties to see if the definitional problems can be overcome. Come what may, we will need to weigh that option against other priorities for funding long-term care.
Secondly, we intend to explore with the financial services industry how it could best design long-term care insurance products and other financial products to see if they could be made attractive to a wider audience.
Thirdly, we are exploring the costs and effects of possible changes to the residential charging rules. Those include the treatment of houses where a former carer continues to live. They also include measures to ensure that local authorities use their powers to avoid an immediate sale by helping with care home fees while taking a charge over the person's home.
Fourthly, we are considering the implications of changes to two social security benefit payments. As we said in the social services White Paper, we are considering transferring to local authorities the funds for the income support residential allowance, which is currently paid only to people living in independent residential care homes. We are also considering transferring to local authorities the funding and care management responsibility for people who entered care homes before the 1993 community care changes and who have preserved rights to income support towards their care costs.
Fifthly, we are reviewing policy and guidance on continuing health care with a view to improving consistency and equity of access to services.
Sixthly, we shall consider the implications of a forthcoming report by the Audit Commission on charges for care at home, as we look at ways of reducing the scale of variations in local authority domiciliary care charging policies.
Where appropriate we intend to publish short consultation papers on those issues. The lead Government Department in each case will involve key organisations, including users and carers as well as independent sector care providers. That detailed work will help to inform the Government's final decision on the future funding of long-term care following the conclusion of the next spending review.
As well as preparing for that detailed work on funding issues, we have been considering the royal commission's other central recommendation for a national care commission. Devolution means, as the royal commission recognised, that the remit of any such organisation is likely to be confined to a single country. However, we 453 believe that many of the functions proposed for a care commission are just as usefully done for England as for the United Kingdom as a whole.
The four main roles suggested for the care commission were monitoring, representing the consumer, providing national benchmarks and encouraging the development of better services. Those are all important. Each is already being carried out, at least in part, by existing organisations, including my Department, ombudsmen for the NHS and local government, and professional training and regulatory bodies. We also believe that there is merit in bringing together many of the individual functions suggested for the care commission through a single organisation covering England. The key test is that any such body should have a coherent role which will improve matters for everyone who needs long-term care.
Our social services White Paper published last November proposed the establishment of eight regional commissions for care standards to enforce new minimum standards for residential as well as domiciliary services. In the light of the royal commission's report I have looked again at whether eight regional bodies would give us the national overview and consistency that we seek. I have concluded that they would not. I can therefore announce today that we have decided broadly to accept the royal commission's recommendation in this area. Our Bill on care standards will establish a single national care standards commission. The measure, which sets out its broad functions, will be introduced in another place today. The commission will take up the four main roles that the royal commission proposed and will, therefore, be established in the way in which the royal commission suggested. I hope that the Bill will complete its parliamentary stages next summer.
The national care standards commission will be responsible for ensuring that all long-term social care in this country is provided at a consistently high standard. For the first time, there will be a single, independent, national watchdog, which will be responsible for ensuring high standards of care wherever it is provided and whoever provides it. The new regulatory regime will be simpler and more streamlined than previous regimes, and, crucially, there will be a level playing field for public and private sector providers.
The new commission will be uniquely well placed to advise and inform Government and consumers. It will build on its regulatory function by monitoring and reporting on trends in the provision of long-term care. We also intend that the commission will be able to put together the information with demographic and resource data, and thus advise Government, as required, on trends in the long-term care market.
The commission will have the power to investigate complaints and to report on them. It will also be able to ensure that consumers have clear and accurate information on services. Building on its regulatory role, it will be able to take a view on quality standards nationally, as well as reporting publicly on each of its inspections. The standards that it enforces will include output measures, and it will have to reflect the views of local service users on the service.
The commission will report every year on service performance against standards, and it will give providers advice on meeting the national standards. It will also be able to run helplines to guide people to registered providers.
454 Overall, the national care standards commission will be a powerful new body, which, I believe, will make a major contribution to driving up standards of care and to giving people the necessary information to make choices about their long-term care needs. I hope that it will be up and running by spring 2002.
The Government are committed to improving long-term care for older people and for disabled people. The changes that we are already implementing, and the further changes that I have outlined today, seek to promote choice, improve quality and provide fairness for people who need long-term care.
The royal commission has played its part, and I thank it for its work. My speech today, by outlining work in progress and broadly accepting one of the royal commission's two main recommendations, shows that we are tackling seriously and constructively the issues that it raised. My announcement today is not our last word on long-term care, but it shows our determination to take the necessary steps to put long-term care on a sounder and more sustainable footing.
§ Mr. Philip Hammond (Runnymede and Weybridge)
The Secretary of State has created a smokescreen of minimalist announcements and reheated old announcements in his attempt to distract attention from the Government's simple failure to address the royal commission report's principal recommendation. There is much worthy exploring and investigating, but nothing of substance. I hope that the Secretary of State appreciates the disappointment that his words will cause those up and down the country who have waited with bated breath for some sign of a Government response to the royal commission report, which has been in the Government's hands for nearly nine months.
§ Mr. Kirkwood
The hon. Gentleman puzzles me. I have a brief from the Conservative parliamentary resources unit—
§ Mr. Kirkwood
I shall happily pay for it—it is a very useful document. It contains a revealing sentence:Over the next few months, the party will develop new areas of policy which will be ready well before the next general election.Is the hon. Gentleman criticising the Government for that?
§ Mr. Hammond
I am glad that the hon. Gentleman is reading Conservative research department briefs—perhaps he seeks a position in the shadow Cabinet. However, his idea of opposition may be different from mine. We shall develop our policies and put them before the electorate at the next general election. They will be based on our response to Government policies that are outlined at that time. It is no part of our responsibility to develop policies and feed them to the Government to steal from us—just as the hon. Gentleman has acquired that brief by means that we know not.
It is a delicious irony that the Secretary of State, who has come to the House today to defend the Government's inaction in response to the principal recommendations of the royal commission report, 455 may be the Treasury Minister who ensured that those recommendations were rejected in the first place. Before the general election, Labour apparently identified long-term care as an area for urgent action. Perhaps it would be more accurate to say that it identified that as an area to be exploited in the pursuit of votes. In a press release dated 10 March 1997, the then shadow Secretary of State for Health said:We will establish a royal commission which will lead a national debate on a comprehensive review of the care system. Changes cannot be made piecemeal.I hope that the Secretary of State will bear that in mind as the Government embark, as he has said, on an exercise to cherry-pick the report and dribble out a series of piecemeal changes, as he has admitted they are doing.
§ Dr. Nick Palmer (Broxtowe)
The hon. Gentleman has said that the Government have rejected the main recommendations of the report. There are two main recommendations, one of which they have accepted. They have promised a response on the other within months, so how does he explain his assertion?
§ Mr. Hammond
Well tripped. When I referred to the principal recommendations of the report, I meant the one concerning funding. As the hon. Gentleman knows, that is the key issue being debated in the country and it is of key concern to the 400 organisations that submitted evidence to the royal commission. We must address ourselves to that issue first and foremost.
In a press release dated 25 April 1996, the—now—Secretary of State himself said:Labour would end the geographical lottery in community care by setting national eligibility criteria for NHS continuing care".To date, the Department of Health's contribution to fulfilling that pledge has consisted of intervening with taxpayers' money in the Coughlan case to overturn the court decision and re-establish the legal basis for precisely thatgeographical lottery in community care".Most laughably of all, in a press release dated 10 March 1997 the current Secretary of State for Culture, Media and Sport told the world that by focusingon quality rather than throughput in the NHS we will remove the perverse incentives for hospitals to discharge patients too early".In office, the Government have sacrificed quality of care and practically everything else on the altar of throughput in an attempt to meet the Prime Minister's waiting list pledge. Far from ending premature discharging, the system of cash bonuses and penalties that they have introduced has encouraged health authorities and trusts to discharge patients early.
Immediately after the general election—in fact, on the first day of the new Parliament—the right hon. Member for Brent, South (Mr. Boateng), then an Under-Secretary at the Department of Health, gave some pointers to the Government's thinking:We recognize … the importance that people attach—particularly in their later years—to the home in which they have lived all their lives and which, if they are home owners, they hope to pass on".456 He identified at that stage that avoidance of enforced home disposals was a key issue. In the same debate, he said:The previous Government … began a process of consultation on insurance provision as a response to the crisis in long-term care … We will not go down that road.He was ruling out in advance any consideration by the royal commission of an insurance-based solution—a policy that contradicts the later Green Paper on welfare reform—which does not seem to have done his career any harm. However, I was interested to hear the Secretary of State apparently ruling insurance-based solutions back into the equation.
The then Under-Secretary went on:For us, consensus on how we provide for our senior citizens … is a critical issue that we do not intend to shirk."—[Official Report, 14 May 1997; Vol. 294, c. 156-58]Whether he intended it or not, the Government have given a pretty good imitation of shirking. After the setting up of the royal commission in December 1997 and its reporting in slightly more than 12 months, as it was asked to do, nine months have passed during which the listening audience of 10 million pensioners could have heard a pin drop.
§ Mr. Desmond Browne (Kilmarnock and Loudoun)
Will the hon. Gentleman remind the House of how long it took the then Tory Government to respond to the Audit Commission's 1984 report? Was it not an Act of Parliament of 1990, which then took three years to implement, that represented that response?
§ Mr. Hammond
What I will remind the hon. Gentleman of is the fact that, at the last general election, the Conservative party presented a specific proposal for starting to deal with problems in long-term care. The then Opposition rubbished that proposal, and promised the public an urgent alternative solution. Here we are, two and a half years later, with 100,000 more homes forcibly sold to pay for long-term care; and what has the Secretary of State told us today? He has told us that we shall have to wait another year for the Government's solution.
The former Secretary of State, who presented the royal commission's report to Parliament, indicated that he agreed about the need for an informed debate on the recommendations. Given that he told us in the same statement that the commission had taken evidence from 400 organisations and received more than 2,000 written submissions, had made more than 100 visits and had met 1,000 individuals—all of which had informed its recommendations—I think we are entitled to ask what further debate will achieve, other than providing the Government with a fig leaf enabling them to reach conclusions that are diametrically opposed to those of the commission.
More experienced hands than me, both inside and outside Parliament, instantly recognised in the call for informed debate Whitehall-speak for "Drive it into the long grass, and hope that it gets lost." Ministerial answers to oral and written questions since then have confirmed that view. Typical was a question posed on 6 July by the hon. Member for Pendle (Mr. Prentice), who humbly inquired when the Secretary of State expected to have concluded the debate. And the answer he received?We expect that debate … to be an on-going one".—[Official Report, 6 July 1999; Vol. 334, c. 499W.]457 In other words, "Never".
Even more enigmatic was the Prime Minister's reply to a similar question asked by me on 26 July. He told me:We are considering the Royal Commission's proposals and the reactions to the Commission's report. We will announce our decisions in due course."—[Official Report, 26 July 1999; Vol. 336, c. 30W.]That prompts us to ask whose reactions were being considered—those of the hundreds of organisations that have welcomed the commission's principal recommendation with open arms, or those of the Prime Minister's next-door neighbour.
The truth is that the Government set up the royal commission expecting it to propose a low public spending solution. The Government would then have hidden behind the commission's report, and argued that it had weighed the evidence and reached a proper conclusion. Unfortunately for the Government, however, the commission did not play ball.
§ Mr. Clifton-Brown
May I make a point on that very subject of funding? Is my hon. Friend aware of a serious report in today's Times? It states that, according to the Royal College of Nursing,many of the 42,000 nursing home residents who pay for all or some of their nursing home costs could be entitled to have the nursing care element of their fees paid".Furthermore,Christine Hancock, general secretary of the RCN, said that the way health authorities used criteria to exclude the vast majority of nursing home residents from long-term NHS care amounted to 'wholesale rationing in the NHS'.
Is that not wholly contrary to what Ministers, including the Prime Minister, have been saying? Unless further funds can be found for the health service, there will be no real solution to the long-term care problem.
§ Mr. Hammond
I have seen the draft report from the Royal College of Nursing, which will be published tomorrow, and I will shortly deal with the implications of the Coughlan judgment and access to long-term care.
The Government find the report's principal recommendation unacceptable, but they have not had the courage to say so openly. Only the persistence of the grey lobby has prevented the ball from being lost in the long grass—and, if I may say so, only the repeated insistence of Opposition Members has eventually given the House an opportunity to consider the matter.
§ Mr. Desmond Swayne (New Forest, West)
Is my hon. Friend aware of the recommendations of the Select Committee on Health consequent on the report? It said:Failure by the Government to act urgently would be a serious dereliction of duty.Does my hon. Friend think that there might be anything in the fact that the Select Committee happens to be abroad while we are holding this debate?
§ Mr. Hammond
The Secretary of State feigns amazement, but my hon. Friend is right. The Health Committee clearly stated that failure to act urgently on the commission's recommendations would be a gross dereliction of duty. I was looking forward to hearing whether the hon. Member for Wakefield (Mr. Hinchliffe), the Committee's Chairman, regards the Government as 458 guilty of that charge. Sadly, as we know, the debate has been timed to ensure that some of the most well informed and interested Members who would have wanted to contribute cannot be here. Most notably, some Labour Back Benchers who are critics of the Government on the issue are not able to take part in the debate. I look forward to a discussion with the hon. Gentleman, when he returns, to find out his view on that issue.
One suspects that the only debate on the royal commission report that really mattered happened long ago in the Treasury and that the conclusion of that debate was clear some time before the public even saw the report. As I have said, one might speculate even that the Secretary of State for Health, then Chief Secretary to the Treasury, would almost certainly have been the one wielding the veto.
Meanwhile—we must never forget the point—each year, some 40,000 home owners whose plight the then Under-Secretary of State, the right hon. Member for Brent, South, so touchingly acknowledged in May 1997, have been forced to sell their homes to pay for long-term care. Another 100,000 homes have been lost as another early pledge gathers dust.
§ Mrs. Humble
How many people were saved the indignity and distress of selling their homes by the Conservative Government's proposals to increase the limit to £16,000 in the early 1990s?
§ Mr. Hammond
A number of people will have been saved that indignity and distress by the increase in the limit. It is self-evident that if the thresholds are increased, fewer people will be caught by the trap. At the general election, the previous Government proposed immediate relief—not a total solution to the problem—which the Labour party rejected outright with the promise that it had a comprehensive solution. Two and a half years later, 100,000 homes have been lost and no comprehensive solution is available.
§ Mr. Hammond
I allow the hon. Member for Broxtowe to intervene and tell me what the royal commission said about those proposals.
§ Dr. Palmer
The royal commission said:The scheme as presented by the previous Government was rather complex, and it was difficult to see where the benefits lay, and to whom.I also note that a later paragraph casts considerable doubt on the £40,000 figure.
§ Mr. Hammond
I wonder whether the hon. Gentleman believes that everything in the royal commission report should be accepted. Is he arguing that all the report's arguments should be accepted by the Government and the House? I do not accept the royal commission's analysis of the previous proposals.
As the hon. Gentleman knows, the private insurance industry feels that it was not given an adequate opportunity to present its ideas to the royal commission. The royal commission rightly observed that private insurance could never be the complete solution. The industry itself has acknowledged that, but it feels that it 459 was not given an adequate opportunity to put the case for a mixed model of private insurance and public provision. Now the Secretary of State has effectively told us that the Government are considering going down the route of private insurance.
The range of options is no different from what was available in May 1997. The only difference is that 100,000 people who could have benefited then from change have already lost their homes. "The debate" is code for delay and indecision, while a private battle rages between the Treasury and the Department of Health over who should take the rap.
§ Mrs. Sylvia Heal (Halesowen and Rowley Regis)
The hon. Gentleman appears to be concerned about people losing their homes as a result of the cost of long-term care. I suggest that he refresh his memory as to which party was in power when many long-stay national health service beds were closed and care was transferred from the NHS to local authorities, which marked the beginning of the policies that he is now criticising. I remind him, in case he has forgotten, that it was, of course, the Conservative party.
§ Mr. Hammond
The hon. Lady is right, but that is not the point that we are discussing. I shall come to the demarcation line between NHS continuing care and social care provided by local authorities in a moment.
I make no apology for concentrating the greater part of my remarks on the Government's inaction in response to the royal commission's principal recommendation, which is about funding. However, the report also deals with other vital issues that remain largely unaddressed as a result of the Government's paralysis over the principal recommendation.
The provision of care—what type of care, what type of choice and who should provide it—is as important as the means of paying for it. I was pleased to hear that the Secretary of State agrees that choice is the key. We must never forget that in discussing long-term care for the elderly we are talking not about statistics or units, but about individual people—and elderly people at that, who almost by definition have clear and precise ideas about what they want and do not want. No single model of care will provide adequately for such a disparate population. It is essential that in structuring a funding system we should seek to stimulate choice and diversity in supply so that provision is responsive to the needs and wants of the individuals who will use it.
There is a consensus across the House that the promotion of domiciliary care—care for people in their own homes—is greatly preferable where practicable. All the surveys show an overwhelming preference among elderly people for staying in their own homes for as long as possible. I was interested in the Secretary of State's announcement on standards for domiciliary care and his allusion to the possibility of a short-term disregard at the beginning of a period of care to avoid what might be termed accidental institutionalisation of people because they needed to leave their homes for a relatively short period. It was disappointing that the Secretary of State had nothing concrete to say on that, even though the press had been speculating that the Government might be able to make an immediate announcement.
460 The Government have rightly recognised the vital role of voluntary carers in supporting the elderly, among others. How best to support them—whether to provide support directly or through more effective respite provision—is a matter for debate. There is broad consensus that support for carers is not only a moral imperative, but economic common sense, recognising the huge burden of work that they shoulder, unpaid and often unsung. I hope that the Secretary of State will acknowledge that we confirmed to his predecessor our broad support for the initiatives on that.
There has been a significant transformation in recent years, as local authorities have increasingly retreated from the direct provision of accommodation. However, there is still a significant amount of local authority accommodation in the system. We support the Government's proposals, subject to seeing the details, to level the playing field by requiring local authority care homes to meet the same standards as those operated by the independent sector. I should like an assurance that the final standards that the Secretary of State alluded to will be available before the House has to consider the forthcoming Bill on care standards, so that if, as we suspect, the detailed standards are to be introduced by regulation, we might at least have an idea of the standards that are to be imposed later when we consider the principal provisions of the Bill.
§ Mr. Cotter
I wonder whether the hon. Gentleman has had the same experience as I have. Residents in residential homes have expressed concern in my surgery that their homes might be closed. Does he agree that any future regulations must be implemented sensitively, particularly with regard to the size of rooms in residential homes? A lot of small homes are concerned, and we hope that a constructive point will be made here.
§ Mr. Hammond
I am grateful to the hon. Gentleman for introducing that point. The Government have gone about this from the wrong angle. The "Fit for the Future?" document is an inspector's document, designed for the convenience of inspectors. It seeks to focus on what is easily measurable and to ignore what is not, including—importantly—the overall care experience of residents. It totally fails to acknowledge the individuality of elderly people, some of whom may have different needs and wants from others.
In its present form, the proposal would drive a significant part of the independent sector—and an even larger part of the local authority sector—out of business. We have to hope, for reasons both philosophical and practical, that the Government will approach the draft standards with caution, especially as they refer to minimum room sizes. It is for that reason that I asked the Secretary of State to give an assurance that we will be able to see the definitive form of the regulations before we debate any Bill on care standards, or at least at the same time.
§ Mr. MacGregor
My hon. Friend makes an important point. Is it not essential that the costs to both sectors be fully taken into account, especially if the income to meet those costs does not follow? I suspect from what the Secretary of State said earlier that it is unlikely that that income will follow. It is therefore essential that, in any 461 steps that are taken, an assurance be given to private and local authority homes that the income will be there to meet the extra costs.
§ Mr. Hammond
My right hon. Friend makes an important point, too. One cannot have quality without paying for it. If one is prepared to pay for it, one does not need regulations to get it. If providers were offered premium payments for premium products, they would be happy to provide them.
The Secretary of State has not introduced any voluntary premium payment scheme—or encouraged local authorities to pursue such a scheme—to increase the standards of the physical amenities and the training of staff in care homes, and intends to do that by regulation. From that, we can only conclude that he is not willing to pay or to provide the resources that will be needed to support the Government's wholly laudable aspirations.
The Secretary of State will be aware that although he said that there was no crisis facing the financing by local authorities of care, his much vaunted increase in social services spending has not been distributed evenly around the country. I am sure that there is not a problem in Darlington, but there is certainly a problem in Surrey, Sussex, Hertfordshire, Oxfordshire, Essex, Kent, Buckinghamshire and Worcestershire.
Local authorities' own funding crises have forced them to keep payments to independent sector providers down below the rate of cost inflation and, in some cases, below their break-even levels. This has resulted in local authorities in some areas—Hertfordshire, for example—being unable to purchase beds in the independent sector at a price they are willing or able to pay. The evidence for that—as the Secretary of State will know—is to be found in the re-emergence of extensive bed blocking by elderly people awaiting social services placements across the south-east of England, before the onset of the—now routine—winter crisis.
The scandal is that, against the background of inadequate funding, leading to a drying up of independent sector supply, there are still many local authorities all over the country which are directing elderly people to local authority-provided accommodation that carries with it a much higher cost than equivalent or better independent sector accommodation.
Without bringing ideology into this matter, it seems to me that there can be no justification in a resource-constrained environment for restricting the total amount of care that can be purchased by a local authority by buying a more expensive product, where an equal quality, less expensive one is available. I urge the Secretary of State to take steps to assess the scale of the problem, and to calculate the additional care that might be purchased with the money saved if expensive local authority provision were substituted by better value independent sector provision.
The figures are substantial. In many councils—on local authorities' own admission, as the Secretary of State knows—the cost of providing care in their own establishments is 60 per cent., 70 per cent., 80 per cent. and, in some cases, more than 100 per cent. higher than the price at which they can buy comparable care in independent sector establishments.
On eligibility, I am grateful for the comments made by hon. Members, and by the Secretary of State. The dividing line between NHS and social care for the elderly is of 462 great importance, because NHS continuing care is free but local authority care is subject to the means test, making this a critical issue for many families. The royal commission's principal recommendation would greatly reduce, if not entirely eliminate, the significance of the distinctions.
If the Government have set their face against that recommendation, they have to revisit the aftermath of the Coughlan judgment and issue clear, transparent and universally understood guidance as to the demarcation line between free NHS care and means-tested social care. I am not entirely sure whether the Secretary of State's mini-announcement earlier was an undertaking to do that early in the new year. If it was, I welcome it.
To date, the Department of Health's involvement in the matter has been limited to paying lawyers to slug it out. I see that the Royal College of Nursing is now spending its money on obtaining counsel's opinion on the matter. I say to the Secretary of State that it is abundantly clear that this is a policy issue, requiring a political decision. It is a job for Ministers, not lawyers.
It will be clear from what I have said that there are huge areas beyond the central issue of funding which can and must be addressed if we are to establish a proper system of long-term care delivery in this country. At present, unsurprisingly, the focus of attention is on the Government's response—or lack of it—to the central recommendations of the royal commission. Until we understand how the Government are to take that agenda forward, there can be no real progress on the broader issues.
I hope that the Secretary of State will contemplate the fact that while he ponders and announces another delay of six or eight months before something is to be done, 800 people each week are losing their homes to pay for their long-term care needs.
§ Mr. Hammond
I am sure that the people facing the loss of their homes while the right hon. Gentleman dithers and considers the matter further do not agree with him.
§ Mr. Leigh
May I be fair to the Government for a moment? Sir Stewart Sutherland and his colleagues have put the Government in an impossible position by asking for an increase in spending of up to £6 billion. The key is the means test, and I hope that my hon. Friend will commend the note of dissent from the royal commission report—particularly the point made on page 115 concerningmodifying the existing means-test, so that it is less harsh towards people with small amounts of wealth and does not force elderly people to sell their home".That seems to be a sensible proposal, and I hope that both sides of the House can agree that we should at least do that.
§ Mr. Hammond
I thank my hon. Friend, and there is much to be recommended in the minority report of the royal commission. I can assure my hon. Friend that we are working hard with outside bodies and looking at an appropriate response to the issues raised by report.
There is much in the royal commission's report that all sides will welcome and can agree on, but it seems to me that the commission has missed one of the most important 463 points. The crisis today in long-term care arises from a real and genuine sense on the part of many older people of a breach of contract by the state. For years—perhaps all their working lives—they paid high taxes on the assumption of a cradle-to-grave welfare system. That system changed, as it had to if our nation was to prosper, and this generation of politicians and taxpayers—operating in a globalised economy—prefers, indeed needs, lower taxes. The intergenerational contract, to which the report refers, has failed. The state, as a contracting party, suffers from a fatal flaw—it is above the law and reserves to itself the right to change the rules unilaterally and, in the case of the time scales for the subject of this debate, at the whim of generations of politicians yet unborn. When the report speaks of a contract between Government and people, and between all generations of society, it means not a contract but a blind faith that can draw little inspiration from experience.
I make a distinction between the need for a system for future generations and the need to relieve the immediate, legitimate concerns of today's generation of pensioners. If a system for future generations is to command the confidence of today's 20-somethings that it will deliver for them 50 years hence, it will have to be based on enforceable contractual rights or on individual control of assets. A vague promise of "pay up now and we will look after you later" is unlikely to convince them.
Government policy would appear to dictate that the partnership between the state and the individual for future generations will depend on the principle that those who can make planned provision for their long-term care should do so. One of the principles of the Government's Green Paper on welfare reform says precisely that. We urgently need to know what the Government's solution for future generations of older people will be.
There can be no doubt in anyone's mind that today's generation of retired people have legitimate expectations that the current system does not meet. The royal commission has proposed a solution for them based entirely on an additional public spending commitment, but it also offers the same solution for future generations, which inevitably generates an open-ended public spending commitment scary enough to guarantee a Treasury veto.
Today's elderly are left in limbo because the Government will not seize the initiative and separate the question of provision for them from the longer-term and perhaps more challenging question of provision for future generations. It is only by separating those two issues that there is any hope of clearing the Treasury hurdle and moving forward rapidly to address the real injustice that is being experienced by hundreds of thousands of older people. In each week of delay that goes by, another 800 pensioners lose their homes.
The Government, in this area as in so many others, have cynically raised voter expectations. Now they must deliver on those expectations or pay the price.
§ Mrs. Joan Humble (Blackpool, North and Fleetwood)
I am sure that we can all agree that this debate is very important. It affects many people—not just the elderly, but those with disabilities and young people who will need to look to the future when they may need long-term 464 care. The Government inherited a system in a mess. It was full of uncertainty, with no coherent policy on funding for long-term care. That has caused concern and anxiety to the users of the services and to the planners who need to deliver the services.
In what is a complex debate, I shall concentrate on two key points. First, we need to consider a fairer system of funding long-term care and finding solutions that are fair to the current generation of older people and to younger people, so that they know what to expect for their futures. Secondly, I shall consider the quality standards necessary to reassure people about the care available to them, given the uncertain and variable pattern found in different parts of the country.
One of the major reasons behind the Government's decision to set up the royal commission was the genuine anger and resentment that had built up in the 1980s and 1990s among many older people who had been forced to sell their homes. That has been mentioned already in the debate. We should not use those older people as a political football—they are real people with real concerns that should be addressed in our debate. The problem is not new, but it demands complex solutions. I doubt whether any homes in my constituency are worth less than the £16,000 capital limit introduced by the previous Government, so virtually all home owners fear losing their homes if they go into residential care.
Many people come to Blackpool and the Fylde coast to retire. They save up and buy a home to live by the seaside, and then when they need residential or nursing care, they face selling the lovely bungalow they had bought to settle in for the rest of their lives. We must find a fairer way to fund long-term care, but—just as important—we must give back to today's pensioners a faith in the state and a belief that Members of Parliament listen to their needs and are willing to address them.
Many of my constituents will welcome the Government's announcement today that they will examine the charges for nursing care. That issue formed a large part of the Sutherland report. It is difficult for many people to understand why nursing care provided in one setting is free, but not free if it is provided in an alternative setting. I hope that all the issues covered by the report will be examined to offer people reassurances and to enable them to understand the system, because they do not understand it now.
I am sure that many people will also welcome ways to delay the sale of a property to finance care. We have all had cases of constituents who had gone into residential care but had then recovered sufficiently to want to go back to their homes, only to find they had a "For Sale" sign outside. Any mechanism that we can introduce to ensure that homes are not sold prematurely will be very welcome.
In this debate, we must consider the spectrum of care available. Many people prefer to remain in their own homes as long as possible, so we need to consider the support services available to them—whether provided by social services, health services, voluntary organisations or church groups. I also welcome the Government's announcement of the long-term care charter. That charter and the draft guidance that was issued to social services, health departments and housing authorities will improve services for people needing on-going support by setting out exactly what they can expect from their local service 465 providers. Many people come to my surgeries to find out what is available: information should be much more easily available in local libraries and day centres.
The introduction of the charter next year will be a vital step towards the seamless service that should be provided for people. We think of the services as a spectrum that starts with people in their own homes having home helps coming in, then going to day centres, followed by residential care, where they end their lives. However, it does not always follow that pattern, even for people who have been in residential care for some time.
I attended the 100th birthday party of an elderly blind lady who had been in residential care for three years. Two or three weeks before she turned 100 she decided that she could manage in the sheltered accommodation in which she had previously lived. I walked across the road with her to the home in which she had lived until recently, and she marched into the room where all the other residents were sitting around. Even though she could not see any of them, she said, "I know what you are doing. You're all sitting there slumped in your chairs and you're only 70. I'm 100 and you should imitate me and get out into the community." People's social and health care needs can improve, as well as deteriorate, and we need a flexible system that can cope with that.
I especially welcome the Government's announcement that they will look at and regulate home help services. Traditionally, people have thought of such services as involving cooking, cleaning and basic domestic tasks, but that is not so now. Home help services have become home care services, and they are often intensive. The workers going into elderly people's homes perform very personal care tasks for them. Because such work has never been regulated, untrained and unqualified young people have gone into the homes of frail, elderly and vulnerable individuals to perform very intimate functions without supervision or regulation. I believe that those elderly people are therefore at risk. Any mechanisms that we can employ to introduce appropriate registration and monitoring of home care services will reassure them. They welcome the people who come into their homes to look after them, but they need to know about those people's backgrounds and training.
§ Ms Debra Shipley (Stourbridge)
I agree with everything that my hon. Friend has said about home care help, and I endorse her view that not all the people caring for the elderly are of the appropriate type. I hope that a vetting system can be established, but does my hon. Friend agree that it would have to be statutory rather than voluntary? Does there not have to be a requirement that the people providing that help are vetted, and should not sanctions be applied to people who fall short of the required standards?
§ Mrs. Humble
I recall that, four or five years ago, Lancashire county council social services department introduced a voluntary system of registration and inspection of domiciliary care agencies. That has worked very well, but such systems do not operate elsewhere in the country. We need to consider whether a national voluntary system would work: if it would not, we should consider putting the system on a statutory basis. The bottom line is that we must protect those vulnerable people who are cared for in their own homes.
466 I also welcome the announcement by my right hon. Friend the Secretary of State that he is to examine the charges for home care services, as they vary across the country. Why should a frail, elderly person in my area pay more—or less—than one in Kent, Shropshire or somewhere else? It is very important to find a way to remove the huge variation in charges that exists.
There is a perverse incentive for local authorities to place people in residential care, as that is often cheaper than providing intensive support in a person's home. Most people who come to see me want to stay in their homes for as long as possible, but their local authorities often encourage them, for financial reasons, to go into residential care before they want to. As part of the comprehensive review, I hope that the Government will consider that problem and listen to what elderly people say.
We must also remember that not only elderly people require long-term care. In his opening remarks, my right hon. Friend referred to the many younger disabled people who require long-term care and who prefer to receive it in a community setting. I should like to take this opportunity to pay tribute to the thousands of informal carers supporting relatives or friends in the community. Over the past two years, I have had several meetings with the parents of adults with disability at one of the day centres in Fleetwood in my constituency. Those parents are in their 70s—some are in their 80s—and have cared for their now adult children throughout their lives. They have done so with love, care and affection, and they have accepted their responsibilities as parents. However, they are getting old: the elderly carers now need care, and the adults with disability must plan for their future.
In Lancashire, the local authority has been developing schemes to involve those carers in planning the future long-term provision for their adult offspring. Some of the necessary resources have come from the very welcome additional funding that the Government have made available to support carers. The carers whom I meet are pleased to be part of the planning process. In the past, they felt very excluded and that decisions were being taken by faceless bureaucrats and social workers a long way away in county hall. They very much welcome the fact that they are now being consulted, but my hon. Friend the Minister of State will not be surprised to hear that they want more—more respite services, more support and more homes in the community for their children.
Many other people in the community provide care. Their role is vital in ensuring that the phrase "long-term care" means what it says. I am sure that all hon. Members will praise the professionals whose job it is to look after people with care needs, in both the residential and community setting. However, without the support of informal carers, many of those professionals could not do their jobs. I hope that the House will take the opportunity provided by this debate to pay tribute to the invaluable work of those informal carers.
The second element that I want to mention is the quality of care. The recommendation for a national care commission is excellent, and will be widely welcomed. Standards of care are very variable, depending on where people live and on whether they are able to find out about the services that are available.
Mention has been made of the quality of care in nursing and residential homes. The Department of Health commissioned the Centre for Policy on Ageing to consult 467 on and prepare draft standards for such homes. Those draft standards included minimum requirements for space, facilities and quality of service provision. I understand that the Government have considered the CPA document and have published a consultation paper entitled "Fit for the Future?".
The question of standards is very important. Everyone wants standards to be improved, but it is also vital to ensure continuing provision in communities so that people can choose. Care for older people should be consistent throughout the country. Many of the requirements in the consultation paper are found already in good quality residential and nursing homes. Other requirements can be adopted at little or no cost, and they will substantially improve the quality of care provided.
However, it must be acknowledged that, in Lancashire, some of the physical elements of the standards could be achieved only with great difficulty, and some could not be achieved at all. It is not easy to move walls in old buildings, for example, and many of the care homes in Lancashire are both old and small. Although many people prefer them because of their homely environment, they would be hard to adapt to modern requirements. Simply knocking down a wall between two small rooms to make a larger one is not always the answer, as that may undermine the viability of a small home.
The regulatory impact analysis in the consultation document attempts to quantify the impact of the proposed changes. Given the surplus capacity in the market, the analysis states thatcompliance could be achieved without markedly destabilising the market.However, that is not what care home owners in my constituency tell me.
I recently met representatives of the Lancashire Care Association, who told me that of the 556 private homes in the county, 394, or 71 per cent., will not meet the proposed standards. That is nothing to do with the quality of care in the homes; it is the physical nature of the buildings. The picture is even worse in Blackpool, where the figure is 91 per cent. There is understandable concern. My worry concerns the residents of such homes and elderly people planning to enter them as part of their long-term care. We must ensure that there will still be homes for people to go into and that elderly residents in existing homes will not be threatened with evictions or moves. All that must be considered in the context of wanting the highest possible standards.
I urge my hon. Friend the Minister to consider carefully the representations that have been made. All those to whom I speak, including those in the private care sector, want to improve standards, but they want to have time to do it. They want to discuss some aspects of the document that they feel are not conducive to improving care standards. It is an important issue in my constituency. Lancashire, with perhaps Kent, has the highest number of private care homes. We have 20,000 residential and nursing home beds. It is clearly an issue, but I stress that there is a genuine commitment to move forward because we want top quality homes so that people will want to enter them and, if necessary, enjoy their final years in them.
468 On a more positive note, Blackpool is improving standards through a new star rating system. People can choose a hotel in Blackpool by how many stars it has, and now they can choose a residential or nursing home in the same way. It is a new and innovative scheme that I commend to my colleagues. I believe that it is the first independent scheme—it is not run by the local authority. There was a good deal of consultation between my local council, the private sector and the voluntary sector to consider ways of guaranteeing standards in homes. They brought in a company called Residential and Domiciliary Care Benchmarking Ltd.
I have seen the documents involved. They are immensely complex and ask a range of questions across every possible aspect of care in a home. Care home owners have to pay for the scheme, which is self-financed, but they come forward voluntarily, answer the questions and are assessed according to the star rating. Blackpool council's care homes have been subject to the same scrutiny as the private sector. The new scheme has already raised expectations, increased staff awareness of good practice, encouraged the spread of training and, perhaps most importantly, enabled purchasers of care—elderly people and their relatives—to make informed choices about which home they want to enter.
Earlier this year, I presented the awards of the first ever star certificates. I hope that more homes will come forward to be tested in that way and so improve standards in the industry. An independent, second opinion on care should help to promote public confidence in the residential care industry, as well as improving the confidence of the people who enter such homes.
The purchase of care is invariably a traumatic moment for individuals and their families and involves major budgetary expense for local authorities. A reliable standard of care is essential to allow the purchase to be made in confidence. Blackpool's system is expected to do exactly that. I hope that my hon. Friend the Minister will see this as Blackpool moving ahead before the introduction of the new national care commission, and examine it. I am advised that there is information on the net and a website. Brochures will be produced. This is my hard sell; I will give anyone more information about it.
§ Mr. Hammond
The hon. Lady may be interested to know that I visited Blackpool recently and was told all about the scheme. I have just been told that at least one other county council in the south of England is actively considering it.
§ Mrs. Humble
Where Blackpool leads, the rest of the world follows. This is a serious matter because there is over-provision in residential care and elderly people often do not know what to look for in choosing a care home. Too often, they look at the furnishings and the depth of the carpet instead of asking about the care provided.
Such schemes are an excellent way forward, as are the other proposals announced by the Government today. Long-term care is complex. There are no easy answers, but it is incumbent on us to review and revise the current confused situation to make it fair and acceptable to all.
§ Mr. Paul Burstow (Sutton and Cheam)
This is an important and, I hope, informative debate on long-term care and the Government's position. From what the 469 Secretary of State said earlier, we appear to have moved from the phase where the Government fly kites about what they will do to the phase where they consult and review, but not yet to the stage where they actually do anything. That concerns many who expected the Government to move ahead on such questions, not least the person who said:I don't want to live in a country where the only way pensioners can get long term care is by selling their home.That is what the Prime Minister told the Labour party conference in 1997.
Since then, at least 100,000 people have been forced to sell their homes to pay for their care. Those people had every right to expect that things could only get better after the general election. By the end of this Parliament, the essentials of our long-term care system will remain the same. We will have had a lot of consultation but not much delivery.
What the Secretary of State said was welcome in that it removed some of the veils behind which the Government have been working—feverishly, I hope—to respond to the royal commission. Unfortunately, it was little more than window dressing because it ducked some of the fundamental questions that were raised and, I believe, answered in the report.
I start with a proposition that I hope all hon. Members can agree with: the current system for funding long-term care cannot continue. The status quo is not an option because we are all living longer. As the Secretary of State rightly said, that should be a cause for celebration, but too often the talk is of crisis, demographic time bombs and tidal waves. Such language is unhelpful and divisive because it sets generation against generation and sets older people apart. What is more, it is not true.
The trends are clear, but they are not new. We have had birth certificates to enable us to plan for many years. We know that over the past 100 years, the number of people aged over 85 has increased 15 times. By 2050, there will be three times more people over 85 than today. The demographic time bomb is not ticking; it has already gone off.
As things stand, the way in which long-term care operates robs people of their dignity and drives them into dependency. Care is means-led, not needs-led. Who pays for care depends on where they are being cared for. The economics of health and social care are warped and twisted. Putting means testing at the front end of assessment drives people into high-dependency, high-cost institutionalised care. As a result, the NHS and social services are locked in a vicious circle of crisis management. Bed blocking, cost shunting and buck passing are the hallmarks of the system. This drives standards down, wasting resources and delivering poorer outcomes for many people.
However, what would another Tory term have delivered? The boundaries of state-funded care would have been even more tightly drawn than they were during the previous 18 years of Tory government. The destination of Tory social policy was a residual welfare state, based on exclusion, stigma and less eligibility. If the Conservatives had been re-elected, the fate of the public sector would have been to be the 21st century administrators of a new poor law. Before the general election, the Conservatives set out plans for a private, 470 insurance-based solution to finance long-term care costs. Those plans were complex, as the royal commission rightly pointed out. It noted:it was difficult to see where the benefits lay, and to whom.
The American experience of schemes similar to those proposed by the Conservatives shows that take-up has been low. In practice, many current pensioners would be too old, too poor or too poor a risk to qualify for immediate private cover. However, as we have heard today, the Secretary of State wants to examine how the private sector can make itself more attractive through the insurance packages that it offers. If that is to be so, I hope that proposals will soon be introduced for the proper regulation of the insurance market in long-term care. At present, the market is unregulated. If it is to be successful, the industry must be regulated to provide people with security and certainty.
We are only halfway through this Parliament. What have the Government done so far? They set up the royal commission, and the Liberal Democrats very much welcomed that. The royal commission reported in March—almost nine months ago. The Government wanted the commission to report quickly, and the commission delivered its report in 14 months. When will the Government deliver? We have been told that they will produce a White Paper, but when will action flow from that White Paper?
By the end of this Parliament, the essentials of our system of long-term care will remain unchanged. Each year, 35,000 to 40,000 homes will continue to be sold to provide care that many people thought would be provided free when they needed it. More than 100,000 have been forced to sell their homes since the then Secretary of State, the right hon. Member for Holborn and St. Pancras (Mr. Dobson), announced the royal commission. How many more must sell their homes before there is any action?
§ Dr. Palmer
We heard earlier in the debate that, despite their rhetoric, the Conservatives are not ready to respond to the royal commission's report and that they may be ready to do so only at the next election, although the tenor of their response was against the majority report. Do the Liberal Democrats have a view? Do they accept the majority report, the minority report or neither?
§ Mr. Burstow
The hon. Gentleman asks a fair question. For the past three or four weeks, I have been making applications for an Adjournment debate on the Coughlan case and its impact on long-term care. I should welcome the opportunity to have such time allocated to me so that we could debate the issue on my terms. In today's debate, the Government are setting out what they are doing, so we must test them on their proposals. The Liberal Democrats welcomed the royal commission and its terms of reference; we believe that provides a foundation on which we can build a modernised—to use the Government's word—long-term care system.
It is no wonder that Labour Members do not want to dwell on their policy, because too many aspects of it will cause great concern to people outside this place—not least the majority members of the commission. The majority members will feel that much of their work—especially in respect of their main recommendation on personal care—has been jettisoned as a result of the statement made by 471 the Secretary of State today. I shall return to that matter. I hope that the Minister will be able to reassure us when he replies to the debate—[Interruption.] If he wants to intervene now to tell us that personal care costs—not just nursing care costs—will be included under the six points that the Secretary of State set out earlier, that would be most helpful.
§ The Minister of State, Department of Health (Mr. John Hutton)
I am glad to correct the hon. Gentleman's wholly false assumption on that matter. Most of his remarks have been completely inaccurate and wrong. We have not ruled anything out today, and we have not ruled anything in. He is quite wrong to infer from my right hon. Friend the Secretary of State's speech that we are not giving full consideration to all the royal commission's recommendations.
§ Mr. Burstow
I am grateful for that non-statement—the Government are not ruling things in and they are not ruling things out—
§ Mr. Burstow
Perhaps the Minister would at least allow me to finish the sentence. I shall then be happy to take his intervention.
I listened to the Secretary of State's speech. He spoke explicitly about looking at nursing care and then about definitions. Did he mean that the definition question extends to the possibility of widening the definition of nursing care to include personal care?
§ Mr. Hutton
With respect to the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), the hon. Member for Sutton and Cheam (Mr. Burstow) is making heavy weather of the matter. I tried to make it clear to him and to the House that we are considering all the royal commission's recommendations, including the one to which he refers. I cannot make it clearer than that.
§ Mr. Burstow
I am grateful to the Minister for that reply. I hope that it will help some of his Back Benchers, who may have been misled by some of the comments earlier in the debate. It is helpful to know that the comprehensive spending review will consider all the royal commission's recommendations, and will thus consider the possibility of providing personal care free at the point of use, based on assessed need. That is important and it is useful to hear it from the Minister.
The Select Committee on Health considered some of those matters, as well as the interface between health and social care, and received some forthright submissions. I quote one of them:NHS services are provided to all on the basis of clinical need regardless of ability to pay, whereas local authority services are subject to charges. A particular problem of the caring regime is that many packages of care include elements from health and social services (for example, community nursing from health; home care 472 from social services). Sometimes the difference in the nature of the tasks performed is not clear to the user, and they resent paying for one and not the other. The situation is particularly acute in nursing homes, where a proportion of people are placed by the NHS, free of charge, but the bulk are either local authority placements or self-funders who may have to pay or contribute towards all costs, including nursing costs.Too right—people resent paying. However, that was not just any submission, but the considered opinion of the Department of Health.
When quizzed by the Committee, even the then Secretary of State for Health had to admit that he could not offer clear definitions of health and social care. It is anomalous for the same type of nursing care to be provided free by the NHS in NHS settings—or paid for by the NHS in nursing homes—but to be charged for in nursing homes. There could be two people sitting next to one another, one of whom could be paying for care while the other received it free.
The Coughlan case has already been mentioned. It brought into sharp relief the way in which the previous Conservative Government redefined the role of the NHS as a provider of acute care, by drawing its boundaries more tightly—dumping and decanting people into nursing and residential homes and shedding responsibility for their care. That is rationing by stealth, as the Royal College of Nursing quite rightly described it.
When asked to explain their continuing care criteria, several health authorities listed tasks that they excluded from NHS care—such as artificial feeding, pain control, care of the dying and catheter care. Seven in 10 older people admitted to nursing homes in England and Wales come from acute hospitals. As other hon. Members have pointed out, those people have chronic, complicated medical and social needs, and multiple problems. However, many of them arrive at nursing homes with inadequate documentation—sometimes with no medical information whatever. Through no fault of their own, those people have drawn the short straw of sickness and dependency.
The courts have made it clear that when nursing care is the principal need, the place in which it is provided is irrelevant—it should be paid for by the NHS. As the RCN revealed today, 90 per cent. of health authorities have illegal arrangements for assessing and meeting the continuing care needs of their patients. I realise that Ministers dispute those figures; perhaps the Minister will comment on the matter in his winding-up speech. Furthermore, I hope that he will commission his own review and publish it, so that the House can debate it.
In February, a national audit of nursing home placements for older people in England and Wales was published, although it did not receive much press attention. It is a technical but important document. It was commissioned by the clinical audit unit of the NHS. It found that one third of all people placed in nursing homes were inappropriately placed; that is about 63,000 people who are so dependent that their principal need is nursing care—63,000 people who should not be paying, who have been let down by the system and who are not receiving the care to which they are entitled.
Even the former Secretary of State had to acknowledge to members of the Health Committee thatnursing care is something that people have expected would be provided free by the National Health Service … so in the eyes of many people I guess to say that all nursing care should be provided free is not an extension of what most people see as the principles of the National Health Service.473 We have heard from the Secretary of State that the Government are promising to align social services eligibility criteria with the eligibility criteria for continuing care in the NHS. The findings of the RCN about how the NHS is shirking its responsibilities cause me great concern, and I am sure that many people outside the House will be worried that an alignment of the two will level down, not up, the standards of care that people may expect.
The RCN survey suggests that nine out of 10 health authorities are currently breaking the law. If that is the case, given that the Minister said, in a Health Select Committee meeting in July, that the Government were looking at issuing fresh guidance, I hope that today he can tell the House when that fresh guidance will be published. We need to know soon where the line is to be drawn, because practitioners do not know where to draw it, and it is a lottery whether one gets free nursing care; it depends on where one lives. That position cannot be acceptable; it should not be allowed to persist.
The Government are moving at a snail's pace on other matters, too. Care standards in residential and domiciliary care will remain unchanged during this Parliament, and nothing is proposed in respect of day care and day centres.
I hope that when the Government introduce legislation, we shall, as the hon. Member for Runnymede and Weybridge (Mr. Hammond) said, see the regulations for domiciliary care and for residential care alongside the Bill so that those matters may be debated together. However, it is worth bearing in mind the fact that, although the Centre for Policy on Ageing—which carried out for the Government 10 months of detailed work and consultation on residential care standards—presented its new standards to Ministers in January 1999, it was another eight months before the Department of Health published them for further consultation. As a result, a comprehensive set of standards for all regulated services is unlikely to be completed until 2002. As is clearly stated in the impact assessment attached to the document "Fit for the Future?", that is the year when the regulations will start to come into effect. I am sure that the Minister would have put his pen through that statement if it was not the case. I look forward to his telling us that that is wrong, and that the document will be reprinted.
Reports such as those in the Express earlier this year show why action is needed now. The Express found evidence that residents in one care home wereput to bed against their will and woken as early as 4.30 am to get ready for breakfast; not properly cleaned even though they regularly soiled themselves; left to sit for hours without activities and woken at two hour intervals during the night to be taken to the toilet because they are not given incontinence pads.The Express made it clear that there was no deliberate abuse at the care home that it investigated, but no one could describe what it found as anything but unacceptable and appalling.
As has been said, there are beacons of good practice. The star scheme that was described by the hon. Member for Blackpool, North and Fleetwood (Mrs. Humble) may be a very good way to proceed. Those places that follow good practice need to be recognised and acknowledged. However, there are still too many care homes where care has been reduced to little more than life support.
Why must elderly people wait for the Government to legislate for new commissions for care standards? Why not use the existing inspection and registration system, 474 patchy and inconsistent though it may be, to start to drive up standards? Why must we wait another two years to tackle some of the issues of control, quality and choice? I hope that the Government will stop the dither and delay in that respect.
Dither and delay characterise issues of charging policy, too. It is a further damning indictment of the Conservatives' record in that respect that they failed for 10 years or more to commission any serious work on the impact of local charging policies on the provision of social services. The Government therefore inherited a chaotic picture of charging methods, ambiguous Department of Health guidelines and confused local procedures.
The confusion remains. Local authorities set their own rules, driven by Government funding plans that assume that councils will recoup at least 9 per cent. of what they spend on social care. The variations are enormous. In a recent report, the Audit Commission found that Tower Hamlets recouped 1.1 per cent., whereas Slough recouped 1.5 per cent. Social care charges are a complete and utter lottery. They distort local priorities and fail to meet need. What will the Government do to get things moving? We have heard that there will be further consultation about how a level playing field is to be provided. When will that level playing field be a reality?
The tone and substance of the Secretary of State's speech had more in common with the note of dissent in the royal commission's report than with the majority recommendations, although the note of dissent was not written by two people who agreed with each another on everything. In fact, there was a note of dissent to the note of dissent.
In the kite flying of the past nine months, far too much attention has been paid to the views of the dissenters, and not enough to the majority recommendations. I believe that the dissenters lost the plot during the inquiry, because they were more concerned about cost than social justice and failed to grasp the paradigm shift inherent in the majority's proposals.
In reaching our view about the best way forward, we as Liberal Democrats have set three goals for a reformed system of long-term care. First, the system must promote independence and dignity. The central goal of policy on long-term care should be to ensure the greatest possible opportunity for people to lead the life that they want. Services should be directed to and by older people.
Secondly, the system should ensure intergenerational equity. The risk of long-term care should be spread across the whole population and over the lifetime of the population. That is the most efficient way economically to address both the risk and the cost of insuring against it. Thirdly, the system should be based on co-payment. We believe that it is a shared responsibility between us as individuals and collectively, as a society and a community, to pay the costs of old age.
The royal commission provides a way forward, but all the kites that have been flown in the past nine months and all the negative press briefing have obscured what the majority on the commission proposed.
§ Mr. Letwin
The hon. Gentleman used the words "intergenerational equity", but I am unsure what he meant. Did he mean that people now living should pay collectively for those who now need long-term care; 475 or that a person, during the course of his or her lifetime, should pay, effectively, for their own long-term care and that of their generation?
§ Mr. Burstow
In their evidence to the Health Select Committee, the Government said that many people felt that there was a clear contract between the state and themselves—that they were paying towards not only their own care but future care. I believe that we need a system that reflects the fact that we, as a community, are a wealthy nation, that we can afford to pay for long-term care, and that one generation should be able and willing to afford the costs of care for their elders. That is really what this is about.
All the kite flying that I was talking about obscures some key aspects of what the majority on the commission proposed—first, that a clear distinction should be drawn between living costs, housing costs and personal care; and secondly, that a national care commission should be set up to set standards and oversee the system. We have heard that the Government will consider all those questions, and we welcome the fact that the Minister has clarified that, but hon. Members and people outside the House still do not know what the Government's stance will be in six or seven months, when they publish their White Paper.
We therefore want to know whether the Government will seriously consider, and give high priority to, the commission's proposals on personal care, including nursing care free at the point of delivery after a rigorous assessment of needs. Do the Government understand that such a change would honour the Prime Minister's commitment before the general election to free people from the crippling financial burdens and the prospect of selling their home to pay for care? It would give everyone a stake in how care is provided.
Above all, such a move would mark a step change in the way that care was provided. It would end at a stroke perverse cost incentives and create a level playing field between home-based and residential care. For example, it would remove the need to decide whether a bath was being provided to meet social needs, in which case it would be means-tested, or medical needs, in which case it would be free. By drawing a clear distinction between personal care and daily living costs, the royal commission offers clarity where confusion has reigned.
The second, and equally important, recommendation supported by all members of the royal commission is the establishment of the care commission.
§ Mr. Hutton
The hon. Gentleman started his speech by stating that he could not say whether he agreed with the royal commission's main recommendation on personal care, but—I am sure he will correct me if I am wrong— he has just accepted, on behalf of the Liberal Democrats, the main recommendation about personal care being free. Can he confirm that?
§ Mr. Burstow
I have been saying that there are very powerful arguments in the majority's report, and I have outlined them this afternoon because not enough has been done to outline them until now; and apparently the Government have not been listening to them, but have been listening far too much to the dissenters.
476 The debate is about what the Government are doing, not about what the Conservative party or the Liberal Democrats are doing. It is about what the Government, who are charged with this responsibility, are doing, not least because they set up a royal commission to do a job for them and have since spent nine months wondering what to do with its findings.
The second of the Government's main proposals is undoubtedly a welcome piece of news from the Secretary of State. There can be no question but that we need a body to provide a strategic overview of the care system. We shall obviously consider in detail the Secretary of State's proposals when the Bill comes before the House. However, I wonder why we must wait for two more years before the new body comes into being. Why cannot we take a leaf out of another Secretary of State's book and establish a shadow body to start pulling together the necessary elements of the new agency so that it can start to do some of its work in advance? It is possible for a shadow body to be established, and I wonder why the Minister has not considered that possibility.
§ Mr. Hutton
We have. We have already announced that we shall be doing that. That is what we have in mind.
§ Mr. Burstow
I am pleased that the Minister has been able to make that announcement. I do not think that the Secretary of State said that a shadow body would be established. The right hon. Gentleman talked about 2002, but we have now had an additional announcement, which is very much welcomed.
I believe that the royal commission offers a rational and humane basis for reforming our care system, but how is the care to be afforded? We know that the costs of the royal commission's proposals come out at about £1.1 billion. All too often we hear the figures of £6 billion to £7 billion, which might be the costs in 2050. I cannot think of any other policy that any Government have produced that has had costings through to 2050. The comprehensive spending review, for example, had a three-year forward view.
If we average out the good and bad years over the past 100 years, our gross domestic product has grown by 2.25 per cent, a year, and over that period there has been an explosion in the number of people living longer. However, we have been able to afford the increased costs. Perhaps these facts have been overlooked.
It is said that the royal commission's proposals will benefit only the well off. I believe that those who produced the minority report have that wrong. If the argument is valid, surely it applies to the winter allowance and free television licences for the over-75s. Both those welcome new universal entitlements are going to rich and poor alike, and they add up to £1.1 billion per annum in public expenditure.
Why is personal care any different? The fact that personal care costs fall heavily and unexpectedly on a few makes the case for ending charges even stronger. That is why I asked the Secretary of State—I did not get a satisfactory answer—why the wealth of a dementia sufferer should determine the care that he or she receives.
The Government set up the royal commission to recommend reform of the long-term care system, and it has reported. However, the report is not a manifesto pledge redeemed on its own. The Prime Minister told us 477 at the beginning of 1999 that this was the year of delivery. Nine months of dither and delay have fuelled uncertainty about future arrangements for long-term care. Can we have some straight answers? Will the Government rule out free personal care? We have heard that they are not ruling it in, but nor are they ruling it out.
If the royal commission's personal care proposals have no place in the Government's plans, they should make that clear and not wait for a White Paper in six or seven months' time. Are the Government saying that the nation cannot afford to vote an extra one fifth of 1 per cent. of GDP—0.2 per cent.—to the care of senior citizens? The next comprehensive review must deliver a durable and compassionate policy that puts an end to uncertainty about long-term care costs.
We had a royal commission at the beginning of the Parliament, and we have learned today that we shall have a White Paper at the end of it. I fear that many people outside the House will take the view that what we have heard today is little more than a whitewash.
§ Mr. Phil Hope (Corby)
I welcome the debate. I particularly welcome the announcements made by my right hon. Friend the Secretary of State on national care standards; the finance of long-term care; consultation papers on the detail, which we look forward to; access to social services; and minimum standards.
The royal commission has produced a far-reaching report. It is interesting that it is entitled "With Respect to Old Age". Perhaps it should have been subtitled "In Condemnation of the Tory Government". The report includes some damning indictments. It describes the system of care that we inherited when we took power. It refers to it being designed around a series of different bureaucracies rather than around the needs of individual older people. It prevented the national health service and local authorities developing joint working and created a strong lack of trust in the system. The commission says that the result was a sense of betrayal, a lack of trust and a genuine sense of helplessness. That is what we inherited from the Conservative Government. It is so important that we have a response from a Labour Government, who will tackle the inequities and unfairnesses and allow older people to have trust in a system that meets their needs.
§ Miss Kirkbride
Is the hon. Gentleman proud of those on the Government Front Bench and of the Government, who clearly will not introduce legislation on these matters within this Parliament? Only a White Paper is on offer next summer, not legislation and not real proposals.
§ Mr. Hope
According to my maths, the Conservatives were in power for 18 years, during which time they could have brought forward proposals to deal with the needs of older people. We inherited a situation where 1 million pensioners were living below the poverty level. We have tackled that directly through a basic income guarantee for pensioners and free television licences for over-75s. We need take no lessons on support for pensioners and other people from the Conservative party.
I shall draw attention to experiences in Northamptonshire and to the work that the county council has been doing in its best value review—one of the most comprehensive and detailed analyses of social care ever 478 undertaken in the county—of residential care for older people. The provision of social care services to older people represents possibly the largest area of activity for social service departments, in terms both of spend and of the number of people receiving those services. The spend in Northamptonshire is about £45 million, and 7,000 people are affected.
The review highlighted the key issue that services for older people cannot be considered in isolation. For example, the provision of residential care is directly affected by home care services, care management and assessment services by other organisations such as health authorities and health trusts, and housing departments. There is a complex interrelationship between different services. If change is introduced in one area, we must consider the impact of that on others.
A critical feature of the review was that the county council widely consulted and involved users, carers and staff at all the homes in the area to ensure that they understood the problems and the issues that the council was trying to tackle and had some ownership of the outcome of the review.
I hope that my hon. Friend the Minister will take note of what I am about to present as Northamptonshire's solutions. A consensus has been built up in the county about the right way forward—a way that builds on best practice. I hope that the work that has been done will provide a model that will inform the response and the White Paper when it is published.
Emphasis was placed on offering choice in meeting the needs of older people, on supporting people in their own homes when that is their wish, supporting carers, ensuring high quality in all service provision, joint working between the different agencies that affect the lives of older people and a whole-systems approach. That is designed to ensure that everything is taken into account, including the policies of the health authority and the Department of Health, as well as of the local authority and the social services department. Unless we take the picture as a whole, we create perverse incentives, bed blocking and the practice of passing on elderly people like parcels around the system, without the resources to meet their needs. Unless we adopt a systemic approach, we shall not achieve the outcomes that older people deserve.
All the available evidence from service mapping, activity data and expenditure patterns reveals in Northamptonshire an over-reliance on residential care, with the result that funding is being diverted to relatively high-cost residential care. Fewer resources are available to invest in a broader range of preventive and other services that would help people to be supported at home. That over-reliance on residential care appears to be associated with relatively high rates of admission to hospital of older people, especially those aged 75-plus.
What can we do about that? What is being proposed in Northamptonshire? The research that was carried out in association with the review showed that any decision to enter into residential care does not have to be inevitable. It showed also that early action can be taken to provide support in the community, and that that can alleviate a perceived risk and a major factor. People are predisposed to think that they have to go into care because they cannot be cared for at home. However, if there is a full assessment of need and a consideration of rehabilitation and the wider range of services that can provide support in 479 the community, many service users, who would otherwise enter residential care, can be cared for in their own homes. That is an important philosophy for the individuals involved and it has huge implications for the development of services in the community.
The widespread consultation that I mentioned clearly highlighted a strong preference for people to remain at home wherever possible, and the provision of a broad range of community-based services was also seen as particularly important. The need for residential care will remain—there is no question about that—but there should be a strong emphasis on high standards of provision and of care, with more people being cared for in their own homes.
Northamptonshire began to develop specialist services in several key areas. We discovered that rehabilitation can provide the time and the opportunity for service users to regain lost skills and abilities, for example, after a period of hospitalisation or an accident at home. Experience elsewhere suggests that, with the appropriate services, people can be helped to return home with support rather than being warehoused inappropriately in residential care that does not meet their individual needs.
Another area of specialism is respite care. It can provide essential support to carers and it is most effectively provided in familiar high-quality surroundings. Flexible respite care can benefit both service users and carers.
Services for older people with mental health needs must be arranged in a way that is appropriate to the particular needs of that user group. Familiarity and continuity will be important features in that specialist service to offer a continuum of care that offers day, respite and long-term residential provision.
Another area that we considered was access to services and fairness. There is evidence that the take-up of services by members of black and minority ethnic communities is low, although, if special services are provided, the take-up is significantly higher. Therefore, all services—whether in the local authority, the independent or the health sectors—need to ensure that they provide equality of access at all times. An emphasis must be placed on that. As well as recognising the merits of that approach, we need to recognise the merits of supporting initiatives that provide specific services to meet specialist needs. The Government could take many new initiatives to promote equality of access for the black and minority ethnic communities in Northamptonshire and the rest of the country.
Supported housing is another critical way of promoting independence. The importance of developing a range of housing options for older people was widely identified during the consultation process, as a critical element of any strategy to maintain more people in the community. Full consideration of housing needs, through joint assessment arrangements, must be an integral part of any care management activity. The potential of aid, adaptations, new technologies and imaginative approaches to the flexible delivery of care in people's homes must be exploited to the full. I am sure that the Government can do a lot more to promote such innovative approaches. Similarly, a greater availability of very sheltered housing 480 provision, which offers intensive care and support, can be part of the strategy to promote the independence of older people.
The conclusions as to the way forward were interesting. The best value option that is provided in Northamptonshire has three or four main elements. The first involves the transfer of 15 to 17 of the county council's residential care homes to the independent sector. In Northamptonshire, what works is what counts. Seeking to find the right blend of provision includes that transfer. The county council is also developing the specialist services that I mentioned and works with district councils to promote a programme of reprovision in the form of very sheltered housing.
That package enables the commissioning of such specialist services and of very sheltered housing through the release of capital that was locked up in existing long-term care provision. That service model may also be able to attract private finance into the sector in Northamptonshire to support older people. Better value for money is therefore being achieved in the long-term care places purchased by the council, and that releases money for community-based alternatives. Early action to prevent admission to hospital and residential care will limit the growth in the number of people supported in long-term care in the future. The strategy is to keep more people in their own homes and to provide specialist services, very sheltered housing and private sector residential care of a high quality. That strategy will provide a continuum of care for older people in Northamptonshire.
Of course, some issues—especially that of raising standards—need to be addressed. I much welcome the review of standards in residential and nursing homes that is being undertaken. We have seen the draft standards and there are resource implications. If those standards are to be met, we must provide the means to do the job. My hon. Friend the Member for Blackpool, North and Fleetwood (Mrs. Humble) referred to home care, and we need to increase standards there.
If I heard him correctly, the hon. Member for Runnymede and Weybridge (Mr. Hammond) seemed to say that we did not need regulations for the care of people in their own homes or in council or independent residential nursing homes. I cannot believe that anyone could possibly leave older people vulnerable to the problems that were mentioned earlier without a regulatory regime being in place. That is the legacy of the 18 years of the previous Government that we inherited. We want no more of it; we need a real change. We need proper standards and must take a systemic look at the whole way that older people are handled by all the different providers in the system in any locality to ensure that people are not shunted about.
The Government's announcements are welcome. We all look forward to the White Paper that will be published in response to the royal commission on long-term care. Choice, fairness and quality are critical and we must have action to achieve them. I hope that the experiences and the proposals being introduced in Northamptonshire will provide a model of good practice for the Government.
§ Sir John Stanley (Tonbridge and Malling)
I wish to focus my remarks on one group of people and on one provision in one piece of legislation. The people on whom 481 I want to focus are those who are called the "preferred rights group". They were in residential homes on 1 April 1993 and therefore, by definition, they include some of the frailest and most elderly in our community. The legislation on which I wish to focus is section 43 of the National Health Service and Community Care Act 1990, which inserted a key new section, section 26A, into the National Assistance Act 1948.
The key consequences of what the then Conservative Government did to that group of people were to give with one hand and to take away—and to take away a great deal—with the other. They conferred an entitlement to a higher rate of income support on that group of frail, elderly people and they preserved their rights to that higher rate. However, in section 43 of the 1990 Act, the then Government imposed a statutory block on any form of financial assistance, through local authority social service departments, for that group. That block was total and inflexible and it was not capable of being tailored to any individual's circumstances. It left no discretion whatever in the hands of local authority social services departments and it took no account of the consequences for individuals of those legislative provisions in particular cases.
The course of events in a significant number of individual cases has been as follows: inescapably, as elderly people get older, they become more frail and incapacitated and require more care, and the cost of providing that care inevitably escalates. The residential home is therefore obliged to increase its fees to cover the cost of increased care. As fees go up, they often rise beyond the level of the higher rate of income support. In those circumstances, if the individual resident has no means left of providing additional funding and has either no relatives or none willing or able to provide the increased funding, one appalling option is left—eviction.
The royal commission on long-term care recognised that this was a very serious position. In paragraph 4.30 of its report the royal commission said that it was aware that "preserved rights" rates of income supportare becoming increasingly inadequate. Many of the people concerned are in increasingly difficult circumstances. As they survive longer, it seems increasingly difficult to justify treating this group of people differently from those who entered the care system on or after 1 April 1993, for whom local authorities meet fees in full, subject to a contribution based on means. Equity demands that they should be treated in the same way. We recommend that the Government should consider whether 'preserved rights' cases should be brought within the post-April 1993 system or whether some other solution can be found to address the shortfall in funding experienced by this group.
Of course I very much welcome the royal commission's recommendation, but its implementation is time critical. I share the disappointment expressed by hon. Members who have already spoken about what the Secretary of State said about his time scale for responding to the royal commission's report and introducing the legislation necessary to give effect to that response. As hon. Members have pointed out, we are promised a White Paper this summer, and, on that basis, we cannot even be sure that legislation will be forthcoming before this Parliament ends.
I can only try to bring home to the House just how time critical it is to deal with the outrageous situation that will exist as long as section 43 remains on the statute book unamended. I shall tell the House of the latest constituency case with which I have been dealing. 482 My constituent is 96 years old. She is a widow. She has multiple infirmities, but she is sound of mind and therefore fully aware of what is going on around her. She has been living in a nursing home in my constituency since 1989—for the past 10 years—and her room there has become her home and her security. She is, by definition, one of the preserved rights cases on whom there is, under section 43, a total block on any financial support from local authority social services departments.
In August, my constituent's daughter and son-in-law came to see me with what for me has become an all too tragically familiar request. They found that the nursing home, faced with increased care costs for my constituent, was no longer able to cover those costs even with the higher rate of income support, and had said that there was no alternative but to have her forcibly removed from the home that she had been occupying for the past 10 years.
I brought the case to the attention of the Secretary of State, who said that there was nothing that he could do. I brought the case to the attention of the Kent director of social services, who took fresh legal advice and confirmed that the position was exactly as I have described it to the House: section 43 is totally inflexible and there are no circumstances in which it is legally possible for local authority social services departments to provide top-up funding, even when the individual concerned is facing eviction. He went on to say that he and all his care team considered that my constituent should remain in her home.
I am sorry to have to tell the House that my constituent's eviction took place yesterday, Wednesday 1 December. She was moved, forcibly, to a cheaper home where she no longer even has a room of her own. Earlier this morning, I rang my constituent's daughter. I wish that the whole House could have heard the conversation, because she could have conveyed the trauma of the situation and its impact on her mother far more eloquently that I possibly could. However, I took down what she said to me as best I could, and these are her words. She said:The move has been terribly, terribly distressing for my mother. When it was time for me to go, my mother took my arm and said, 'Please don't leave me. Please don't leave me. I want to go home.' To which I could only reply, 'Mother, this is now your home.' It was heartbreaking. I wish you people in Parliament could have been there.
It is a monumental disgrace that there is legislation on the statute book that results in infirm, elderly people who have made their lifetime's contribution to this society, have paid their taxes and national insurance contributions throughout their lives—and, in this generation, helped to see this country through a world war—being offered by the state at the end of their lives only the option of eviction from their home. I am deeply ashamed that such legislation has been passed and has so far remained unamended.
I hope that my sense of shame will be shared in all parts of the House. I am sure that no right hon. or hon. Member would want their constituents to face such treatment. I hope also that Ministers will take account of the fact that, while section 43 remained unamended in the four years between it coming into operation on 1 April 1993 and the general election in 1997, it remains unamended today. I hope that that is a matter of the utmost concern to the Secretary of State.
I shall end by making a proposal. I put the proposal forward not as a rhetorical gesture, but with the utmost seriousness and sincerity, believing that it can produce an immediate solution to the problem.
483 We require an amendment to section 43 that would enable local authority social services departments to provide the necessary top-up funding to prevent an eviction taking place. I suggest to the Secretary of State that the situation calls for emergency legislative treatment, and I propose a short, simple legislative provision. I do not believe that any hon. Member in any part of the House can consider it acceptable that, at the end of this century, frail 96-year-old people are forcibly evicted from their home because the legislation provides no other option.
I have examined the legislation. It could conceivably be amended by secondary legislation but, assuming that that is not possible, the primary legislation required would not be more than two or three clauses. The House is perfectly able to deal quickly with emergency legislation. I am in no doubt that the legislation would receive all-party support. I have no doubt that such a two or three-clause Bill could go through the House in all its stages in a day, and through the other place also in a day. If the political will existed, that amending legislation could be on the statute book by Christmas.
That is the proposal that I put to the Secretary of State. It does not necessarily have to be the permanent solution. He may want to deal with the problem in a different way in his White Paper, but I implore the Government to recognise the seriousness and the unacceptability of the present situation, and to do something about it as a matter of urgency. While section 43 remains unamended, it is a shameful piece of legislation to be current in Britain at the end of the 20th century, and this House ultimately has the responsibility for amending it.
§ Ms Rachel Squire (Dunfermline, West)
I, and I am sure other right hon. and hon. Members, share the deep sense of shame and disgrace so powerfully expressed by the right hon. Member for Tonbridge and Mailing (Sir J. Stanley). We must ask ourselves how our society has reached a point when elderly residents of homes that they have occupied for many years do not seem even to be covered by the United Nations convention on human rights.
Whatever system of funding long-term care is eventually decided on, I hope that we ensure that nothing similar can happen again. In the light of what the right hon. Gentleman told the House, I urge my hon. Friend the Minister to give serious consideration to the urgency of amending the legislation.
On the wider issue, I pay tribute to the royal commission for tackling so ably and effectively the subject of long-term care, and for producing an excellent report. I also pay tribute to the Government for establishing the royal commission so early in their term of office, and for showing a genuine commitment to tackling one of the most complex, sensitive and difficult areas of welfare reform.
I admit that, like many other hon. Members, I had hoped that it would be possible to have a full Government response to the report by now. However, I would much rather the Government took their time and made a full and comprehensive response than rushed to make an inadequate and problematic one. A properly considered resolution, as my right hon. Friend the Secretary of State 484 said earlier when he outlined his timetable, is certainly in order, especially as we inherited a total mess from the previous Government of 18 years, who seem to have combined the closure of free NHS provision, such as Milesmark hospital in my constituency, with a massive increase in independent sector residential and nursing home care, much of it means-tested.
The previous Government also failed to deliver on community care. In its report to the royal commission, Alzheimer Scotland—Action on Dementia stated:Figures show that community care has meant a redistribution of places between types of provision within the institutional sector, not an increased provision of the human resources necessary for successful domiciliary long term care.
Part of my anger with the present system is due to the fact that, too often, it does not allow a real choice between long-term care in one's own home and residential or nursing home care. Although I accept that that is not always a realistic option, all too frequently families and individuals have been pressured into accepting some form of institutionalised care.
All of us hope to end our days in our own home, and we as right hon. and hon. Members have a responsibility to do our utmost to make that possible for as many of our constituents as we can. However, our present funding system for long-term care, which combines a false division between health and social care with a lack of an integrated and diverse range of domiciliary services in many parts of the country, pushes people into institutional care. I make no criticism of much residential and nursing home care provision. I have such homes in my constituency which provide a high level of care and a decent life style, but they should not be the only option.
I welcome the Government's actions so far and their efforts to break the mould of institutional care and to promote the possibility of independence in one's own home—for example, the Government's special grant to local authorities of £293 million this year to support independent living at home for older people, and the improvement of services to carers through the allocation of £140 million over three years to fund respite care.
I welcome the announcement today of the publication of the long-term care charter setting out a national framework for improving housing, health and social services to promote independence. Those measures, combined with other Government action, such as the £100 winter fuel allowance, free television licences for over-75-year-olds, and the reduction to a 10p rate of income tax on savings from last April, all make it possible for more people to remain in their homes.
Those steps are all welcome, but we must tackle the crucial issue of who pays and for what when long-term care is needed. I urge the Government to consider carefully the recommendations of the royal commission on the funding of long-term care. That is seen by many of our constituents as one of the most important political decisions that the Government will make.
We have a moral responsibility to provide decency and dignity for the elderly, who are the majority, although not all, of those requiring long-term care. That is especially the case for the present elderly population who endured so much during the first half of the century to give our generation and subsequent generations greater opportunities and a better life style than they have had.
Today's pensioners believe that they deserve state-funded long-term care. They believe that they have paid for it through their taxes and national insurance 485 contributions. The majority believed that they had a responsibility to work hard, to pay tax and national insurance and to support their families, but they did so believing that, on their death, any savings that they had accumulated or assets that they had acquired could be passed on to their children and grandchildren. They believed that if they ever became ill and in need of full-time care, it would be provided without additional charge.
We are dealing here with a generation who accepted responsibility for their lives and those of their families. Even today, around 1 million do not claim benefits because they see them as charity. However, today's pensioners, certainly in my constituency, feel betrayed— a word that many have used to me, not just the political activists or members of the lobby groups with whom we all come into contact.
It is all very well for us to say that a two-tier system of free NHS care and means-tested social care has existed since Beveridge's reforms. That is true, but the majority of today's pensioners see it differently. Their view is that during their working lives they paid for long-term care in the event of their ever needing it. Until the previous Government, most long-term care was provided free in NHS long-stay beds, but during the past 20 years, thousands of those beds have been eliminated and replaced by means-tested care.
Particularly galling to pensioners who have worked and saved all their lives is that they now have to pay, whereas those with no assets or savings do not. If one of the Government's aims is to encourage people to save more and to make arrangements for an income in their retirement, we must consider carefully whether our eventual decision on long-term care will achieve that.
I urge the Government to recognise and deal with the crucial injustice highlighted by the royal commission that someone diagnosed with cancer receives care free of charge, while someone diagnosed with Alzheimer's disease is required to pay. Any action on long-term care funding must tackle that.
I appreciate that the cost implications are substantial, but for a number of reasons I urge the Government to be cautious in believing that they can offset the costs of long-term care to the state by going down the road of private insurance. First, the private insurance sector is not particularly interested in long-term care in general. It made that clear in its evidence to the royal commission. In the United States of America, that most privatised of care markets, only 5 per cent. of the population is insured against long-term care.
Secondly, I know from my own experience that private insurance companies are basically reluctant to provide any kind of cover to anyone with a blemished health record. Because I had a serious illness a few years ago, I, a Member of Parliament, have been refused insurance by private companies as large as Scottish Widows. It has now been five years since I had major surgery and radiotherapy, which is considered to be a bit of a guarantee that one will be around a bit longer yet, but if I sought long-term care insurance I would be required to pay a thumping price for it, which I would find difficult even on a Member of Parliament's salary, let alone the average family income. As a result, I believe that the private sector would cherry-pick and the state would end up carrying the majority of such costs. We need to take that into account.
486 We are finding it difficult to encourage people to save more and to put more into a second pension, so we must recognise the difficulty of persuading people to put money aside for an event which they hope will never happen— the need to leave their homes to go into some form of long-term care.
I welcome yesterday's announcement by my right hon. Friend the Chancellor of the Exchequer in his St. Andrew's day speech on a joint action between the Scottish Parliament, the Welsh Assembly and the UK Parliament to tackle pensioner poverty. However, supporter as I am of devolution, any decision on the funding of long-term care must be UK-wide. It would not be right for pensioners in Dunfermline, Dorking and Denbigh to have different rules and regulations on the funding of long-term care.
§ Mr. Letwin
I have been reflecting on the hon. Lady's latest series of remarks and I am unclear whether she supports the position that I think we clarified was that of the Liberal Democrat's spokesman, that the state, and hence the present generation of taxpayers, should meet the full cost of long-term care for those in long-term care today regardless of their income or capital. Is that what she is saying?
§ Ms Squire
I am urging the Government to give serious consideration to the royal commission's recommendations on personal care and on that being free of charge. Today's pensioners deserve top priority in whatever money is available. I need to hear more of the arguments about whether that should apply to those of us who have a few years yet to retirement age. But we have a particular responsibility to today's pensioners because of what they went through and the expectations that they built up during their working lives.
I welcome Ministers' comments about the importance of recognising the contribution of carers to our society. Voluntary carers provide the largest amount of long-term care, free of cost or at low charge, estimated to be worth up to £40 billion a year. I hope that Government announcements next summer will recognise the role that carers play and ensure a system of full support for them.
I welcome today's debate, but I urge that we recognise in our decisions and in our future debates our moral obligation to today's pensioners that long-term care funding should be universal. We must tackle the false division that exists between health and social care and, all too often nowadays, between nursing and residential care. We must meet the needs of carers as well as users, and ensure decency, dignity and independence. The awful circumstances of the 96-year-old that the right hon. Member for Tonbridge and Malling described must never occur again.
§ 4 pm
§ Mrs. Marion Roe (Broxbourne)
I welcome the opportunity to contribute to a debate on the important subject of long-term care, and to consider the recommendations in the royal commission's report and the points made in the note of dissent. However, I must point out, as other hon. Members have done, that people inside and outside Parliament have expressed grave disappointment because the Government have not made decisions on all the report's recommendations, although 487 they were published in March—nine months ago. The Government have still not declared their position on future policy.
The royal commission's report is not the first report on long-term care to be presented to the House of Commons. When I was chairman of the Select Committee on Health, it held two inquiries into long-term care. One related to national health service responsibilities for meeting continuing health care need, and was published in November 1995. The other covered the future provision and funding of long-term care, and was published in July 1996. Both reports were unanimous and provided the initial investigation into and detailed analysis of a highly complex and controversial issue. Therefore, I speak as somebody who has taken an interest in the subject for a long time.
What is the question to which answers are required now? Population forecasts up to the middle of the next century are relatively reliable. Unfortunately, future demand for long-term care is dependent not only on the size of the elderly population but, crucially, on much more unpredictable factors such as the number of people who live alone and the health status of the elderly. Of course, the latter depends on developments that cannot be foreseen, such as the extent of medical progress and the degree to which healthier life styles are adopted. Therefore, all attempts to calculate future demand towards the end of the lifetimes of those who are not young will contain an element of crystal ball gazing; I think that statisticians call it "an expanding funnel of doubt".
I endorse the royal commission's view that there are no immediate demographic time bombs for long-term care; the demographic and dependency ratio trends suggest that no major problems loom in the short to medium term— that is, up to around 2020. After that, the trends will present more of a challenge and we should consider their implications now.
It is right that any changes to present models of care and methods of financing long-term care should conform to seven key principles. First, any changes should maximise the individual's independence, self-respect and choice. At the heart of any system should be encouragement of independence and autonomy for the individual, and provision of reasonable opportunity for people to choose the type and setting of the long-term care that they require. It is also important that the system is sensitive to the particular needs of ethnic and religious minorities.
Secondly, any changes should be understandable and perceived as equitable. There is a widely held perception that the current arrangements for funding long-term care lack fairness.
Thirdly, any changes should improve the way in which long-term care is planned, organised and purchased by multidisciplinary, knowledge-based agencies. The community care reforms are based on the aspiration for services to be purchased and provided to suit the needs of the individual rather than the interests of service providers. Therefore, good information is required on the needs of individuals and local populations, and on the effectiveness of the varying forms of long-term care services, including, for example, preventive and rehabilitative services.
488 Fourthly, any changes should provide better support and encouragement to informal carers, in terms of practical help—for example, training and respite care—or financial help. Informal care is, and will remain for the foreseeable future, the bedrock of long-term care provision. Given the potential for changing demographic and other social trends to reduce the supply of informal carers, there is a strong argument for ensuring that priority is given to changes that will improve the ability and willingness of informal carers to provide care.
Fifthly, any changes should include mechanisms to ensure that an efficient and high-quality service is provided in all care settings. Long-term care services are often provided to clients, who, by the nature of their conditions, are vulnerable. Therefore, it is clearly important that mechanisms are in place to ensure high-quality services in all care settings.
Sixthly, changes should be affordable. Public support for changes is likely to be forthcoming only if they are seen to be affordable by individuals as well as the state. Any movement towards a system of long-term care that is "funded" as opposed to "pay-as-you-go" should recognise that one generation would be expected to contribute twice—for its own future care and for the care needs of today's elderly people. I believe that any such change would need to be phased in over a long period in order to be affordable and acceptable to the transitional generation.
Seventhly, any new programme of public expenditure on long-term care should, in the case of services provided or funded by the national health service, be—as it is now—available equally to all citizens according to their assessed need for care and, in the case of means-tested social care services, be designed to meet necessary care need for citizens who have insufficient income or capital to pay for such care from their own resources. We all listened carefully to the remarks of my right hon. Friend the Member for Tonbridge and Malling (Sir J. Stanley) about his constituent, with whom we have great sympathy.
What are the options for funding long-term care? It is apparent that long-term care is an expensive service for the taxpayer and for any individual who contributes towards the cost of his or her care. As I said earlier, there is a perceived unfairness in the current system for financing long-term care by means testing state-supported residents in residential or nursing homes. That approach penalises people who have saved during their working life, while rewarding with free care those who have been unable, or unwilling, to save. It is grossly unfair to the thrifty, because it represents a disincentive to save and a challenge to those able to divest themselves of capital. If we are to build a more secure society, we should encourage people to help themselves and to be independent, if possible, through saving carefully for their old age. Thrift should be encouraged and assisted, not undermined.
Surely it must be right to find a way for the state to work with those who are prudent and not against them. For example, partnership schemes give additional protection of assets against a means test when it is applied. We must not forget that society as a whole has become wealthier and the substantial increase in the number of elderly people who own their own homes means that many people have assets significantly above those specified in the means-tested threshold. If that is 489 coupled with the fact that people are, on average, living longer, the disquiet on that issue can be understood. I therefore fully support the Conservative party's policy whereby, if individuals make provision for themselves, the Government will protect more of their assets should that provision run out and they need to use state-funded care.
It is important that as many options for future funding of long-term care as possible should be considered and assessed. The partnership schemes are only part of an overall package that may include other mechanisms such as immediate need annuities, long-term care insurance, equity release schemes, geared pensions and tax relief as well as schemes founded on general taxation or social insurance such as those in Germany. As we know, state expenditure on long-term care in the United Kingdom is currently funded on a pay-as-you-go basis, which would mean—bearing in mind the changing demographic profile and, in particular, the changes in the dependency ratios— that such schemes could ultimately become too expensive for the country as a whole to afford. I wait, with great interest, to learn exactly where the Government are going on that crucial question of financing.
I shall now discuss the caring services that should be provided. There is no doubt that examples of good practice in the provision of long-term care should be publicised more widely and that there is a need to expand the scope and quality of domiciliary, rehabilitative and respite care. In my view, that would benefit the individuals concerned and be likely to be more cost-effective for the funding authorities. Greater attention should also be paid to the need to improve housing facilities for the elderly and the disabled and to achieving more effective liaison between housing, social services and health authorities.
Housing improvements can offer a happy conjunction of cost-effectiveness for the providing authorities and improved quality of life for those who inhabit the housing. It is important that housing services fully exploit their potential for contributing to the Government's community care objectives, particularly with regard to the development of very sheltered housing schemes and ensuring that ordinary sheltered housing schemes are attractive to current and future generations of users. For example, account should be taken of the wider development of collaborative schemes such as those in respect of community care alarms.
We are all aware of the anomaly whereby it is possible to receive free nursing care in some situations but not others. Nursing care is free in hospital and at home, but citizens pay for it if they have to go into a nursing home. That creates all sorts of barriers to achieving seamless care. However, the cost implications of any changes to that situation must be taken into account for any comprehensive provision of nursing care. A number of colleagues have commented on those implications, and again I await with interest the Government's decision on an important issue.
I should also like to raise the question of under-resourcing by social services departments for independent sector placements and the resulting pressure that that is putting on the sector. My hon. Friend the Member for Runnymede and Weybridge (Mr. Hammond) has already commented on that issue. There is no doubt that many people who have been assessed as needing residential care are being forced to wait on a waiting list while some local 490 authorities persist in wasting money on direct provision of care that is often more than 60 per cent. more expensive to provide than comparable or even better care provided by the independent sector. Surely that cannot be an acceptable way to proceed and I should like the Minister to tell the House what action he is taking to stop that practice.
As chairman of the all-party hospice group, I should like to make a plea on behalf of the hospice movement and its involvement in long-term care. The Department of Health, in circular EL(96)85, stated that the palliative care approach should be integrated into the routine clinical practice of all health care professionals in the NHS. The hospice movement believes that that principle and policy objective should be extended to all long-term care in the private and voluntary sectors.
The Government's proposals for regulating private and voluntary health care present an opportunity to introduce new national standards for nursing homes and one of those standards could be that the staff in nursing and residential homes are trained in palliative care. The voluntary hospices and NHS specialist palliative care units are well placed to lead the development of education and training for nursing and residential home staff in the palliative care approach, provided that they are resourced to do so. Some nursing homes already seek out and pay for such training, but all need to be encouraged to do so through the introduction of training and staff development standards. The professional carers of those in long-term care need to be able to access the specialist advice and support of the community-based hospice and specialist palliative care services. They need to know in what circumstances to seek specialist advice. Education, and perhaps the development of locally-agreed procedures for assessing such advice, would assist in that.
Finally, whatever the outcome of the Government's deliberations, may I draw the Minister's attention to, first, the importance of public awareness of the issues and choices involved? After all, the decisions will affect every one of us. Secondly, I remind him of the current Health Committee observations on the issue:There is a consensus that the status-quo is unacceptable. Failure by the Government to act urgently would be a serious dereliction of duty".
§ Ms Debra Shipley (Stourbridge)
Like other Members, I welcome the debate as an opportunity to discuss important issues concerning the care of our elderly citizens. How we care for them must surely be a clear marker as to what kind of society we are and what values we hold dear, and there are many examples of excellent care, both in residential homes and families.
Families often struggle with difficult conditions and circumstances and have access to far too few resources and support systems. Carers of dependent relatives are nothing short of heroes and heroines who work hard and make great personal sacrifices to give their loved ones all the attention that they need and deserve. We all owe those individuals a great debt: not only do they help us to believe that we live in a caring society, but they save us all a great deal of money by endeavouring to care for elderly relatives and partners at home.
It is, therefore, only right and proper that the Government are improving services to carers by allocating £140 million to help to fund respite care. I welcome 491 that measure, which is a good step in the right direction. Of course it is not enough; we want more. I also pay tribute to those who devote effort, enthusiasm and commitment to making some residential homes beacons of excellence. They are the shining light in what I believe to be a murky world of neglect and, on occasion, abuse.
I had the great honour, as a Back Bencher, of being the Member in charge of what has become the Protection of Children Act 1999. The Act contains mechanisms to help protect children from abusers. During the Bill's passage, I was approached by numerous colleagues who wanted the protection offered to children by my Bill to be extended to elderly people. I also received numerous pleas from people all over the country who begged me to help elderly relatives or friends who had been consigned to leading what I would describe as a dehumanised existence. I was given many examples of neglect and, in some cases, abuse.
It was with immense sadness that I had to dash the hopes of those desperate people. I had to tell them that, as a Back Bencher, I had limited means at my disposal, and could not extend the powers contained in the Protection of Children Act. Ministers, however, do have the means and the powers. I hope that the Minister of State will be able to tell us about any measures that he can take to make it a statutory responsibility for all who work with elderly people to be vetted, and, if found to be abusers, prevented from working with them. I also hope that my hon. Friend will find ways in which to tackle the numerous instances of neglect.
I welcome the proposals for a new regulatory system, and the development of a set of national standards through the national care commission. I hope that my hon. Friend will be able to say something about how the standards will be enforced, what sanctions will be imposed against those who fall short of them, and how the standards will be policed. On the basis of the evidence I have been given, I firmly believe that fully accredited lay visitors with powers to enter residential homes at any time of day or night must be part of any monitoring scheme. Only unscheduled spot visits will capture the sort of neglect that is currently prevalent in residential homes for the elderly.
Carlton's "Thirty Minutes" programme recently sent an undercover reporter to a number of residential homes in the west midlands, where I come from. The broadcast that resulted featured none of the headline-grabbing shock stories that require immediate action—someone being sacked or prosecuted, or both. What it did reveal was constant, pernicious neglect: neglect that can be described as institutionalised. There seemed to be little comprehension among those being filmed that the ways in which elderly people were being treated were, quite simply, wrong.
For example, an elderly woman was left lying, for a considerable time, on the floor in a communal area where she posed a danger not only to herself but to other residents. She was also denied dignity. The programme also revealed poor standards of hygiene, and the incorrect administering of drugs. A reporter seeking work in a residential home was not asked for a reference, and no checks were made on her suitability. It is a measure of the complete lack of any sort of proper employment practice that on one occasion she was not even asked for her home address before being allowed to start work; 492 she was simply allowed to work with vulnerable, dependent elderly people who relied on her for their care and well-being. Given such poor employment practices, is it any surprise that our elderly people are neglected and abused?
Neglect, however, is even more far-reaching than that. Our elderly people are often subjected to regimes that, on occasion, defy human rights. There are examples of elderly people being woken and dressed at 5.30 am because that suited the shifts of the employees, and of elderly people being forced to go to bed early in the evening—perhaps at 6.30 pm—because that, too, suited the staff. That reminds me of a prison regime, rather than a home. It does not make me think of a place of safety, warmth and care. Dragooning people into behaviour patterns better suited to a penal institution is no way to treat our elders, and if we continue to allow it that will say as much about us as it says about those who perpetrate such regimes.
In fact, it says much about us that we can allow elderly people to lead the remainder of their lives sitting in an armchair with little to stimulate, interest or entertain them. What kind of society is it that turns and looks away because the problem is difficult to solve, or because it is inconvenient to take action?
I have visited residential homes in my Stourbridge constituency, which is a delightful place to live. It has pleasant surroundings, working practices that ensure dignity and respect for residents and activities that provide companionship and interest. Those homes are good places, but many others are not. I plead with the Minister to act as a matter of urgency to raise standards in residential homes. There is a vital need for an independent agency to inspect homes. Can the Minister tell us whether there is a proposed date for such an agency to become operational? Failure to act would be a national disgrace.
Let me deal briefly with the funding of residential care. My Stourbridge constituents have raised the issue with me at two public meetings, and on numerous occasions individually. Their comments show a lack of trust in the present system. Many people are unclear about what to expect for their relatives and, looking a little into the future, for themselves. I think that their fears are understandable. The last Government left the system in a mess, and it is up to the present Government to take urgent and serious action.
The last Government failed to offer support to elderly people and their carers to help the elderly to stay in their own homes—something that most people want. They also encouraged the creation of an independent residential care sector without introducing the checks and balances that were necessary.
§ Miss Kirkbride
One thing that can be said of the last Government is that we introduced the National Health Service and Community Care Act 1990, which allowed people to stay in their own homes—[Interruption.]
§ Ms Shipley
That comment has provoked a good deal of sedentary dissent. Certainly, if the necessary measures were in place to safeguard elderly people, we should not need to take the steps outlined earlier by my right hon. Friend the Secretary of State.
As I was saying, residential homes need checks and balances which are certainly not there at present. I look to the present Government to introduce them as a matter 493 of urgency. Furthermore, as has already been said, people were pressurised to sell their homes as soon as they entered care. That meant that, if their health improved, they would have no homes to return to. That is clearly a deplorable and very sad situation.
I believe that the Government's proposals to keep as many people in their own homes as possible for as long as possible is what the vast majority want, and must be properly supported. Most of my constituents tell me that they want to stay in their own homes, looked after by their relatives in the first instance, and moving into residential care only later, if that proves necessary. Individuals, however, must be free to choose the living conditions that provide best for their needs, and must be able to plan financially to meet the choices that they make.
My constituents are realistic. They realise that long-term residential care costs a great deal. The royal commission estimated that free personal care would cost around £1 billion a year. My constituents realise that funding for a high-standard programme of care will have to be provided in a variety of ways, but they want it to be fair funding. We urgently need a better funding system for elderly people who need residential care, and it must be fair and be seen to be fair. Vitally, it must be sustainable over a long period, so that people can plan to meet their own needs and those of their families. I should be pleased to hear from the Minister how he will ensure that those with modest amounts of capital are not hit hardest when they come to fund their care.
I welcome the fact that the Government have honoured their election commitment to publish a charter for long-term care. It is important that, for the first time, people will have access to information that they need: they need to know what they can expect from local services.
To be elderly and vulnerable is difficult. To be fearful as well is totally unacceptable. We have a duty to offer high standards of care to the elderly and to build a new system that is transparent, sustainable and offering choice and quality. When we have done that, we will have earned the trust of the elderly and their carers—a trust that was destroyed by the Conservatives.
§ Rev. Martin Smyth (Belfast, South)
I follow the hon. Member for Stourbridge (Ms Shipley), having served with her in seeking to bring the Protection of Children Act 1999 into being. As she spoke, I thought of long-term care for children with handicaps and the proposals for means-testing income with regard to the house that they might need.
A person wrote to me from the Foyle constituency urging me to bear it in mind that means testing was unnecessary because those who had the funds would go ahead. They were not prepared to wait for things to happen, whereas those who did not have the money or facilities required immediate help.
On long-term funding, the hon. Member for Dunfermline, West (Ms Squire) reminded us all of the problem of relying merely on insurance provision. I know that we are all glad that she has done the five-year sentence and look forward to her presence in the House for many more years.
From the poignant contribution of the right hon. Member for Tonbridge and Malling (Sir J. Stanley), we all learned a lesson. It was the House of Commons that 494 passed the legislation in question. A Government of whom he had been a supporter, if not a member, brought it before the House. The tragedy is that, often, in passing legislation, we do not think about its impact on the community out there. It is a salutary lesson that we should bear in mind.
There is much excellent care and provision for the elderly, but the right hon. Member for Tonbridge and Malling reminded us of the old saying that we are living in a generation of people who know the price of everything and the value of nothing. I have had to deal with young colleagues in the ministry who thought that paying attention to young people was all that mattered. I used to tell them to be careful. I told them that, if young people saw them ignoring their parents because they were concentrating on them, the parents could suddenly say, "Can we rely on them to look after us when we get older?" The Government have to look at the whole span. We may look for support from the younger generation, but we should also care for the older generation.
I am a little concerned. We welcome the fact that, as of today, Northern Ireland has devolution, but I am not convinced by some proposals. I understand the Secretary of State's view that the standards should be for England, but in my view, they should be for the whole kingdom. We should all have the same standards to aspire to. I hope that there will be not the lowest, but the highest common denominator—something that we build on, rather than trying to get away with what we can.
We have to bear it in mind that human beings look after themselves to a large extent. I am reminded of a person who did not live in my constituency, but who looked after her parents. Then, after years of caring for them, she required a break. She went on holiday. Her parents were looked after by her brother and sister-in-law, who suddenly discovered that it upset the routine of their home, so they put the parents in a residential home.
When the daughter came back, she was heartbroken, especially when she saw the conditions at the home, but it was the brother who had put the parents in. The authorities hid behind that fact.
We complained about the conditions at the home. The authorities replied that the home had a clean bill of health and that the general practitioner who was responsible for it had said that it was all right. Ultimately, they closed it: we were right and they were wrong. The GP was receiving a retainer fee of £3,000 a year to say that it was all right. We have to deal with human nature and to provide the standards that our people expect in relation to long-term care in the community.
There is a division between health and social care. Again, we have to be careful. Some time back, legislation was passed that did not permit local authorities in England to purchase provision outside England.
We had an interesting development. As we all know, we are a mobile people. People come to England to work from Scotland, Northern Ireland and Wales. I think of an individual who spent many years in England working. Then he was incapacitated and put into a home. No one around there really knew him. Cousins and others in Fermanagh would have been delighted to have him close to them, so that they could give him some back-up. Although the provision there was cheaper for the local authority and better for him, it was not allowed in law to purchase the provision to allow that person to go back to 495 his native heath, where family would be around to help him. In legislating, we have to be careful that we do not get so parochial that we hive off the different regions, forgetting that we are one common family.
I make a plea about financing and the concept of preserved rights. A voluntary home that was started by a Church of Ireland rector for people with profound learning difficulties has been going for some 25 years. It never had a ha'penny from the state to help with capital or running costs. Different authorities purchased its places, which have been kept at a certain limit.
The clergyman concerned has run voluntary efforts, raising, for example, £70,000 last year primarily to increase patient comfort and to give those people the quality of life that he believes they should have as human beings; but he cannot run the home on the amount that is received through purchase of the provision by the different boards—12 places with preserved rights were purchased by the Department of Health and Social Services. That is happening throughout the country. We have to re-examine it, so that we deal with people according to their needs.
We speak of community care. Is the problem affecting just Northern Ireland, or is it affecting other areas? One of the difficulties for people who would love to remain in their homes is that the adaptations required in their homes are so long in coming that they think that they will be dead before they get them.
One of the weaknesses is that occupational therapists' waiting lists are so long that they prioritise. I have asked how they prioritise. It seems that, as people come in, they add them to the list. That is not proper prioritisation, although it might seem fair.
A constituent of mine, a woman of 90, is blind. Her sister of 84 has a severe back problem. The OT said that they could handle the heater—one of those solid fuel things. I tried to move the thing myself. I know a little about fires and plumbing because that was my father's trade. My first Sunday work was helping him to do some maintenance work at the York street spinning mill. An 84-year-old with a back condition was expected to cope with the heater by herself. Then we were told that the problem was that there was no gas in the area. We knew that. The nearest gas point was two miles away, but no one wanted to put the oil in.
Having fought the good fight, the ladies now have a measure of comfort, but they should not have had to fight that good fight and a Member of Parliament should not have to act in that way. The servants of the state should at least be aware of human needs and should seek to help rather than sticking to red tape.
I understand the financial pressures on the Government when considering long-term provision for the elderly, but tell that to people who read about the billions of pounds in the national insurance fund. They wonder what it is there for if not to provide for the generation who were partly responsible for amassing it.
§ Ms Ann Coffey (Stockport)
I congratulate the members of the royal commission on the work that they put into producing their report, which deals with some 496 difficult and complex issues for today and tomorrow. Those issues deserve consideration. I also welcome the Government's announcement of the establishment of a national care commission, which will regulate and improve standards nationally. That is long overdue.
I welcome the royal commission's call for the modernisation of long-term care in a framework of fairness, recognising that that involves shared responsibilities between the individual and the state. Funding arrangements should be affordable, sustainable and fair to present and future generations of older and working people.
Older people are not a homogenous group. With today's increased life expectancy, they are not even all of the same generation. The people we call pensioners can range in age from 65 to 90. That covers different generations with different life experiences that have shaped different attitudes. Every one of them is an individual with his or her own life story, successes, failures, family experiences and financial circumstances. In recognition of that, the commission emphasises that older people are contributors to society. They are carers, members of voluntary organisations, and neighbours who do a good turn for each other. Some of them have part-time work, but they are also enjoyers of society—they use leisure facilities, they go to the cinema, the theatre and the pub down the road and they go walking. They want the same opportunities as the working-age population. The Government must ensure that they have them. That is why I welcome the better government for older people initiative, which shares that view of older people.
Being old should not take away the right to be treated fairly or the right to exercise choice, but neither should it take away the responsibility to contribute. The royal commission considered the funding of long-term care, looking at elderly people's expectations for dignity and security and the constraints of public funds. That is the agenda of rights and responsibilities.
In looking at funding issues and sustainability and affordability, the commission tried to take a long-term view, while admitting the difficulty of that. The future is more unpredictable than ever, because we need not only to take into account medical advances, economic changes and the impact of technology, but to try to predict people's expectations and behaviour in 50 years. The challenge of the next century will be to maintain social cohesion. We need to hold together the rights of the individual and the expectation that we all have to control our lives and exercise choices with the responsibilities that we each have to others in a fair society. That can involve contributing financially for the good of others and limitations on our personal freedom. That is a tension in any democratic society.
I shall judge one of the royal commission's main recommendations on the criterion of fairness and balancing everybody's rights and responsibilities, examining whether it achieves a partnership between the state and the individual and, most importantly, whether it targets resources while ensuring that everybody gets a first-class service. The recommendation is that personal care, whether in a residential setting or in the home, should be provided free of charge irrespective of people's income, but that housing and living costs should continue to be means-tested and paid for by general taxation on the basis of an assessment of need.
497 In arriving at its recommendation, the commission commented on two general resentments from the public against an expectation that the welfare state should provide from the cradle to the grave, including care. There is resentment that some get for free that for which others, because of thrift, have to pay. It is also generally perceived as unfair that some are forced to sell their house and what they regard as their children's inheritance to pay for long-term care.
Residential care has never been free. It has always been means-tested. Before the National Health Service and Community Care Act 1990, when older people decided that they needed nursing or residential care, the Department of Social Security provided a grant if they did not have the resources to support themselves. That means test has been applied to my certain knowledge for 20 years. I applied it as a social worker in 1971 and it still exists. For 20 years, people have been liable to lose their homes if the means test shows that they have sufficient resources. That is nothing new.
The argument for means-testing is that it is a good form of targeting resources on those in need. However, older people, particularly the poor, have powerful memories of the means test of the poor laws, when means-testing was synonymous with descent to the workhouse and was a mark of shame. I do not accept the argument that it stops people saving, which is the new argument against means-testing. People save because they want the choice that saving brings, and the independence that it provides. Of course there are people who do not save, but there are also people who cannot save because, during their working lives, they have not had the means.
The royal commission's main recommendation is free personal care. It provides for a partnership between the state and the individual. Housing and living costs would be the individual's responsibility, after means-testing. Personal care would be provided irrespective of income. It certainly creates equal treatment, but the problem is that that effectively passes the funding of the current private provision into the public sector, without one extra bit of care or improvement in care being provided. That does not deal with the savings issue, because people would still have to sell their homes to pay for their living and housing costs when they get below the capital limit. For domiciliary care, there are practical problems of implementation.
One of those problems would be that, at the moment, we have the attendance allowance, a direct payment for care needs which people can choose to spend as they wish—on care, on paying home helps or paying informal carers to do tasks for them. It gives them the choice. Logically, if one accepts the royal commission's recommendation, the attendance allowance for care costs would have to be withdrawn, so the choice would be taken away from the elderly. That would not be popular.
There is an argument over what constitutes social care and health care, and it has been raging for several years—particularly when changes in technology or in what professionals do change the boundaries. However, the argument over what constitutes personal care—which the royal commission defines as being care which involves touching people—and what constitutes indirect care is also difficult. In accepting the royal commission's argument about making personal care free, we would not 498 escape the difficulties of deciding where the boundary is, or about what should be paid for and what should not. It simply puts that into another area.
The National Health Service and Community Care Act 1990 wanted to develop alternatives to residential care and to increase choice for older people. The evidence is that community care has increased, but the concern is that provision is pooled for those with greater care needs. One can hardly be surprised about that. There are arguments about the importance of early intervention—in domestic help and other support—to enable people to retain their independence. There is concern that those sort of services are disappearing.
If the royal commission's recommendation is accepted, it would make the position worse because personal care would be free and the kind of domestic help which people describe as important would be subject to a means test. Those on low incomes would not then have the attendance allowance to enable them to pay. It might have the opposite effect to what is intended.
The main difficulty I have with the recommendation is that free personal care would not provide any extra care—even in the community or in the home—and would not benefit those on low incomes, as they already have free provision. More importantly, public funds would be diverted from raising standards in homes, which I believe to be a matter of priority, the essence of social justice, and fundamental to decent care for all our elderly. That is the essential fairness that old people, whatever their situation, need and deserve. They deserve and need good quality domiciliary and residential care, and we have not got there yet. It requires money—it requires public funds and investment. I believe that if public funds are available, that is where they should be directed as a priority.
There is an issue of how care is paid for. There must be a partnership between the state and the individual. However, I do not believe that free personal care achieves that partnership. The system could be made fairer, and could achieve a better balance between the benefits that people get from their savings and the contributions they then have to make from their own resources. The case has been well made.
The Government could look at freeing up equity schemes where older people might have choice about how they use their capital resources to fund long-term care. I do not believe that there is one solution, and we need a range of options to enable people to have choices and to make plans about how they fund long-term care. A multiplicity of provision would enable people to make those choices. I believe that they would welcome that.
I welcome the White Paper "Modernising Social Services" and the Government's intention to regulate, to have independent inspection, to encourage flexibility in the provision of care and to introduce nationally required standards which all homes will have to meet and from which all people would benefit. That is making progress on the road to social justice for the elderly.
I welcome the Government's intention to legislate for joint budgets, which will help the development of community care. It is an exciting proposal. I have noticed the feeling of excitement in my constituency at the possibility of working across agency boundaries and at being able to achieve a common objective without being constrained by an agency. As the legislation stands, it is still constraining. Legislation that allowed joint budgets 499 would release a lot of creative talent among the people working in the agencies, and I have seen an example of what can be achieved by working in that manner. Last year, a hospital—not one in my constituency—used some of the winter pressures money to employ a social worker in the casualty department. That social worker worked with a nurse and, when elderly people were admitted to casualty after a fall or some other accident, all the outside agencies were involved to try to return them home as soon as possible—which is what they wanted.
I hope that such initiatives will be carried further after the legislation for joint budgets. When I was in the casualty ward of the hospital I mentioned, I noticed how many elderly people were admitted after falls. As we all know, this is the time of year when the leaves fall from the trees and make the pavements difficult to walk on. Clearing pavements of leaves tends to be bottom of a local authority's priorities, but it could result in huge savings for health authorities. Under joint budget arrangements, perhaps health authorities could pass some money to local authorities which could sweep up the streets so that nobody would fall. That seems to be a simple answer to the problem, but it cannot happen at the moment. The Government's legislation would allow it to happen and would have a huge impact on the way in which agencies work together and the value for money provided. Millions of pounds is spent in each of our constituencies and we can all think of ways in which it could be better spent. The artificial boundaries between agencies is one factor that prevents that from happening.
§ Dr. Palmer
Does my hon. Friend agree that the process works both ways? For example, the National Institute for Clinical Excellence is considering whether treatment for multiple sclerosis will enable social services to reduce the amount of care they need to provide. Joint planning of social services and health could mean money flowing both ways, rather than one donating it to the other. I understand that some counties in Sweden have carried out successful experiments of that kind.
§ Ms Coffey
I am sure that all hon. Members could give further examples, not to mention the people who work in those agencies. The freeing up of that creativity will have a major impact on the quality of life for the people they work with.
I welcome the announcements by my right hon. Friend the Secretary of State because they will make important progress towards improving quality of service for older people, and I look forward to more announcements to come.
§ Mr. Archy Kirkwood (Roxburgh and Berwickshire)
We have just heard a fascinating speech from the hon. Member for Stockport (Ms Coffey), who has previous professional experience and who, in her current position as a Parliamentary Private Secretary in the Department of Social Security, might have had a glancing involvement in some of the Government's discussions—
§ Mr. Kirkwood
I accept that that was not the case. I am not saying that the hon. Lady was not the author of 500 her own speech, because she spoke with passion and brought experience to the argument. My point was that it was interesting that she and my close friend, Lord Lipsey—who was the author of the main part of the dissenting note in the royal commission's report—have come to roughly the same conclusion.
The arguments made by the hon. Lady sought to attack the main recommendation of the royal commission, and Lord Lipsey, who has good contacts at all levels in the Government, took the same view. I fear that they may have predicted what we are going to get, and the hon. Lady's speech may have been the most honest of the afternoon. The argument is between the main and the dissenting points of view, and I can tell the Minister that I am happy to engage in that argument. However, I am grateful that he cleared up the point on which the Secretary of State left me in some doubt.
The Secretary of State certainly left some doubt in my mind about what the Government intend to do. However, there is certainly no doubt in my mind that the royal commission's report is an excellent and ground-breaking piece of work, not just for its volume of recommendations but for its three volumes of appendices. I sat down last summer and read it all. I must admit that that was the first time in my parliamentary career that I have read a report all the way through. Although I have forgotten much of it—my excuse is that the Government have taken so long to stage this debate—I learned a lot from it and it certainly repays careful study.
I hope that we will not concentrate solely on the recommendations as that would not do justice to the work that went into the report, which was done in a very short time by a group of exceptional people. We shall not do their work justice if we concentrate on the political points that have been discussed today, important though they are.
When it came out, the report received a disappointingly dusty response from the former Secretary of State, the right hon. Member for Holborn and St. Pancras (Mr. Dobson). If today's statement had been made nine weeks after its publication, I for one would have been delighted and would have said that it provided something for us to work on. I should have been happy to enter into some of the discussions that must take place.
However, a gap of nine months between the publication of the royal commission's report and today's announcement is too long. We have lost quite a lot of time. A White Paper will be published in the summer. In his report, Sir Stewart Sutherland said that many of the royal commission's recommendations could be implemented without primary legislation. However, given the three-year departmental spending review, the Government have no realistic chance of achieving in this Parliament the primary legislation needed to establish the care commission and the necessary reform of the funding system.
I welcome much of what the Government are doing. I was a fellow Lib-Lab co-conspirator with the former leader of my party, my right hon. Friend the Member for Yeovil (Mr. Ashdown), but I do not keep diaries, so the Government need not worry about any revelations that I might make. However, although I think that the Government are doing much good work, I do not think that it will now be possible to deal with these matters properly until the next Parliament.
It is legitimate for the Government to say that they tried to deal with a previously intractable problem by setting up a royal commission. I was prepared to accept that at 501 the last election, but at the next election the Government will be saying that the response to the White Paper will come in the Parliament to follow. The process of delay will continue, with the result that the momentum will slip seriously. That is to be regretted.
I believe passionately that to do justice to the report, the House has to decide whether the hon. Member for Stockport is right, or whether I am right. That key question must be decided. If we do not find the necessary funds, a huge opportunity will be missed.
The hon. Member for Belfast, South (Rev. Martin Smyth) made an excellent speech. He has much experience in these matters. The trends in the national insurance fund must be examined. We must be a little careful about the idea that the fund has a surplus of £12 billion. That is easily said, and £12 billion sounds like a lot of money. However, the Government Actuary believes that if current trends prevail, there will be the possibility that the level of individual contributions to the national insurance fund could be reduced.
As the hon. Member for Stockport knows better than most, there is a projected underspend at the Department of Social Security of about £7 billion over the next three years. The Select Committee on Health looked into the matter and was quite robust about how the necessary funds should be secured.
Sir Stewart Sutherland has himself suggested recently that increasing inheritance tax could provide a potential source of additional revenue, although it clearly would not be able to realise the whole cost of £1 billion. In that context, it is not helpful to talk about an end cost of £50 billion in 50 years. Of course one has to be prudent, but it does not further the argument to talk about Monopoly money figures such as that, which are totally meaningless.
I do not doubt that the sums of money involved are large, nor that such matters must be considered very carefully, but the reaction of the great British public should also be taken into account. I hope that the Minister will look at the British social attitudes survey that was published recently. The copy that I have ordered has not arrived yet so I am quoting from press reports, but the survey apparently makes it clear that a significant majority of British people want more money to be spent on education, health and the long-term care of the elderly—even if that means increased taxes. The survey also states:people still favour rather than private or voluntary provision".
That is what the focus groups tell pollsters. I do not know why the Labour party is not picking this up. It has a national network of focus groups. Some of these questions should be put through that process. People do not want to pay taxes for nothing, in a profligate, unfocused way. However, I bet a monkey to a mousetrap that if the question were properly constructed and taken to a properly constituted focus group that was told what we would have to spend to achieve our end, we would get a majority. We would need to promote the argument but we could win a majority in favour of moving in the direction that I have described in the longer term. If the Government were prepared to do that, I would support them.
The current system is not fair. If any hon. Member doubted it, Sir Stewart Sutherland's royal commission demonstrated it beyond peradventure. The system is 502 unjust and insufficient. Eloquent speeches from hon. Members of all parties made that point. The right hon. Member for Tonbridge and Mailing (Sir J. Stanley) made one of the most powerful speeches that I have heard for a long time. I am sorry to keep referring to her, but the hon. Member for Stockport may have a role in this. The long title of the Child Support, Pensions and Social Security Bill that was published yesterday suggests that it might admit of a new clause that could deal with preserved rights and section 43 of the National Health Service and Community Care Act 1990. Can she write that down and take it to the Department? If she does not get an answer soon, we will start tabling written questions. The right hon. Gentleman's speech deserves some positive response. I will happily sign up to such a new clause if he succeeds in tabling one.
We all have constituency stories and I want to mention my local circumstances to underscore the urgency of getting something done. Starting from now, with a White Paper in the summer, it will take at least two or three years before we get beneficial outcomes that change things on the ground. Some 70 or 80 families in my region of south-east Scotland face terrible decisions each year about selling their houses to pay the costs of long-term care.
The hon. Member for Stockport is wrong to say that the main majority recommendation would not produce new resources. Nor is she right to say that it is simply a question of this always being the system. When the current system was introduced in 1948—she is right that as a social worker in 1971, she was applying it—people were not paying as much as £1,600 a month in long-term care costs or living to 96. Events on the ground have overtaken available provision. If we do not recognise that, it will be another 10 years before we do anything about it. I find that an intolerable prospect. Thankfully, I have never had an eviction from a home take place before my eyes. I hope that it never happens, but it is a real and corrosive problem.
The hon. Member for Dunfermline, West (Ms Squire) spoke well. She has had a good track record on the subject in her time in the House. Trying to talk people through the implications of care costs is corrosive. People end up feeling let down, if not, as she eloquently said, betrayed. That is happening in the borders now. I checked before the debate and found that 28 NHS beds are blocked. What does it cost to leave 28 people languishing in long-term NHS hospital wards when they could perfectly well be put in residential nursing places in south-east Scotland? The care homes are all full up. If we multiply those local figures to a national level, we would find that such care costs a fortune. We cannot ignore those costs lightly.
Several hon. Members mentioned respite care. The Government allocated£140 million for carers, which will be most helpful. Although it has not yet started feeding through the system, it is a step in the right direction. I endorse the eloquent and passionate plea made by the hon. Member for Stourbridge (Ms Shipley) on that matter. In the borders, we do not have the means to take the pressure off, for example, families who have to deal with youngsters with multiple disabilities. Those families are deeply affected and concerned. Science enables some of those young people to outlive their parents. It is devastating for parents to know that when they die, they will bequeath the state a complex set of different 503 problems, and they cannot even receive a little respite care to enable them to pick a way through their domestic difficulties.
By the summer—between now and the publication of the White Paper on this subject—several of the private residential homes in my constituency will have closed. There will be shutters on the windows and the staff will have had to go to the jobcentre. That will put more strain on a hard-pressed local authority. Those are urgent problems—they are happening now. Families hit by such problems—often unexpectedly—are devastated, as the right hon. Member for Tonbridge and Mailing so eloquently explained.
We have no time to lose. I welcome the Government's statements on standards, care, consultation and so forth. However, they must make haste to introduce legislation. I am a passionate advocate of the primary recommendation for funding made in the royal commission's report. I will argue the case for finding that money with anyone, at any time and in any place. The money will not be easy to find; perhaps we shall have to make do. In five years' time, the hon. Member for Stockport and I will meet and she will no doubt say, "I told you so." Perhaps she will be proved right, but I am not yet conceding the argument. I hope that other Members on all sides take the same view.
§ Dr. Nick Palmer (Broxtowe)
Like other hon. Members, I welcome the Government's speedy establishment of the royal commission after the general election. However, we should note that the debate is not on the royal commission. That is probably just as well, because we have discovered that none of the parties has yet finished analysing all aspects of the commission's report. The Government have come closest; they have already adopted more than half the commission's recommendations. The Conservatives say that they are waiting until the next election. The Liberal Democrats welcome the establishment of the commission, but they have not yet told us whether they accept its conclusions— with the exception of the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), who took a refreshingly clear view of the matter.
I declare an interest. Until three months ago, I was the sole carer of my mother, trying to combine looking after her with the work of the House. That was possible only thanks to the good will of the Whips. We should all declare an interest, because each of us might eventually need long-term care. On current trends, about six of those who have spoken in the debate will do so. We do not know which six—that is the problem.
We all hope that we will not end up in a home such as the one that I visited some time ago. When one of the inhabitants asked if she could have a cup of tea, the manager shouted into the canteen, "Here's a silly old woman who wants some tea". That seemed to sum up the policy of that home: he ran the place and no one else was worthy of much respect. Of course, many homes are completely unlike that. I mention that example only to demonstrate that there is a range of care—I shall return to that subject later.
We are all familiar with a general problem in dealing with welfare reform: the system has been built up piecemeal and it is replete with inconsistencies and 504 unfairness. If we try to level it up, it is extremely expensive; if we try to level it down, it is distressing for those people who have benefited previously.
The hon. Member for Roxburgh and Berwickshire suggested that focus groups would advise us to spend more money on long-term care of the elderly. I am sure that he is right but, although I am second to none in my admiration of focus groups, I believe that one tends to get from them slightly imprecise answers. I do not believe that we have obtained a clear picture of what a focus group or the public in general would say if we asked, "Would you prefer us to spend more money on better care for the elderly"—as my hon. Friend the Member for Stockport (Ms Coffey) advised—"or on enabling people not to use their own resources for care?" Those are two distinct areas, which we shall grapple with today.
Apart from the general problems of welfare reform, of which we are all aware, long-term care presents the additional problems that the people involved are elderly and vulnerable, and that there is a huge dependence on unpaid voluntary carers. No political party has got to grips with that to any degree. If there were a voluntary carer strike, we would all be in a mess.
Broadly, there are five ways in which we look after elderly people. There is voluntary care, for which relatively little has ever been done. The new Government have introduced two important new features there—the money for respite care and stakeholder pensions for carers. Those are the first steps towards recognising the importance of the service that voluntary carers provide. The second level is paid home care, for which there are no standards whatever, and for which the amount of support varies with the area. The statement by the Secretary of State emphasised what is being done in for home care, with the proposed national standards and national levels of provision and support.
There is nursing home care, where limited support is provided, although not for the nursing; there is residential care, where partial support is provided, including for nursing; and there is hospital care, where full support is provided. People note those inconsistencies and feel that it is unfair—and it is. The problem is what to do about it: whether to level up, level down or try to find a third way.
The royal commission report and this afternoon's debate may have downplayed the fact that it is very much what most people want, and in the national interest, that people should stay at home for as long as they feel comfortable there. About 70 per cent. of people spontaneously say that that is what they want—and it obviously makes life easier.
The royal commission gingerly suggests that more help could be given to improve the home to make it easier to live in. I believe that it underestimates the amount that can be done by imaginative local councils. For example, the hon. Member for Broxbourne (Mrs. Roe) suggested community care alarms. In Stapleford, in my constituency, a centre is being built that will support houses in the vicinity. Without changing the architecture of every house, one can do more to help areas where there are many elderly people by ensuring that there is nursing care—and other kinds of care—close by. Experience in Denmark and Switzerland suggests that there is a big role to be played by mixed communities of older and younger people, who spontaneously give one another support.
505 Given the limited time, I shall focus on the aspect of the issue that comes up most frequently—distress at the loss of one's home. People who have gone into care that they hope will be temporary find that they must sell their home to cover the cost, and they feel a door slamming shut behind them. They know that they can never go home. That is very grim for them.
I believe that, if we asked the focus groups, or the population at large, whether they would accept that taxpayers' money should be used to help avoid that agony for our elderly people, the great majority would say yes. If we went a step further and said, "Do we also feel that taxpayers should help ensure that young people can inherit valuable homes as far as possible without deduction of value and that this is a key area for public expenditure?", I think that we would get a more mixed response. Nowadays it is quite rare for the children of a couple still to be living in the home when the couple die. Usually, we are talking about a house that is left to the children but that they will not live in. They will sell it and share out the proceeds. That does not seem to be a crucial element of national priority.
I favour any solution that enables the couple to maintain ownership of the house for as long as they live. One solution, suggested in the minority report, is the long-term loan. Another, referred to rather dismissively in passing in the majority report, involves the local authority imposing on the house a charge that is exercised only when it is sold on death of the owners. Both solutions would provide a relatively low-cost option to protect the couple from the trauma of losing their home.
I have talked to older people on the doorstep, including some of the angry pensioners whom most hon. Members have met. I find a somewhat reluctant but basic acceptance that such a solution could be the way forward. It provides security and leaves the bulk of the money that we hope will be provided for long-term care to make improvements in care to enable people to live better. It gives them the chance to hang on to their home as long as they are alive and it also gives the health authority the chance to recover the costs before the next generation takes over. Basically, I favour the minority report or a variation of it. Difficult though it is, I think that it achieves the right balance.
§ Miss Julie Kirkbride (Bromsgrove)
I am honoured to be called in the debate. I shall not speak for too long, so that all hon. Members who are in their places and who have not yet spoken may contribute to the debate. To take up a remark of my hon. Friend the Member for New Forest, East (Dr. Lewis), I put on record again that, when the debate has been called for since the royal commission made its recommendations some time ago, it is improper that it should take place when the Government knew that the Select Committee on Health was away, given its trenchant criticisms of the Government for not moving forward quite so quickly as it wished. As a member of that Committee, who gives it her time and attention, I think that it is a gross discourtesy that other members of the Committee have not been given the opportunity to participate in a debate on matters that they feel strongly about.
We welcome the debate, but the time scale within which the Government will address these issues is disappointing. There is no doubt that, at the last election, 506 the selling of homes in this context was a major issue. The Conservative party brought forward proposals, which it intended to implement had it won the general election. It is clear that the Labour party felt strongly about it. The Prime Minister said that it was a major issue that people should not be expected to sell their homes and that action needed to be taken. The public had a reasonable expectation that more would be done more quickly than the time scale envisaged by the Secretary of State as set out today.
If the opinion polls are correct, Labour Members, who will be fighting hard for their seats in some instances, will find it difficult at the next election to justify the fact that their Government, who will probably have been in power for four years when the general election is called, did not put any legislation on to the statute book to deal with a major issue. The fact that we shall have a White Paper by the end of next summer without any proper legislation in place is deeply disappointing to Opposition Members, to the nation and most particularly to our constituents, in whose name we all speak.
It has been an interesting debate. Members from both sides of the House have expressed their ideas on the royal commission's suggestions and on other proposals for the funding of long-term care. The hon. Member for Stockport (Ms Coffey) may have been privy to some information, and she made an interesting speech. Her views on the attendance allowance will be pored over at a later stage, because they may represent the views of Ministers as well.
My hon. Friend the Member for Broxbourne (Mrs. Roe) set out an interesting picture of the difficulties that will be faced. The bottom line is financing. Although many ancillary issues are involved, the bottom line is how we will pay for long-term care, given that we have an ageing population. People are living longer and medical care will allow them to live even longer. Later in their lives, people will rightly expect to enjoy, and participate in, the improving standard of living that will be available to everyone in the United Kingdom. That fact raises some difficult issues.
I have listened to the debate, and it appears that there is a growing consensus that the people who are elderly today may deserve a better deal than the rest of us might be able to expect if we are elderly, infirm or require 24-hour care. I hope and believe that proposals will be introduced that will provide extra help for the elderly of today. However, the current working population will not be able to afford such help unless we make proper provision for ourselves. The statistics suggest that one in six people will find that the lottery of life means that they require long-term care in their old age, while five in six will, I hope, avoid what can be for some an unhappy option. However, many people enter nice nursing homes, and there are many of them in my constituency. They find that they are pleasant places in which to live out the rest of their natural lives.
The rest of us will require private insurance schemes. I am pleased to hear that Ministers, having decisively rejected that option when the Government first came to office, will reconsider their potential. We should expect people to insure themselves against a need that is foreseeable in one in six cases. A mixed economy of provision for long-term care is the right answer. I regret only that that right answer will not be in place sooner. It will not be in place until after the election, and then it 507 will take legislation to implement. Private providers and private insurance companies will have to get the schemes up and running before the mixed-economy regime is put into place.
§ Mrs. Humble
Will the hon. Lady comment on that part of the royal commission report that deals with insurance? It points out that women are more likely to be in residential care for longer, but that they also earn the least. Therefore, the people with the least to pay would have to contribute to a system, but the insurance companies would have to pay out the largest sums for them.
§ Miss Kirkbride
The hon. Lady ignores the fact that many working women participate in the work force, and their number is increasing. Not everyone will be able to save, and there will always be a safety net. However, the primary political concern at the moment is for those who have saved all their lives and now have to sell their homes to pay for their long-term care.
Two issues have already been set out. On the one hand, it is difficult to say that such people should not contribute to their long-term care needs if they leave an inheritance to their children and benefit from other people's tax bills. On the other hand, if we can offer those people an insurance scheme, a portion of which is guaranteed by the state—that is similar to the proposals that we made before the previous election—we can share the provision of the care that people reasonably expect now that standards of living are improving.
Like the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), who fears that some of the care homes in his constituency may need to close, I make a plea for care homes in my constituency because I fear that Worcestershire is facing a serious situation. Historically, Worcestershire gets a poor settlement from the standard spending assessment, and that has not been addressed by the Government's reforms of the SSA. Last year, our social services budget was cut by £5 million. Nevertheless, the county council was able to offer care homes a funding increase of 3 per cent.
My right hon. Friend the Member for Tonbridge and Mailing (Sir J. Stanley) mentioned the huge problem of preserved rights. That keeps people in long-term care homes on a low amount of money, which means that, in most cases, others subsidise their stay, although sadly that is not true in the case of my right hon. Friend's constituent. The amount of money that is available for long-term care needs is a growing problem.
The Government's programme to improve employment rights, such as the minimum wage, is part of that problem. The Government's own figures suggest that the minimum wage costs industry as a whole some £8 billion. The working time directive, which will significantly affect care homes, costs around £6.5 billion. It is estimated that the cost of running a care home has increased by some 9 per cent. over the past year. Yet, as I said, care homes in Worcestershire have received only a 3 per cent. increase in funding. We do not know what the increase will be this year, but it will clearly affect care homes a great deal because it is very unlikely that any increase will match the costs brought about by the Government's legislation for improved employment conditions.
508 We are talking about not only jobs but the closure of people's homes. Many will have been used to living in a care home for several years. I therefore appeal to the Minister to consider that matter along with the proposals, however welcome, that people going into homes should be assessed according to national requirements. I appeal to him also to consider what impact the proposals will have on various counties, particularly Worcestershire, and how they will be financed in counties that, like mine, have historically received a low SSA.
I draw attention to the "Fit for the Future?" proposals, mentioned by the hon. Member for Blackpool, North and Fleetwood (Mrs. Humble), which are causing great concern in my constituency. My hon. Friend the Member for Runnymede and Weybridge (Mr. Hammond) put forward the very valuable proposal that we should be increasing the amount of money available for those nursing homes that make improvements, rather than trying to penalise those that cannot improve because of strict financing requirements and low funds.
I hope that, in his closing remarks, the Minister will mention the problem that VAT is to be levied on personal social services, a problem that has not yet been mentioned in the debate. That development might cause great problems for the supply of labour in nursing homes and for the supply of personal social services because the cost of such services will rise while the people receiving them will get no extra care.
§ Mr. Desmond Browne (Kilmarnock and Loudoun)
As I have listened to the debate, I have collected a whole sheaf of paper containing comments that I hoped to make in response to contributions by other hon. Members. They will understand, however, that as time is short, I will cut to the chase.
I hope that hon. Members will excuse me for taking the opportunity to speak in support of the call by my hon. Friend the Member for Dunfermline, West (Ms Squire) for the same rules to be applied throughout the United Kingdom in the determination of which services will be free and which will be means-tested, and how the means test will operate. If I understood my right hon. Friend the Secretary of State, he said in his introductory remarks that he was aiming to achieve consistency throughout the UK, and perhaps when replying my hon. Friend the Minister of State will address that issue.
We are reaching the end of a century that has been rich in advances for older people, from the introduction of the old age pension in the early years of the century, through the advances made by the Labour Government in 1945 in implementing the Beveridge report and introducing the national health service, to the present, where the issue is how we provide for those who, through improved nutrition, a better standard of living, better health services and so on, are living longer.
As my right hon. Friend the Secretary of State said in his introductory speech, we should see that not as a problem, but as a success story. The aspiration of every Labour Government has been to reduce poverty, improve living standards and improve health. The task that we now face is to manage the consequences of that success.
The challenge to us is to ensure that we put in place arrangements that continue to fulfil our aspirations to promote social justice and social welfare. We need to put 509 arrangements in place that will enable our older people to remain part of the local community, with clear rights to services to meet their reasonable expectations. Clearly, because of the legacy of the previous Government, we are not getting that right at present.
Sir Stewart Sutherland and his committee thought not, and others agree with him. In a memorable quotation, Professor Alan Walker said that care services for older people put in place since the formation of the NHS and national assistance have been50 years of broken promises".
When the Audit Commission examined community care in 1984, its report concluded thatthe only option that is unavailable is doing nothing",and as the hon. Member for Sutton and Cheam (Mr. Burstow) said, the status quo is not an option. That should be our watchword, and indeed it is.
Echoing the words of the Audit Commission, the Sutherland commission stated in its executive summary:The Commission conclude that doing nothing with respect to the current system is not an option.There we have three ways of saying the same thing.
What the Government asked Sir Stewart Sutherland to examine is not a picture with which we should be comfortable. In each of our constituencies, there are older people who want to remain at home, but cannot do so because the services are unavailable. In each of our constituencies, older people assessed as requiring intensive 24-hour support cannot be admitted to an establishment because the funds are unavailable. In each of our constituencies, carers are placed under extreme pressure over many years because support services are unavailable.
How did we get into such a situation? To understand that, we must examine the funding of community care in the past. In the 1980s, it became the norm for older people who had become more dependent to be admitted to institutional care. That was a pattern quite different from previously, and in some ways we are still dealing with the legacy of that change.
To some extent, it is still the expectation of individuals and families that care in an institution is the inevitable consequence of increasing dependency among older people. That is not necessarily their wish, but their expectation, because that is what they have been conditioned to expect since the 1980s.
I shall digress for a few minutes to instruct the House that that is not a new idea. As I was preparing for the debate, I was reminded of a Para Handy tale. As some hon. Members may know, the great Para Handy tales were written by Neil Munro at the turn of the century, at just about the same time as pensions were being introduced. They are a wonderful set of short stories about the Vital Spark, the puffer that plied its trade up and down the Clyde crewed by Para Handy the captain, the chief engineer, and Dougie, the boy.
Tale No. 27 is entitled "Pension Farms". It was written in 1906. Let me set the scene for the House:The Vital Spark was making for Lochgoilhead, Dougie at the wheel, and the Captain straddled on a waterbreaker, humming Gaelic songs, because he felt magnificent after his weekly shave.As they were looking over what they call the Glasgow promontory, Macphail was musing that there was a hen farm at the end of the promontory, and he had always 510 wanted a hen farm. Para Handy told Macphail that he did not want one of those; what he wanted was a pension farm. The tale continues:'Rearm pensioners?' remarked Macphail, 'ye would lie oot o' your money a lang while rearm pensioners; ye micht as weel start growin' trees.''Not at aal, not at aal!' said Para Handy, 'there's quick returns in pensioners if you put your mind to the thing and use a little caation. Up in the Islands, now, the folks iss givin' up their crofts and makin' a kind o' ferm o' their aged relations.I have a cousin yonder oot in Gigha wi' a stock o' five fine healthy uncles—no' a man o'them under seventy. There's another frien' o' my own in Mull wi' thirteen heid o'chenuine old Macleans. He gaithered them aboot the islands wi' a boat whenever the rumours o' the pensions started. Their Men's had no idea what he wanted wi' them, and were glad to get them off their hands. 'It's chust a notion that I took,' he said, 'for company; they're great amusement on a winter night,' and he got his pick o' the best o' them. It wassna every wan he would take; they must be all Macleans, for the Mull Macleans never die till they're centurions, and he wouldna take a man that wass over five and seventy. They're yonder, noo, in Loch Scridain, kept like fightin' cocks; he puts them ott on the hill each day for exercise, and if wan o' them takes a cough they dry his clothes and give him something from a bottle.'Holy smoke!' said Dougie, 'where's the profits comin' from?''From the Government' said Para Handy. 'Nothing simpler! He gets five shillings a heid in the week for them, and that's £169 in the year for the whole thirteen—enough to feed a regiment! Wan pensioner maybe wadna pay you, but if you have a herd like my frien' in Mull, there's money in it.'So, this was nothing new.
When, in the 1980s, the Audit Commission urged the Government to action, it did so because it had found two things about those pensioner ferms that were growing up. First, the uncapped budget for nursing home and residential places was out of control and far beyond any financial projection provided to the Treasury. Secondly, it was becoming normal for older people to be placed in residential and nursing homes because funds were available for such placements but not for services at home. The Audit Commission called that—a phrase that we have already heard today—the "perverse disincentive" to care at home.
On the basis of the Audit Commission's promptings, in 1985 the Government commissioned Sir Roy Griffiths to report on future arrangements for community care. It is clear in retrospect that it was not within Sir Roy's remit to identify the required level of funding for community care; he was explicitly told to deal with the funds already in the system. They were the funds that became available as part of an unplanned growth, but there has been no growth in the funding arrangements for community care since 1993. The legacy of the Griffiths' recommendations and the legislation that followed them in 1990 are the problems that we face today. It is only this Government, in their remit to Sir Stewart Sutherland, who have taken the step of projecting the anticipated need for the next 20 years and identifying the level of commitment required to provide appropriate services.
We have now had the royal commission report for nine months. The hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) made an impassioned plea for more speed, but this time we should get matters right, not just quickly.
§ Mr. Browne
We already have the experience of a Government taking nine years to do the job and getting it wrong, giving us these problems, so it is better that we get it right.
511 We all know that we cannot allow the crisis to continue. With an eye on the Whip, I simply say that, having reached the meat of my argument, I need not propose the arguments which are ably set out in chapter 6 of the report. However, I am impressed that at 1995 prices the commission's core recommendation for the separation of the elements of long-term care would cost about £1 billion, and I understand that that will rise to £5 billion in 2051.
I, like the hon. Member for Roxburgh and Berwickshire, have read the report only once, but I understand that the commission itself says that its model breaks down after 20 years and is unreliable thereafter. All I say to the Government is, if we can get the job right for 20 years, it will be 20 years longer than any previous Government have managed.
§ Mr. Desmond Swayne (New Forest, West)
It is always a great pleasure and privilege to follow the hon. Member for Kilmarnock and Loudoun (Mr. Browne). I am particularly grateful to him for reminding me of that great fount of wisdom and humour, the Para Handy tales.
The political imperative for striving to deal with the problem of long-term care is, in many cases, the 40,000 houses per year that have to be sold to meet the cost of providing such care. Behind those 40,000 houses are many tales of horror and misery. An impression prevails that legitimate expectations have been dashed and that a contract for welfare either never existed or has been torn up. In analysing the problem, we must be clear about the precise nature of the complaint.
What is wrong with people using their savings to pay for their long-term care when they are old? That is a proper way in which to spend one's savings. It is often said, "Well, using savings is fine, but not the house." However, in this country we have used the tax system for many years to encourage people to use houses as their principal savings vehicle. I supported those policies and regret that we have abandoned them in recent years. Nevertheless, the consequences remain: most people's principal saving is their house. Why should not it be used to fund their long-term care? If one is not prepared to use one's own savings for that purpose, whose savings would one use?
Those who have legitimate expectations of inheriting a property form a powerful lobby. However, is it proper for us to encourage people to have their cake and eat it? In our society, which is increasingly dominated by the nuclear family, people make implicit life style choices throughout their lives that often prevent them from actively participating in the care of their elderly relatives. Therefore, is it proper to encourage them to expect to inherit property and assets from those elderly relatives?
The sense of betrayal and unfairness persists. The real source of the grievance is means testing, and the perception that the state will provide for both the unfortunate and the improvident. I apologise for mentioning those categories in the same breath. However, we have no alternative but to put them in the same category because no state-run welfare system in the world has successfully devised a means of distinguishing between the deserving and the undeserving poor. 512 Nevertheless, it is perceived that those who are unable will be cared for whereas those who have been prudent, or merely fortunate, will be penalised. That powerful sense of injustice fuels much of the argument that underpins our problems with long-term care.
The imposition of a means test will always generate a sense of unfairness and the belief that it will encourage anti-social behaviour by reducing the incentive to be prudent and save, thereby providing an incentive to be dishonest. The only way to deal with the irritation caused by the means test is to implement an accompanying principle of less eligibility whereby those who qualify on the means test will be provided for according to means that are less than those that would provide any form of independent existence. However, I do not believe that a return to the principle of less eligibility is politically possible. Indeed, we have heard powerful arguments today—not least from my right hon. Friend the Member for Tonbridge and Mailing (Sir J. Stanley)—to show that less eligibility already exists in the system and is unacceptable.
We are left with a problem, and there are two principal ways of dealing with it. First, we can nationalise by providing a universal benefit funded by the taxpayer. That is an attractive if expensive option, but we should always remember that, ever since the passing of the Great Reform Act 1832, whenever a Government have offered us such an attractive option they have bribed us with our own money. We shall pay for that option, with all the consequent economic inefficiency that flows from high taxation.
The second way in which we might deal with the matter is by reviving the concept of social insurance. We could seek the widest pooling of risk based on a renaissance of the contributory principle, with all the social virtues that that might also revive. If we were to take that route, early in the next century we should have to learn a great deal from the mistakes that we have made in the latter part of this century regarding the contributory principle. In many respects we must await the findings of the Social Security Committee report on the importance of that principle, but I suspect that we shall pursue neither of the two options. We shall be left with our existing difficulties, although we might implement a number of measures that mitigate the most offensive aspects of the problem by providing new incentives and removing, to an extent, old disincentives.
I see the substantive and minority reports of the royal commission making their most significant contribution in that respect. They are welcome and contain little that I can disagree with; indeed, I have heard little this afternoon that I can disagree with. I appreciate that these are long-term problems and we have to consider carefully what proposals to implement, but we have discussed in the debate a number of short-term measures that could alleviate the problem. I urge Ministers to act as, indeed, the Health Committee report enjoined them to do— urgently.
§ Mr. Kerry Pollard (St. Albans)
The concept of a nationally applied standard for care of the elderly is welcome, but care home owners and proprietors have concerns about its application—in respect of room size, for example. I ran care homes before being elected to the 513 House and remember having endless arguments with the local authority about the small box room of a standard house; it was fractionally below approved size. I therefore had to persuade the authority, with lots of arguments, that using the room was a viable option. We had clients ready to go into it.
The standards for room size are fine for new-build houses—they can easily be incorporated at the design stage—but it is often difficult to meet every standard when houses are being converted. That is particularly relevant to small homes—for instance, when a pair of semi-detached houses are being knocked together—and in such an example two rooms could be lost as they would be below standard. Major refurbishment, including knocking down walls, could be required, and that would increase costs considerably; it might even make the scheme non-viable.
I recently attended a regional conference in Towcester organised jointly by the National Care Homes Association and the Forum of Private Business. Also present were the hon. Members for Daventry (Mr. Boswell) and for Havant (Mr. Willetts), as well as about 100 care home owners. A great deal of concern was expressed by those owners because they believe that full implementation of the proposed standards will force many of them out of business. Indeed, a recent survey of care home owners undertaken by the Forum of Private Business found that 73 per cent. of homes would not be viable if the standards were implemented as presented in the report.
Although other recent changes made by our Government—such as the minimum wage and extra holidays—are welcome, they have added to the financial burden on the care sector. I can speak from certain knowledge of the squeeze that the care sector has been experiencing for many years, and there is no doubt that the financial situation is grave. The departure of one client, for example, can mean that a place is empty for some weeks while a replacement is found—someone who will need to be assessed and fitted in. That often places small care homes in great financial difficulties.
Twelve years ago, there was an independent review of the charges on which current fees are based. I think that it may be time for another such review. If we are to have national standards, we should have a national minimum fee. In Northampton, for example, the local authority fee is £247 per week, while in neighbouring Norfolk it is £265 a week. Moreover, benefit increases are not always passed on, and the same applies to Government grants to local authorities.
I am particularly concerned about elderly people suffering from learning difficulties and mental incapacity, who are often overlooked. Traditionally, some were not even cared for in their own towns, but were farmed out to where care was cheaper. In my view, carers are saints. I well remember taking a newly elected councillor in my constituency to meet some residents in a care home. One lady whom we approached had just messed herself, and had messed her hand. My councillor colleague shook her hand, and when he realised what he had done, had to dash out to be sick. The care staff did not turn a hair; they persuaded the lady to go out and be bathed, after which she was given new clothes and taken back. Not a job for me!
Rates of pay are also among the lowest. In my area, a care assistant is paid £10,500 a year, while the head of a small care home is paid £15,500—and must be qualified 514 to national vocational level 4, and be approved by the local authority. None the less, those who work in the sector are dedicated, and provide high-quality care.
In St. Albans we have many excellent care homes. We have Grace Muriel House—an Abbeyfield home—Fosse House, Vesta Lodge, Allington Court and Maryland, run by the Sisters of Mercy. They are first rate, and I would have no difficulty in living in one of them when my time came.
Although high standards are obviously necessary, what is vital is tender loving care. It is small comfort to be in a home that meets the "square metre" criterion and has the right number of double sockets if physical care does not match the tender loving care that we would all want for ourselves.
§ Mr. Edward Leigh (Gainsborough)
This is a sensitive subject. It is easy for us to assuage our consciences by speaking in debates such as this or writing reports, but we shall each be judged on what we do to help our own elderly relatives by looking after them and visiting them.
I say that because I am critical of the royal commission's report. I consider it irresponsible. I know that it is well researched, and that those who were asked to be members of the commission put a great deal of their personal time into its work, but I see no chance of the report's being implemented by any political party that is likely to take power. That is why I think it irresponsible. Politicians as a race are derided, but they are not part of a debating club; they must propose solutions that are capable of being implemented. No serious politician would come up with a proposal whose implementation would cost £1 billion now, rising to £5 billion or £6 billion over the century. Some doubt has been cast on those figures, but they are based on demographics.
If the report were ever implemented, however, it would not just be demographics that would result in such enormous expenditure; perceptions and behaviour would be changed. I think that the report is wrong—not factually wrong, but in a sense morally wrong, and dangerous and irresponsible for that reason. I believe that those who wrote the note of dissent were more courageous, fairer and more realistic. I was not surprised that neither the Secretary of State nor my hon. Friend the Member for Runnymede and Weybridge (Mr. Hammond) were prepared to commit themselves to carrying out the royal commission's proposals. Even the Liberal Democrats, who are usually anxious to please everybody, tiptoed back from that precipice.
The proposals are not going to be put into effect. We have heard metaphors about long grass, but this is not a ball lying in the long grass—it has already been chucked out of the stadium by the Treasury. That is not a criticism, because I think that the Treasury is right.
We should be realistic. No one denies that the issue causes a tremendous sense of grievance, but that is what the real world is about. Means testing is rough justice, but it broadly works. I do not understand the principle of believing that people have to be responsible for their care and their housing throughout their life—until the unique moment when they reach retirement age, when, whatever their resources, the state should be willing to care for them. That does not seem morally right or justifiable—or even to make sense.
515 Implementing the proposals would require massive resources. If elderly people are in need, it does not matter whether they have been improvident. Are we going to deny them resources because we are worried about people who are angry because they want to inherit an entire property from their parents? Of course children want to inherit their parents' property, and of course they resent the fact that when their elderly parents go into a nursing home the state says that the family home has to be sold to pay for the care; but why should we satisfy those children and deny other elderly people who have nothing? Those are the people we should be spending our resources on.
§ Dr. Evan Harris (Oxford, West and Abingdon)
I apologise to the House for not having been here earlier. I was in a Delegated Legislation Committee during the early part of the debate. Does the hon. Gentleman recognise the fairness of the case for helping those who were told that they would be provided for by the state, including those who fought in the war? Is there not a legitimate case for realising their expectations of help without forcing them to sell all their possessions? If £1 billion is too much for the Conservatives, is there any amount that they would spend to bring back fairness for those people?
§ Mr. Leigh
I understand from the report that we already spend about £11 billion. If the report were implemented we would spend a lot more. I accept that a myth has been propagated. There is profound misunderstanding about the contributory principle. Every poll carried out on the subject shows that people think that what they pay in national insurance contributions covers all the welfare that they might receive and their health care costs. It does not even begin to pay for those services. We have to be honest with people about the real world. We do not have enough money to meet people's expectations. The more people's expectations are raised and their behaviour is changed, the greater the trap we end up with.
I am prepared to accept some compromises. The real political world tells me that a lot of what was talked about in the note of dissent is sensible. Perhaps the present cut-off point of £16,000 causes enormous resentment. Perhaps people who live in modest houses are being made to pay too much. Perhaps we should phase the threshold in more slowly between £10,000 and £30,000. Perhaps people are being forced into nursing homes and having to make their decisions too quickly. As the note of dissent says, they should be able to take out a loan based on their equity so that nobody is forced to sell a home. Perhaps we should look at the real cost of nursing. Those who wrote the note of dissent said that providing that facility free might cost only £100 million, which might be affordable.
§ Mr. Kirkwood
I well understand the point of the hon. Gentleman's thoughtful speech, but how does his pragmatic approach to the proposals in the note of dissent answer the problem that if I am disabled as a result of a heart attack, nobody looks at my bank balance, but if I 516 get dementia, my credit card is taken from me before I am given treatment? How will his pragmatic approach deal with that essential question of fairness?
§ Mr. Leigh
Those who wrote the note of dissent answer that point. There is no entirely logical answer to the hon. Gentleman's fair question. Everyone understands the principle that people are entitled to free health care. It is based on clinical need, not their resources, but we have to draw the line somewhere. If people—I think they understand this—need clinical care, that will be provided free. If they go into a nursing home and need general care, that will not be provided free.
I know that this is messy and illogical, but it is all we can afford, so why not just be honest with people? If we were to—of course, we will not—go down the path that the royal commission recommends, a general expectation would build up in people's mind that, when they were elderly, the state would be prepared to care for them. That may be a civilised thing to contemplate. If we lived in a Scandinavian country, where people are genuinely prepared to pay 60 per cent. of their income in taxation, we could tread that road, but in this country people are not prepared to pay much more than 40 per cent. in taxation. That is why the new Labour Government have decided—or so they claim; we will not get into that argument—not to increase taxation. That is the real political world. No future Government would commit themselves to that level of expenditure.
We should say honestly to people that the family must help. And we must reinforce the contributory principle, which both parties have attacked over many years. That is why the report of the Select Committee on Social Security, chaired by the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), is important. We must try to rebuild the contributory principle; and we must be honest with people about social insurance.
We were prepared to create the immensely unpopular Child Support Agency. We said that the state would no longer provide; the father would provide. That was intensely unpopular. We have to be prepared to do the same in relation to long-term care. I will not make myself any friends by saying that, but I firmly believe that it is the truth.
§ 6.7 pm
§ Mrs. Sylvia Heal (Halesowen and Rowley Regis)
I welcome the opportunity to contribute to the debate. It is right and appropriate that the House should deal with long-term care, which is of concern to many of our fellow citizens. The issue is likely to affect any one of us: we may require care, or provide it for a spouse, partner or relative.
It is sad that our society's success in reducing mortality and increasing life expectancy has not been a cause for celebration. Instead, the predominant concerns of the media, health planners, policy makers and politicians has been the cost of the growing older population and whether the country can afford to pay for pensions and health care. That often results in older people being seen in a negative light. That is not only ageist but sexist, because women are likely to live longer than men.
Such attitudes ignore the contributions of older people. Many provide care for their spouses or for neighbours and friends—that is particularly the case when members of a 517 family live many miles from the relative who requires the care. Those of us who value the enormous contribution that older people have made and continue to make to society want to ensure that they feel respected, valued and cared for, with choice and dignity in the later years of their life.
The previous Government's policy in the early 1980s was to reduce the services that local authorities provided, just when demographic changes and changes in the national health service produced increased demand for residential and nursing care for a growing number of elderly people. The result was that people were no longer able to rely on the welfare state and the NHS to provide them with that free care—something about which today's pensioners still feel angry and betrayed. We will all have heard senior citizens recalling a lifetime of working, making national insurance contributions and paying taxes in the belief that care would be provided free of charge if they should ever need it.
The previous Conservative Government's policies on continuing care shattered that belief. In the 1980s, we saw the reduction of long-term NHS beds and local authority provision, and the growth of private sector residential and nursing homes. I recall clearly in the late 1980s and early 1990s that, when businesses of every description were going bankrupt and collapsing around the country, the one growth industry was private residential and nursing care. People with little or no experience of providing care became owners of residential and nursing homes. I recall someone I knew who went from owing a garage and selling second-hand cars to opening a residential care home.
The balance of long-term continuing care has been changed radically in recent years. Whereas the majority used to be looked after in either an NHS hospital or a public sector care home, and the minority in the independent sector, the position is now reversed. People are concerned about the quality and cost of residential care and the loss of savings. In many cases, people are concerned about having to sell their homes. Many children are disinherited by a parent entering a care home. Although some are phlegmatic, others are angry. Usually, it is the parent who is angry, because he or she wanted to pass on an inheritance to the next generation.
Let us not forget that some of those who would benefit from the savings are not well provided for. Some will have been carers of that relative, with little or no opportunity to save for themselves. We want to make sure that we can provide good quality care for the elderly and examine how costs can be shared between the taxpayer and the individual. The royal commission was given that task. The report, published earlier this year, made a number of recommendations. The three principles involved in the commission's approach to funding are as follows: that responsibility should be shared between the individual and the state; that any new system should be fair and affordable; and that any new system should be transparent in respect of resources, entitlements and personal responsibility.
The key factor that the commission recommends is the exemption of personal care from means-testing, to make it free to all those who are in need. When Ministers are considering the Government's response to that aspect of the report, I urge them to give serious consideration to this point. I recognise the difficulty of defining personal care, but I urge Ministers to tackle the matter and come 518 up with a solution. They will know, as I do, that there are many organisations working with the elderly and with carers' groups—as well as individuals—who feel that time is no longer on their side. I have every confidence that the Government's decision will be based on fairness and equality.
My right hon. Friend the Secretary of State rightly reminded the House that continuing care is not provided exclusively for older people. There are many younger people with a congenital disability, or who, as a result of an accident or long-term illness or disability, require continuing care. They may have younger families to support and therefore have additional responsibilities and demands made upon them. Clearly, first-class domiciliary and respite care for them and their families is essential.
Funding is an important aspect of long-term care, as has been said. For those who are able to remain in their homes with support, the role of carers is important. The Carers National Association—an organisation for which at one time I was privileged to work—estimates that 80 per cent. of long-term care is provided by carers' relatives or by friends of those who need support. Much of the care for older people is provided by people who themselves are over 65, and in many cases it is only when the carer becomes ill and is unable to continue caring that help is sought from the community or social services. It clearly pays to support carers practically and financially. Together with all the many carers in this country, I was delighted when the Government came into office and began to acknowledge the contribution that carers make.
Fine words are not enough. It is not sufficient to say that carers are a hidden army who have worked very hard. They want a positive, practical response to the huge contribution they make. Therefore, the launch of the national carers strategy was widely welcomed. Also welcome was the provision of £140 million to fund short-term breaks. If there is scope for any extension of that money, that will also be warmly welcomed.
Many carers are either unable to work or can manage only part-time employment. I ask my hon. Friend the Minister to assure me and the many carers who will be listening to or reading this debate that a review of their benefits, which recognises the value of what they do, will take place. Most people want to stay in their homes for as long as possible, and giving people the choice and the support they need to remain there is an important principle. To achieve that requires a good partnership between the health authority, the local authority and the voluntary sector. I am proud to say that both Sandwell and Dudley in my constituency contain some first-class examples of how that partnership is working and supporting some of our senior citizens in their homes.
Sandwell is a health action zone and it has discovered that the very elderly population—those over the age of 85—is rising significantly. Between 1997 and 2011, the number of very elderly people is expected to increase by 37 per cent. It is therefore important to have a well-thought-out strategy. Sandwell's age well strategy aims to increase the expectation of good health and social well-being later in life. It is about older people being involved and consulted about what strategies will benefit them and enable them to stay in their homes.
Some of the solutions have been so simple and obvious that they have been overlooked in the past. The focus is on enabling people to remain in their homes, so the 519 strategy has introduced respite care and a specialist health rehabilitation team; and a housing scheme for Asian elders. It has extended the availability of the community alarm scheme and introduced a new gardening and handy person scheme in conjunction with Age Concern to address the issues that can present problems to older people staying in their own homes.
The other borough in my constituency, Dudley, has also been innovative in its approach to try to ensure that people do not have to go into long-term care and to encourage them—through extra support—to try to stay in their homes. In April, it introduced the extra care housing initiative, which is a partnership approach in which the housing department provides the housing provision elements, while the social services department—in partnership with health colleagues—provides the extra care element through care assessment processes and home care schemes.
That scheme has offered prospective tenants sheltered accommodation with wardens who have an enhanced care role as an alternative to residential care. It provides a package of recuperation and rehabilitation that enables older people to achieve a maximum independent life style within a supported environment. The Government are encouraging such schemes by modernising social services and providing resources, and many Labour-controlled authorities are responding.
I welcome the announcements made today by my right hon. Friend the Secretary of State, many of which are based on aspects of the royal commission's report. I want to highlight the long-term care charter, the national service framework for older people, and the insistence on monitoring home care services. In the past, those aspects of care have been neglected.
This Government will be judged on many things at the next election, and one will be their response to the demands for long-term care. The hallmarks of this Government have been fairness and social justice, and I have no doubt that those same hallmarks will be evident in their approach to the problem of long-term care.
§ Mrs. Caroline Spelman (Meriden)
It is not the Opposition's job to respond to the royal commission's recommendations. That is the Government's job, and I am disappointed that the key points of the commission's report have not been addressed. We are working on our own policy for long-term care which will go much wider than the terms of reference given to the royal commission, but perhaps that is one of the privileges of opposition. However, we shall certainly take account of the needs of young people who need long-term care. They should not be forgotten in any debate on this subject.
This has been a strange sort of debate, with hon. Members on all sides of the House describing the problems accurately. The debate has been interesting, too, as many hon. Members have lobbed into the arena their suggestions for tackling the problems that they have described. They have had the freedom to do so because the vacuum at the heart of the debate is the fundamental question of funding.
I am sure that many hon. Members would agree that they have presented their personal ideas on the matter rather than the official lines adopted by the parties to 520 which they belong. Perhaps the debate has been all the better for that, but the curious effect has been to create the impression that we have prowled around the central question of funding without discovering what the Government intend to do about it.
The welfare state was set up to provide a cradle-to-grave formula for care. There is no point in wasting time discussing how miscalculations were made at that time, but those miscalculations mean that the wrong expectations were set for a fifth of our population. The debate is serious because it concerns so many people.
I expect that the politicians of the time were tempted to oversell their policies somewhat. That problem exists today and probably will persist in the future, but the difficulty left for today's politicians is serious, and it is getting worse.
There has been a consensus in the House in support of the hon. Member for Dunfermline, West (Ms Squire), who said that we have a moral obligation to the wartime generation, if I may call them that. The people of that generation are the ones who feel most keenly that their expectations have been dashed.
In both the majority and minority reports from the royal commission there is a worrying note of complacency about the affordability of long-term care, which is based on the fact that the threat of a demographic time bomb has been exaggerated. However, other key social trends in British society will affect our ability to afford the quality of long-term care that we would like to provide for those who need it.
The effect of increasing job mobility and of more women going out to work will inevitably cause a reduction in the level of informal care provided, especially for older kith and kin. Another, darker trend in British society—family breakdown—will also affect our ability to pay for long-term care.
One in three marriages now end in divorce, and the proportion is rising. More relationships are informal than used to be the case but, sadly, they are also prone to fracture. In families that are constituted along less traditional lines, the sense of obligation to older family members is becoming weakened. Will step-grandchildren feel the same obligation to care for the grandparental generation? Will children feel the same sense of obligation to the absent parent, be it father or mother?
The burden of such broken family relationships and of the weakening of the obligation of family bonds will be borne by the state. While the demographics may prove to be more predictable, the new social interpretation of honouring thy father and mother could turn out to be much more difficult for Governments to cope with. The hon. Member for Kilmarnock and Loudoun (Mr. Browne) may find that the £6 billion assessment of what the royal commission's recommendations would cost the Government in 2051 turns out to be wildly inaccurate because of the loss of informal care. We were rightly given a timely reminder by the hon. Member for Belfast, South (Rev. Martin Smyth) that we must be realistic when dealing with human nature.
We do not start from a strong position in 1999. There is already a significant gap in funding. All over the country, there tends to be a shortfall of about £50 in the funding of residential care. To take only a couple of examples, in Cornwall the cost of residential care averages £252 a week but funding from social services is 521 £208. In Birmingham, the figures are £290 and £230. That gap presents politicians and relatives of people in residential care with the problem of who should pay. The money comes from family members if they are willing to pay; sometimes they are not. That causes enormous friction in the family. It also places the elderly resident in a predicament that can become embarrassing in a care home setting. If residents still have faculties, they worry about the shortfall from week to week.
§ Mrs. Virginia Bottomley (South-West Surrey)
Does my hon. Friend accept that that is a particular problem in some of the high-cost home counties, where the independent sector, to provide a quality service—but one that hon. Members will feel is appropriate for older people—pays 30 per cent. above normal rates for care staff and nurses? In the home counties, the health service gets no London weighting allowance. Those areas are penalised for being prosperous without any recognition of the enormous cost of care. The crisis for the elderly is probably more acute now in the home counties and the officially prosperous areas than anywhere else in the country.
§ Mrs. Spelman
I thank my right hon. Friend. In this debate, several examples were given of how that is inextricably linked with the standard spending assessment, which varies around the country. The problem is aggravated in counties where assessments are unsatisfactory. She provides another example of a badly affected county.
How is the funding gap filled? The resident or the resident's family often have to dip into residual capital. The lower threshold of £10,000 introduced by the previous Government has not proved sacrosanct in reality.
There is some dispute over the number of homes sold annually to pay for residential care, but I hope that no one disputes that it is happening. The hon. Member for Broxtowe (Dr. Palmer) used the word "agony" to describe the reaction of some people whose expectations are dashed and who find that they cannot pass on to their offspring the things that they have worked, scrimped and saved for all their lives. It is to try to underpin a savings culture that the Conservative party has been keen to encourage people to make savings and to avoid policies that would reward profligacy. As the savings ratio is going down, we urge the Government to pay attention to the matter.
Our document "The Common Sense Revolution" sets out some of the steps in our consideration of long-term care for the future. Long-term care partnership is a cornerstone of our ideas. We propose that for every £100 of insurance bought by individuals, £150 of their assets would be protected. In case that proves too ideologically difficult for Labour Members, I refer them to the comments on the report on long-term care made by the former Secretary of State for Health, the right hon. Member for Holborn and St. Pancras (Mr. Dobson). He said that the Government wouldapply the principles set out in our welfare reform Green Paper—in particular: expecting people to insure against foreseeable risks and to make provision for their retirement."—[Official Report, 1 March 1999; Vol. 326, c. 743.]522 Given those remarks, there can be no major ideological objection from Labour Members. Indeed, we are encouraged to hear that the Government are willing to explore that avenue.
§ Mrs. Spelman
I should prefer to continue, as we have only limited time for the debate.
The hard facts are that 500,000 people are in long-term care—150,000 of them in nursing homes—and, of that number, 42,500 are funding their own care. While the commission was holding its consultations and producing its report, 75,000 homes were lost. If we are prepared to be honest, we know, as politicians on the doorstep, that people find that situation unacceptable. Rather like explaining the facts of life, I have had to justify, painfully, to elderly constituents—indeed, to my own relatives—the fact that almost all their assets have had to be used for funding their care. There is not much dignity for elderly people when youngsters have to tell them that.
There is even less dignity in the situation described so movingly by my right hon. Friend the Member for Tonbridge and Mailing (Sir J. Stanley)—the disparity experienced by those who have preserved rights but are evicted from nursing homes where they have lived for a long time. It is worth making one point that he did not make in order to increase the note of urgency in his request to the Government: when elderly, frail residents are moved from one establishment to another, unfortunately some of them do not long survive such an upheaval late in their life.
Given the family unfriendly life style of most Members of Parliament, there is a high chance that many colleagues who have spoken brought some of their personal experience to the debate. Nearly all of us brought experiences gained in our professional capacity. We are concerned when we visit a nursing home and see that something is going wrong—perhaps it was the stale smell of urine, or the vacant look of residents with nothing more stimulating than a flickering television to look at. Perhaps it was the undetected toothache of an elderly resident that resulted from malnutrition, or toenails uncut because chiropody services have to be paid for—that is a false economy because it impedes mobility.
It is not hard to see what we would do better, as a blood relative facing that situation, but, in so many cases, for practical reasons, care has to be delegated. We therefore repeat our request to the Minister that when he reconsiders the care standards Bill, extra attention will be paid to the regulation of the quality of care provided. Perhaps the Minister could confirm that when he winds up the debate.
We question the focus of the document "Fit for the Future?". As the hon. Member for St. Albans (Mr. Pollard) pointed out, the document's proposals would saddle those who provide nursing care with some most unwelcome burdens. It is the quality of human care that is important, not the room sizes, the allocation of wardrobe space, the position of windows or the number of double or single rooms.
The training of care assistants is minimal. My researcher described how, during one of her vacations when she was a student, she was put straight to work in a residential nursing home with no training at all. It would be so different if we heeded the words of my hon. Friend 523 the Member for Broxbourne (Mrs. Roe), who suggested that training should include palliative care, which is such an important part of quality long-term care.
Moreover, vulnerable adults are often involved. We gave assistance to the private Member's Bill, introduced by the hon. Member for Stourbridge (Ms Shipley), that became the Protection of Children Act 1999. I listened with great attention to what she said about the need to legislate for vulnerable adults, and I should like to place on the record the fact that it was my hon. Friend the Member for Runnymede and Weybridge (Mr. Hammond) who tabled an amendment to that Bill to try to ensure that adults of diminished capacity—I think especially of those who suffer from dementia, who often make up a large number of those in long-term care—might be protected by legislation as a matter of urgency. Proper training and checking of the suitability of those who care for people with long-term needs is an imperative.
An older person living in their own home, in need of long-term care, may be subjected to all sorts of indignity: a veritable army of different carers calling during the day, chopping and changing, with no continuity. Demarcation may be a distinct problem when, for example, a home help cannot help someone with a personal care issue. The service is provided at the convenience of the service provider rather than at the convenience of the person to whom that service is administered. Not every grown-up with all their faculties wants to be put to bed at 9 o'clock in the evening. Recipients of long-term care often feel more done to rather than done with.
In the few moments that remain to me, I shall return to a point raised by my hon. Friend the Member for Bromsgrove (Miss Kirkbride) regarding value added tax. Apparently, under the regulation of the private recruitment industry proposed by the Government, there will be a shift in employment responsibility from the elderly or handicapped person requiring a carer in the home to the agency supplying the carer. Agencies will then incur irrecoverable VAT charges. Naturally, the costs will be passed on to the client—hence the term "granny tax".
We have taken advice from Queen's Counsel, and we believe that the Government have the possibility of obtaining an opt-out from the sixth VAT directive as a result of article 13, which permits an exemption forservices closely linked to welfare or social security work".We would most strongly urge the Government to seek such an opt-out because, probably alone in Europe, we have so much private provision of domiciliary help compared with other European Union member states. It is absolutely in our national interest to request such a derogation, which would protect our elderly and vulnerable from that unnecessary tax.
§ Mrs. Spelman
I shall not, as I have only a couple of minutes left.
It seems to me that we have spent most of the last six hours walking round and round the main problem of long-term care—its funding—without a proper response from the Government. The promise of a White Paper is a poor substitute. What is the point of a comparison with other royal commissions on different subjects in the past? 524 The present Government pledged to work out a fair system of funding. The royal commission said that change was imperative, and today we have missed an opportunity.
§ The Minister of State, Department of Health (Mr. John Hutton)
The debate has been of a high quality. It may say something about the time that I have spent in the House of Commons, but I feel that it has been one of the best debates that I have heard.
We have had the benefit of some very strong opinions from my hon. Friends the Members for Stockport (Ms Coffey), for Blackpool, North and Fleetwood (Mrs. Humble) and for Halesowen and Rowley Regis (Mrs. Heal), largely based on their personal experience of that aspect of our society, and from the hon. Member for Broxbourne (Mrs. Roe), who made an excellent speech on the basis of her long association with, and interest in, the subject, which certainly showed. The debate has given us a useful opportunity to discuss these very important issues.
After my right hon. Friend the Secretary of State had spoken, the hon. Member for Runnymede and Weybridge (Mr. Hammond) responded on behalf of the Conservatives. I am afraid that it struck me, and I suspect my hon. Friends, that he had used a speech that he had—obviously and rightly—prepared earlier, which failed to recognise the significance of some of the announcements that my right hon. Friend had made, and the clear timetable that my right hon. Friend had outlined for responding to the royal commission proposals. The hon. Gentleman made the interesting and intriguing remark that he felt that local authorities were inadequately funded. I am sure that the right hon. Member for Horsham (Mr. Maude), the shadow Chancellor of the Exchequer, will want to query and question the hon. Gentleman about exactly what additional money he is asking to be spent in that area.
§ Mr. Hammond
For the record, I said to the Secretary of State that the much-vaunted increase in social service spending was not evenly spread geographically, as the Minister well knows. Counties in the south-east are suffering from underfunding of their social services because of the distribution to the north.
§ Mr. Hutton
All right. I am prepared to accept that the hon. Gentleman might have said that if that is what he thinks he said. We will all have the benefit of checking and reading Hansard in the morning. However, as the hon. Gentleman was speaking, I made a note of his reference to the inadequate funding of local authorities. I am sure that we will resolve the issue in the usual way.
Rather interestingly too, the hon. Gentleman referred to a breach of contract represented by the existing arrangements for funding long-term care. Generally, the debate has been marked by the absence of party rancour, and I do not want to spoil that. But—[Interruption.]—there is always a but—I have to point out to the hon. Gentleman that it was the Conservative Government who drew up the contract. If there has been a breach of contract, we know who is responsible and we know who drafted its terms. Some Conservative Members—not all, because others have approached the debate in a very 525 responsible way—have been attempting to airbrush themselves out of any responsibility for the present mess—
§ Mr. Hutton
I will certainly not give way to the right hon. Lady. I have a great deal of respect for her, but she has not been present throughout the debate. I am happy to give way to hon. Members who have been part of the debate, but the right hon. Lady has not.
§ Mrs. Bottomley
On a point of order, Mr. Deputy Speaker. I think that it is a courtesy that, even if by implication an hon. Member has referred to another hon. Member, it is appropriate to give way. I understand that the time that the Minister was referring to was almost certainly the time when I was holding office and responsible for community care legislation. It is—
§ Mr. Deputy Speaker (Mr. Michael Lord)
Order. It is entirely a matter for the Minister whether he gives way.
§ Mr. Hutton
My hon. Friend the Member for Blackpool, North and Fleetwood made a good speech. She expressed her concerns about whether the new national minimum standards would be a voluntary, as opposed to a statutory, scheme. I can confirm that it will be a statutory scheme enforced by the new national care commission. Our proposals in relation to the national minimum standards will be set out in the Bill on care standards. My hon. Friend has not had the opportunity to read it because it has not been published. It will be published tomorrow, and she will be able then to read the details of our proposals.
My hon. Friend and several other hon. Members referred to their concerns about "Fit for the Future?", our draft standards for residential and nursing homes in England. I shall deal with their concerns later in my speech, because I want to reassure them about the proposals.
The hon. Member for Sutton and Cheam (Mr. Burstow) and other hon. Members wanted us to announce our final conclusions today in response to the royal commission. I must point out to the hon. Gentleman and the hon. Member for Meriden (Mrs. Spelman) that both their parties have been asking for the debate so that the House might express its views before the Government announce their final decisions. It is rather remiss of the hon. Gentleman, and rather a cheap shot, to make the allegation that he did, given that his party has been pressing the Government for a listening debate, for an opportunity to discuss these issues before any final decisions have been made. With respect to the hon. Gentleman, I think that it is probably better if we all avoid that sort of cheap-shot approach to these important issues.
When the hon. Gentleman tried to expound his position on the royal commission, I think that he probably left most of us completely in the dark when it came to whether he was supporting its main recommendations. [Interruption.] I was listening to him. I think that the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) might have shot his fox because he announced his strong support for the main recommendations set out in the 526 majority report. That left the hon. Member for Sutton and Cheam slightly exposed. I am sure that we shall become aware of the position of the Liberal Democrats on these issues in due course. However, I am not confident that that will be before the Government have announced their final set of proposals.
My hon. Friend the Member for Corby (Mr. Hope) made a very good speech. He highlighted the need to develop better preventive and rehabilitation services in the national health service and local authorities. I am sure that he heard my right hon. Friend the Secretary of State make the Government's position on those issues clear: we strongly support such initiatives and developments. That is why we are making additional resources available.
The right hon. Member for Tonbridge and Malling (Sir J. Stanley) made an outstandingly impressive speech. Anyone who heard the strength and the depth of his concern for his constituent could not fail to have been moved; I certainly was. In particular, he asked whether I could announce the introduction of emergency legislation to amend section 43 of the National Health Service and Community Care Act 1990. I am sure that he will not be surprised to know that I am not able tonight to confirm the Government's intention in that respect, but I hope that he heard the Secretary of State make it clear, when he opened the debate, that we are actively considering the implications of transferring to local authorities the funding and care management responsibility for people on preserved rights of income support. That may not be sufficient to satisfy the right hon. Gentleman's immediate concerns, and I understand that. However, I am always willing to talk in more detail with him about them. I should welcome such a conversation, because he obviously has very strong opinions on the subject.
My hon. Friend the Member for Dunfermline, West (Ms Squire) also, I am glad to say, welcomed the Secretary of State's announcement. She spoke strongly about her views on the subject, and we all respect the strength of her feelings. Her support for pensioners was made clear.
The hon. Member for Broxbourne clearly has a great deal of knowledge of the subject, and that certainly showed. She announced that she had seven principles on which she wanted to base any future reform. She has rather trumped the three principles that we announced today, but the broad thrust of the principles that she outlined was consistent with those that the Secretary of State announced. I look forward to her continuing support as we try to introduce fairer arrangements.
I particularly welcomed the hon. Lady's comments about carers, because they are an important part of the system. It is important that we try to build, if we can, a solid basis of support for any future changes, so that people know exactly where they stand and can make proper decisions about their own futures. I also welcome her support in principle for the idea of national standards for nursing homes. I hope that she can persuade those on the Opposition Front Bench about that, because they seem to oppose the idea.
My hon. Friend the Member for Stourbridge (Ms Shipley), who introduced and saw through the House the Protection of Children Act 1999, also made a very good speech. She raised the question of protecting vulnerable adults. I am glad to tell her that new provisions protecting vulnerable adults along the lines of those in 527 that Act will be included in the Bill on care standards, which will be published tomorrow. I hope that she will be able to support those proposals.
My hon. Friend also raised the issue of new national minimum standards. They will be implemented by the national care commission, and I assure her that compliance with those standards will be a condition of continuing registration. She can be confident that those national standards will make a difference.
The hon. Member for Belfast, South (Rev. Martin Smyth) advised the Government to take time to get any new framework right; we certainly want to get it right this time. We now have an important opportunity and we want to make the most of it. We have set out a clear timetable for proceeding, and I hope that the hon. Gentleman will think that that is the sensible approach. He asked whether national minimum standards will apply throughout the United Kingdom. My understanding is that there will be minimum standards for England, Scotland and Wales, but I am not sure what the position is with the new devolved Administration in Northern Ireland. That clearly will be a matter for that Administration.
§ Rev. Martin Smyth
The Minister will remember that I pleaded that the standards should be not the lowest common factor, but the highest common denominator.
§ Mr. Hutton
Yes, I remember the hon. Gentleman saying that. However, he should remember that this will be the first time that we have attempted to set national minimum standards throughout that important sector. That is a significant step forward, which is necessary if we are to tackle the quality of care being provided in residential settings. I know that some people do not like that idea, and I intend to address those concerns in a few minutes.
My hon. Friend the Member for Stockport made a particularly good speech, in which she explored some of the wider principles that could, or should, guide our approach in future, as well as the detailed points arising from the royal commission. She will know that, today, we are not making final announcements about all the royal commission's recommendations on funding long-term care. I am sure that she will continue to take a close interest in those matters, and we certainly look forward to hearing her further contributions.
My hon. Friend the Member for Broxtowe (Dr. Palmer) expressed his concern about the need to avoid compulsory house sales to fund long-term care. I am sure that he will be glad to hear that, as the Secretary of State made clear, that is one of the six areas to which we are giving particularly detailed attention.
My hon. Friend the Member for Kilmarnock and Loudoun (Mr. Browne) made an interesting speech. I tried to follow it closely, but I am afraid that I missed most of it, and I have some sympathy with the Hansard reporters. I wonder what they will make of his contribution. He told me that he had taken the precaution of sending them in advance a copy of his speech, and I am sure that that will make all the difference.
The hon. Member for New Forest, West (Mr. Swayne) made one of his characteristically interesting speeches. He struck me as being a fan of the old poor laws, and some 528 of his terminology harked back to those desperately grim times. If I have done him an injustice, I am sure that he will correct me whenever he wants to.
Many hon. Members have expressed their concerns about the present system of providing long-term care. It is clear that, if we are to address those concerns in a sensible and sustainable way, we will need long-term solutions. That is certainly the Government's approach, and one that my right hon. Friend spelled out clearly in his speech earlier this afternoon. However, we need to recognise that finding those solutions will not be the responsibility only of social services or the NHS. The issues raised are for our society as a whole to face and resolve. As my hon. Friend the Member for Halesowen and Rowley Regis made clear, old age will, inevitably, touch us all, either in our own lives or the lives of those around us. It was Francis Bacon, in 1625, who rightly said:Age will not be defied.
We live in an ageing society. Over the next 40 years, the number of people aged 85 and over will double. People are entering care later—the average age is already 84. When older people enter residential care, they are more likely to be frailer and in need of more intensive care and support. As the hon. Member for Meriden said, as patterns of family life are changing, so too are the networks of care and support for older people. There are therefore big challenges ahead of us if we are to respond effectively to those trends, and in so doing, lay the foundations for a better and more secure environment for our older people. Those are issues on which I hope we can all agree.
First and foremost, we have to ensure that we maintain and promote the independence of older people. All hon. Members who have spoken in the debate have expressed their strong support for that aim. People naturally want to stay for as long as possible in their own homes, where they feel most comfortable and content. We all would want to have that option and to be able to exercise it.
That means providing the necessary support that older people need at home, at the time that it is needed. It also means helping their informal carers to do their vital job more easily, and giving them the support that they need. That is why we are making significant additional resources available in both those areas over the next three years. We are providing £140 million for our carers strategy and £750 million in new local authority grants.
Secondly, when people need to enter residential care, they need reassurance that the quality of care will be of the highest standard, in conditions that respect their privacy and dignity at all times. That is why we are developing, in consultation with providers and all other interested parties, new proposals for national minimum standards for residential care homes so that the public at large can have full confidence in the system.
Those standards must be realistic and affordable. They must give providers a sensible time scale in which to make any necessary changes. The new independent national care commission will need to be up and running before they can be properly implemented.
Clearly, the present arrangements are not good enough. They do not provide a level playing field between the public and the private sector, nor do they guarantee proper consistency across the country. Those are both crucial if any inspection and registration scheme is to be effective 529 and satisfy proper public confidence. There are too many loopholes and problems in the existing scheme, which mean that some homes are not inspected at all, and poor quality homes are not easily closed down.
Our new proposals will deliver a more effective and efficient system. The principle of independent regulation has been widely welcomed by the industry. The care standards Bill, which will be published tomorrow, will contain the details of the new arrangements and I am sure will be considered in detail in the House and in another place. I hope that our announcement today that we are broadly accepting one of the two main recommendations of the royal commission by establishing the new national care commission will be welcomed by hon. Members.
§ Mr. Hammond
I thank the Minister for giving way. Will he clarify whether the care standards Bill will contain the details of the standards, or only the details of the framework? If the latter, can he assure us that the standards will be available to us to consider in parallel with the Bill?
§ Mr. Hutton
Let me correct any misunderstanding that I may have caused the hon. Gentleman and the House. The Bill will not contain the details of the national minimum standards—I hope that that is clear. It could not contain such details, for the simple reason that we have not yet decided what the national minimum standards will be. We are still consulting on that, and the end of the consultation period has been extended to 21 January, because of the concerns about accessing and having the document available for people to read and digest. We have had more than 10,000 copies of the document prepared, given the extensive interest in its contents.
I want to reassure the hon. Gentleman and several of my hon. Friends who have raised concerns about "Fit for the Future?" that we are consulting. No decisions have yet been taken in relation to the detail of those standards. That would be quite improper while the consultation was under way. The consultation period will finish on 21 January, and we hope to settle the final national minimum standards thereafter.
As I do not know the Committee timetable in the House for the care standards Bill, I cannot give the hon. Gentleman the absolute assurance that he wants that the standards will be available by the time that the Standing Committee meets to discuss the Bill. We shall try our best to make sure that that is possible, but I cannot give the absolute assurance that he seeks from me today.
Improving the quality of long-term care will require us to look further than just the buildings in which residential care is delivered. Improving the training of the social care 530 work force will be vital. The social care work force as a whole is now more than 1 million strong, and yet 80 per cent. of the work force have no social care qualifications of any kind.
We must improve the situation as a matter of urgency. That is why the Government have established a new national training organisation for personal social services. We are currently consulting on a draft national training strategy, which has been prepared in consultation with the employers and providers. We are providing an additional £120 million through the training support grant to improve social care training.
Thirdly, the system of funding long-term care must be fairer, not only between the taxpayer and the individual, but across the generations. Any changes must be sustainable over the longer term. That is why it makes sense for decisions in this important area to be taken as part of the spending review that is currently under way and will be completed by next July.
My right hon. Friend identified six issues raised by the royal commission which we are examining in particular detail and which reflect many of the concerns expressed during the debate today. That shows that the Government are taking these matters seriously and are moving forward as quickly as we can.
The way in which long-term care is funded is an important part of the debate, but it would be a mistake to overlook the importance of the quality agenda and the need to give people real and effective choices about where their care is delivered. Making changes to the funding mechanisms without tackling those two related issues would undermine our efforts to find a genuinely long-term solution.
Today, the Government laid out the clear timetable that we are following in responding to the royal commission's recommendations. We have set out the principles that underlie our approach to making the system fairer and better. I am grateful to all hon. Members for their contributions to this important debate, which I am sure will continue both in this place and outside. There are big challenges ahead. We have made it clear that work is in progress. The Government will respond fully and comprehensively to each of the challenges.
§ It being Seven o'clock, the motion for the Adjournment of the House lapsed, without Question put.