§ 3.9 p.m.
My Lords, I beg to move that the Health and Social Services and Social Security Adjudications Bill be now read a second time. This Bill marks another important step forward in the continued development of policies which we believe will improve the health and welfare of the population. It contains provisions on health, personal social services and social security adjudication matters and thus expands the whole range of issues for which I and my right honourable and honourable friends at the Department of Health and Social Security, the Scottish Office and the Welsh Office are responsible. May I briefly remind your Lordships of the main elements of the policies which this Government have vigorously promoted. They have been the subject of debate in your Lordships' House on many occasions. Those which are reflected in this Bill and which are central to our purpose today are, first, to encourage care in the community rather than in institutions for the elderly, mentally ill, mentally handicapped and disabled people; secondly, to provide the best possible services for children, particularly by strengthening arrangements for the protection of those who are most vulnerable; thirdly, to streamline administration, reduce bureaucracy and make all services for which we are reaponsible as efficient and, therefore, as effective as possible.
I turn to the Bill before your Lordships. Part I of the Bill clarifies and extends provisions for health authorities in England and Wales to make payments to local authorities and other statutory bodies and voluntary organisations, and makes comparable provisions for Scotland. The purpose of this Part is to promote care in the community. It is widely accepted that those in need of care should be helped to keep in touch with family and friends and normal life and should have to stay in hospital only if they require a level of constant nursing and medical care which it would be impracticable to provide anywhere else. This is generally what they themselves want and what those responsible for their care believe to be best for them. Similar policies are being pursued in Wales and Scotland.
In recent years local authorities have made considerable progress in building up community care services, but they are finding it increasingly difficult to 721 take on extra commitments within their current resources. If responsibility for the care of many long-stay hospital patients is to be transferred to local authorities, a matching transfer of resources is needed so that the local authorities and the voluntary sector, which has a lot to offer, can provide alternative facilities.
But there are obstacles. In July 1981 the DHSS published a consultative document, Care in the Community, which sought views on a number of ways of overcoming these obstacles. A similar document was published by the Welsh Office. In July this year my right honourable friends the Secretary of State for Social Services and the Secretary of State for Wales announced the Government's decisions. In some cases action can and will be taken administratively. Health authorities will be able to make continuing annual payments for as long as necessary for people moving into community care, and joint finance will be available for extended periods. The joint finance allocation is being increased by £6 million next year to help promote this initiative. Guidance to authorities will be issued shortly.
Other obstacles can be removed only by legislation. The response to the consultative document showed strong support for extending the joint finance arrangements to education for disabled people and to housing. But at present there is statutory provisions for this. The principal object of Part I of the Bill therefore is to enable health authorities to support housing and education expenditure. The other provisions of Part I largely repeat existing provisions for transferring funds but make them more flexible.
My right honourable friend the Secretary of State for Scotland hopes to consult health boards and the Convention of Scottish Local Authorities on means of securing more effective collaboration between the various agencies involved in community care. Meanwhile in this Bill he is seeking legislative power to make comparable extensions to the scope of the existing support finance scheme in Scotland.
For Wales only, this Part of the Bill provides parallel powers for the Secretary of State to make payments for the development of community care. These will enable my right honourable friend the Secretary of State for Wales to act directly where this would be the most effective and efficient means of promoting community care in a situation where he controls, through the Welsh block vote, the expendituere of the range of bodies involved, and where, therefore, he can order priorities within agreed public expenditure totals.
Still on the theme of improving community care, I turn to Part IV of the Bill, which follows on logically, if not serially, from Part I. This part contains provisions for improvements in England and Wales concerning the arrangements for voluntary and privately run homes for elderly people, disabled people and the mentally disordered, and for nursing homes. These provisions arise from consultation earlier this year on the registration system for residential homes. Three hundred sets of comments were received on the consultation document, A Good Home, and there was general agreement on what was proposed. Here I wish to thank all those who sent us their views. They were all most helpful.
722 Voluntary and private homes have a valuable part to play in the Government's policy for community care, as part of the partnership between public services and those provided by others. Indeed, there are areas such as the South Coast where some of the statutory health and social services would be swamped if these homes did not exist. It is most important, therefore, that these homes should provide an acceptable standard of care and service. The consultation confirmed that changes are needed in the law governing the registration of residential homes, and these are in Part IV of the Bill. They include a clearer definition of the establishments to be registered; improved arrangements for appeals against decisions of the registration authority; and provisions for increased fees—on a banded scale—which will offset the registration authorities' costs arising from registration and inspection. Regulations will specify the minimum frequency of inspection, which we intend should be at least once a year. Another important new provision is that nursing homes will no longer be precluded from registering also as residential homes, and this should allow greater flexibility of care within a single establishment.
We believe that a code of practice, which is to be drawn up by a Working Party from the Centre for Policy on Ageing, and the legislative changes, will bring authorities into closer relationship with the private and voluntary sector, and should in many cases result in an improved standard of service. This should, in turn, encourage authorities to make better use of the resources available to them in the private and voluntary sectors.
I will now turn to the family practitioner services, which form the front line of our health service. Part V of the Bill fulfils our commitment to make family practitioner committees fully responsible for their own administrative arrangements. The Government announced their decision in another place in November 1981 and we reaffirmed our intentions in July of this year. The Bill requires the Secretaries of State to establish new family practitioner committees in England and Wales to replace those which are, at present, established by district health authorities. At present DHAs appoint FPC staff, determine and pay their management costs, and provide them with accommodation and equipment. But, at the same time, the committees are directly accountable to the Secretaries of State for arrangements for family practitioner services.
These complicated arrangements were intended to create opportunities for bringing hospital and family practitioner services together within an integrated health service. However, although collaboration has developed satisfactorily in many parts of the country, the administrative dependence of FPCs on DHAs has caused problems of delegation and accountability, and has led to the creation of an unnecessarily complex bureaucracy. Last year, therefore, we sought views about possible changes in the arrangements for FPCs. A majority of those we consulted favoured the decision which we ultimately took, to seek legislation to enable FPCs to manage their own affairs. This Bill sets out a number of measures to this end.
In order to establish the lines of responsibility, the Secretaries of State will establish the committees and 723 appoint their chairmen, vice-chairmen and other members. We intend to consult on nominations and to preserve the traditional balance of membership within the committees. To promote collaboration, there will be cross-membership with DHAs, which will continue to be responsible for producing comprehensive local health plans. At least one member of the FPC will be a nurse with community experience, and we propose that there shall be both formal and informal local arrangements to ensure appropriate communications between the FPC and DHAs. FPCs will also be formally represented on the existing joint consultative committees which involve local authorities in the planning of health and personal social services.
We intend that the provisions governing public admission to meetings shall extend to FPCs, and that Community Health Councils should be informed of appropriate matters relating to FPC issues. FPCs will appoint their own staff and be responsible for their own administrative arrangements and management costs. Cash limits on administrative costs will continue to apply to FPCs, as they do to health authorities, and, like health authorities, FPCs will be called to account.
I come now to Part III which concerns the stream-lining of the Central Council for Education and Training in Social Work. Like Part V which deals with family practitioner committees, this provision relates to two of our main policy objectives—the development of community care and the streamlining of administration. The provisions in Part III are designed to enable the council to operate more efficiently in meeting the demands which are placed on it.
This council has important functions throughout the United Kingdom for the training of staff who work, or intend to work, in the local authority and voluntary social services, the probation service and the education welfare service. The council was established in 1962 and since its creation it has made a significant contribution to the rationalisation of training in the social services and the other services within its remit. Much is owed to the work and dedication of its chairman, members and staff. But since it was established it has grown, through successive restructurings, from 32 to 64 members. Originally Ministers appointed 21 members; now they appoint only eight, with the remainder appointed by a variety of bodies—34 in all—with an interest in the council's work.
Consultation in 1980 with a considerable number of interested bodies showed that a large majority thought the council had become too big. We have, therefore, concluded that the council's membership, excluding its chairman, should be a maximum of 25. This is the most important change provided in this part. But there are four other related changes—appointment of members by Ministers after appropriate consultation; powers for the Secretary of State to dismiss chairmen and members in certain circumstances; more flexible powers for the establishment of committees; and powers to make grants to students, currently made by Government departments.
I hope that your Lordships will see these changes as likely to provide the council with a more efficient and flexible structure through which to carry out its 724 important work. Next I will deal with improvements to children and young persons' legislation. The most significant change we wish to see concerns the 12 regional planning committees set up by the Children and Young Persons Act 1969 to plan a comprehensive system of community homes for children in care. Originally these committees were crucial for this purpose but the need for formal planning machinery is now much less. We therefore agreed, with the local authority associations, that a mandatory procedure was no longer appropriate. We still believe that co-operation between authorities is essential to ensure access to as wide a range of facilities as possible. In future, authorities will be able to provide community homes or use those of others, but without the need for a statutory regional plan.
The existing valuable arrangements for co-operation between authorities and the voluntary sector in providing homes are being safeguarded, but provision is made for local authorities to withdraw from these arrangements under conditions similar to those already available to voluntary organisations. Opportunity has also been taken to widen the use to which community homes may be put—for example, as intermediate treatment facilities.
There are a number of other important individual improvements to children's legislation which I am sure your Lordships will welcome. They include clarification of the requirement to give notice before a child can be removed from care and the introduction of statutory powers of entry where this has been denied to the supervisor of a child believed to be at risk of abuse.
Part VII of the Bill makes the legislative changes required to implement recommendations of a working group of central and local government representatives which reported in 1980 on charges for the personal social services. These legislative changes have been agreed with the relevant local authority associations. The aim of these changes is to eliminate inconsistencies in existing legislation, to reduce the administrative burden of assessing and collecting charges and to give greater freedom to individual authorities in determining their own charging policies.
Clause 12 brings consistency to the various powers under which authorities in England and Wales may charge for services such as home helps, aids and adaptations to houses, or places in day centres. The terms of all these powers are brought into line with those already in Schedule 8 to the National Health Service Act 1977. They enable authorities to make such charges, if any, as they consider reasonable, having regard to the means of the persons availing themselves of the services. No new charges are being introduced, but authorities will be able to take more account of what those using the services can afford. Few would disagree that this is right. The Scottish powers in this clause relate also to contributions in respect of children in care.
Clause 13 gives effect to the group's recommendations in relation to parental contributions for children in care, and contributions by 16-year-olds and over in care. The change now proposed will enable local authorities in England and Wales to fix a flat rate contribution with freedom to waive or reduce the contribution in the light of the parents' or the child's circumstances. The clause also implements the group's 725 recommendation that, in the same way as 16-year-olds who are earning while in care are required to contribute towards their keep, those receiving social security benefits and certain training allowances should also be required to do so.
Clauses 14 to 18 are concerned with local authority charges for residential accommodation. The intention is, first, to reduce the administrative burden on authorities of assessing and collecting charges and, second, to reduce the financial burden on ratepayers of contributing excessively and inappropriately to the cost of accommodation.
Clause 19 and Schedule 8 to the Bill will streamline and strengthen the adjudication arrangements for determining the right to benefits under social security legislation. The Council on Tribunals has welcomed, in principle, the three main changes, which are, first, a single tribunal—the social security appeal tribunal—which will replace the present national insurance local tribunals and supplementary benefit appeal tribunals. Members of the new tribunal will be drawn from panels of people with local knowledge or experience. Secondly, there will be appointments of a president, regional chairmen and some full-time chairmen of social security appeal tribunals and of medical appeal tribunals. All will be legally qualified. These appointments will improve the quality and enhance the independence of second-tier adjudication. Thirdly, the three present adjudicating authorities of first instance—insurance officers, benefit officers and supplement officers—will be replaced by a single independent authority called simply adjudication officers. The Bill provides for a new post of chief adjudication officer who will be responsible for advising the new officers and for keeping the system under review. He replaces the three present chief officers whose posts have no statutory backing. This change will simplify adjudication at first instance and emphasise the independence of the system from ministerial influence. The proposed changes in social security adjudication constitute, I believe, a substantial improvement and I hope that your Lordships will welcome them.
Turning now to quangos, we see no need to preserve these non-departmental public bodies which have outlived their original purpose. Clause 20 of the Bill provides for the abolition of three such bodies: the Advisory Council on Child Care, the Food Hygiene Advisory Council, and the Advisory Committee to the National Radiological Protection Board. This is the first opportunity we have had to seek the necessary legislative powers to implement decisions which were taken and announced some time ago. The three bodies concerned have effectively ceased to exist.
I should, however, like to take this opportunity to thank all those who have in the past devoted time and energy to the work of these bodies. We are most grateful for their efforts. As well as introducing new arrangements for family practitioner committees, Part V of the Bill repeals the provisions whereby health authorities in England and Wales which were designated as having special responsibility for medical or dental teaching included the word "Teaching" in their names. This Bill represents the first opportunity we have had to honour the commitment given, following consultation on the restructuring of the NHS, to introduce the necessary repeal.
726 Another NHS matter is contained in Part VI of the BIll, which concerns sick pay for doctors suspended from the medical register because of ill health. A recent legal action has suggested indirectly that an NHS doctor suspended by the General Medical Council on health grounds cannot receive the same financial benefits as a doctor whose illness is not a concern of the General Medical Council. This would be contrary to the recommendations of the Merrison Committee of Inquiry into the Regulation of the Medical Profession and the intention of the 1978 Medical Act. The purpose of this part is, therefore, to ensure that sick doctors within the NHS receive the same benefits and entitlements whether or not they are suspended by the GMC. I should however emphasise that the amendment specifically states that a practitioner suspended from registration will remain precluded from carrying out duties in the National Health Service as a medical practitioner, and the interests of patients therefore continue to be safeguarded. I hope that this House will accept this part as necessary to allow the few doctors who may be suspended by the General Medical Council on health grounds to be treated fairly, while in no way reducing the protection to patients that is provided by the General Medical Council.
I must say that I look forward to hearing your Lordships' views this afternoon on the general principles of the Bill and we shall be glad to hear your Lordships' views on the details during Committee. As an aid to informed discussion during Committee your Lordships may find it helpful to have a copy of the Notes on Clauses which the Government have prepared. These notes set out details of the background to and the provisions of the various clauses of and schedules to the Bill. Copies will be available as is customary from the Printed Paper Office tomorrow.
As I pointed out in my opening remarks, the measures in this Bill are diverse and wide-ranging. They seek to provide better services for the population as a whole. Whether this means enabling a mentally handicapped person to leave hospital and live a fuller life in the community; or protecting the interests of children at risk from abuse; or cutting away unnecessary institutions or bureaucracy; in the end, it is the user who will benefit. On this basis I commend the Bill to your Lordships. My Lords, I beg to move.
§ Moved, That the Bill be now read a second time.—(Lord Trefgarne.)
§ 3.32 p.m.
Lord Wallace of Coslany
My Lords, my first pleasant duty is to thank the noble Minister for his detailed statement on the provisions of the Bill—it certainly was detailed. However, I must admit that I felt that his claims for the Bill in his early remarks were somewhat exaggerated. On 4th November last, during a debate on the gracious Speech, I drew attention to the fact that a measure would be introduced to improve the health and social services. I said that I had feared the worst but I was reassured by the speech of the noble Baroness, Lady Young. Then, unheralded and unforeseen, the Government have produced with 727 speed this ragbag of a Bill which, like the curate's egg, is good in parts—and that, of course, is putting it in my accustomed polite manner.
We have had so many health and social security Bills in the life of this Parliament that we shall soon need some consolidation measures. In general I would support the provisions of Part I, except that I cannot understand why subsection (4) of Clause 1 is written into the Bill. As I understand it, a joint consultative committee is virtually a veto on payments by a constituent authority. The Bill states that no payment shall be made by any authority unless it is recommended by a joint consultative committee of which the authority is a member. In my view that is an entirely negative and restrictive approach. Situations may vary in authority areas. Some authorities might be progressive and others not so forward looking, and therefore a lot could depend on the composition of the consultative committee. The system indicated in the Bill seems to be somewhat clumsy and complicated.
Voluntary agencies are very much involved in the Bill's provisions, but the Government's consultative documents proposal for voluntary organisations to receive direct funding from the DHSS is not included. Voluntary agencies, housing and education authorities should be represented on joint consultative committees.
As regards child care, Clause 3 will allow individual local authorities to withdraw from constructive regional planning arrangements even if a majority of the authorities wish to continue. In my view, that is not in the interests of efficient local administration and if a majority of authorities wish to continue present arrangements they should be allowed to do so.
As far as residential homes and nursing homes are concerned, I agree with the statement made by the Minister that private and voluntary homes do play an important part in the care of the elderly and handicapped, among others. I welcome with some degree of reservation the proposals to license and inspect such homes. It would appear that the licence when granted will be subject to a fee and possibly an annual payment. No mention is made, however, regarding renewal of the licence. Would it not be better to tighten up control by having the licence renewable periodically—say every three years or so? I agree that inspection should be carried out every 12 months and I welcome the Minister's statement to that effect. But I must agree that inspection must not be cursory: it must be thorough and tight in its effect.
Charges made not only by private homes but also authority-owned homes can in many cases be excessive. For instance, a friend of mine, a bachelor in lodgings and an old-age pensioner with a private pension, was charged some time ago £86 per week for temporary accommodation in a local authority home during his landlady's holiday. Private homes are much more expensive and beyond the means of the majority of people needing such facilities. I am not necessarily referring to places run by charities, but there is no doubt that in many other cases charges are far too excessive and call for investigation and control.
Age Concern in a press release today states:At its best the private sector home is very good but at its worst it represents a scandalous exploitation of elderly people, who may be dumped by uncaring relatives with no questions asked for as long as the money lasts".728 That is a sweeping generalised statement, but to be quite honest it must be admitted that it is not unjustified. There is certainly a need for stricter and tighter control of private nursing homes, particularly in the provision of nursing care, and for a comprehensive code of conduct legally binding. I welcome the fact that there will be such a code of conduct.
As regards family practitioner committees, Clause 10 repeals the designation of certain health authorities as teaching authorities and indicates some move, I assume, to reduce the number of teaching hospitals. It is true that today over 1,000 doctors are unemployed, but it is also true that a number of hospitals are still seriously short of medical staff due to expenditure cuts. One with which I am very familiar has two consultants operating but the regional health authority say that it can have three. There is a need for three, but unfortunately they also add that there is no money to provide the necessary doctor and, therefore, waiting lists will still rise. The increase in the powers of the family practitioner committees no doubt will be welcomed by the medical profession. It is their victory, indeed, against the advice of all other bodies. But the provision in the Bill setting up joint committees could hamper progress. In addition, this would weaken the powers of the district health authorities and, indeed, the new family practitioner committees.
Primary health care services are vital in the prevention of ill health and keeping people in the community, especially the very elderly, the mentally and physically handicapped and the mentally ill. The setting up of family practitioner committees, as envisaged in the Bill, will seriously hinder the planning of primary care services. The Royal Commission on the National Health Service recommended the abolition of family practitioner committees in England and Wales and the assumption of their functions by health authorities as a step towards integration. The Government have taken a completely opposite step. The machinery of liaison, the joint consultative committee, is cumbersome, particularly bearing in mind the fact that a family practitioner committee will cover a number of district health authority areas and quite easily a conflict of interest and need is bound to arise.
The loss of co-terminosity between health and social service authorities has already led to difficulties in establishing joint consultative committees and has seriously weakened health and social services.
I have had experience in serving on a joint consultative committee covering an AHA and local authorities. Quite frankly, from my experience they have proved to be vague talking-shops with frequent conflicts of views and interests between representatives of local authorities. They are certainly not vehicles of positive approach and are weakest in the field of co-ordination.
The operation of the provisions of Schedule 5 regarding the satisfying of family practitioner committees that applicants for inclusion in lists have:that knowledge of English which is necessary, etc.",is understandable, but will have to be operated with care and discretion to avoid charges of racialism. Regard will also have to be had to the extent of the multiracial nature of a specific area. This proposal could, in some cases, lead to serious discrimination. I 729 fully appreciate the point that the Government are making and do not wish to be unduly critical, but this is certainly a matter to be closely watched.
I now come to deal with charges for local authority services. In Part VII we have inserted, naked and unashamed, the means test, not only on recovery from and designation of income, but provision to deduct from assets already passed over to relatives and also from interest in land. When I read that in the Bill, my mind boggled at the thought of old people, the handicapped, et cetera, on low incomes being included in the category of landed classes. It seems to me quite ridiculous to bring that in.
To be fair, it is true that local authorities have always been able to levy a contribution from parents towards the maintenance of children under the age of 16 who are in their care and, in the case of children over 16 years in full-time work, from such an individual. Contributions have also been claimed for or from some adults. In the past, recovery has been on the basis of:such charges as may be reasonable",and this has given rise to a varied pattern from one district to another. The inclusion of the words "having regard to his means" will not get rid of anomalies or variations of the point of recovery. I would ask, is there to be a set formula to provide for a test of means, or will local authorities, in their wisdom or otherwise, make their own decisions? Will there be provided a standard form to be completed by the involved person? If so, it must be borne in mind that in some cases people will not be in a fit state to complete it. Elderly and handicapped people are notoriously independent and sensitive, and as a result may not receive their just rights.
Cases have arisen during the past of elderly people in care worried over financial charges, wanting and pressing for transfer to another area, maybe where they were born or resident at one time, in order to avoid high charges. Indeed, I have had to handle one or two such cases. Charges levied by local authorities in many cases have proved to be arbitrary and discriminatory. I can see nothing in the Bill's proposals to avoid such a situation continuing.
A set standard must be laid down in order to ensure, among other things, that charges are levied not only on a fair, uniform basis, but, even more important, that the person involved is left with an adequate disposable income. This is a very vital matter indeed when we are dealing with the elderly, the handicapped and the mentally ill. In their efforts to effect improvements in this field, the Government have only touched the fringe of a complex human problem, and I would remind the House that we are dealing with people and not statistics, and must always be mindful of that fact.
Finally, we have yet another move to abolish quangos. Quite frankly—and I speak personally here—I cannot understand why the Government want to get rid of the Advisory Council on Child Care. It would appear that the Government do not consider it essential, probably for financial reasons. But there are many problems in that field still to be solved. Surely, with so much needing to be done in this field of child care, such a body is still needed. Similarly regarding the Advisory Committee on Radiation Hazards, et cetera, surely modern technical developments call for 730 its continued work.
As I said in my opening remarks, this Bill is a veritable bag of allsorts, and I look forward to the day when the Government will introduce their Bill to improve the health and social services. When they do, I am sure that the general election will not be far away. In the meantime, I give this assurance to the Government, that we shall all—and I include all sections of this House—give this Bill the closest possible scrutiny in Committee and during other stages.