§ 5 p.m.
§ Second Reading debate resumed.
§ Baroness Faithfull
My Lords, may I join with others in thanking my noble friend Lord Trefgarne for explaining to us the Health and Social Services and Social Security Adjudications Bill. I will, if I may, address myself in the main to Parts I to IV of the Bill. All members of my profession in the social services will be grateful to my noble friend the Minister and his right honourable friend for issuing discussion documents such as, Care in the Community and, A Good Home in order that there can be broad discussions before this Bill is passed. In passing, I should perhaps say that representation has been made to me that in respect of Part VIII of the Bill concerning 748 social security adjudication there was not, as I understand it, full discussion concerning that sphere of the Bill.
The noble Baroness, Lady Robson of Kiddington, commended care in the community and then asked where the money is to come from in the health service. I also commend care in the community not, as the noble Baroness said, because it is cheaper but because by and large it is happier. That is not to say that there is no need for some residential or custodial care, because there is—and we must not get this out of balance.
The noble Baroness, Lady Robson of Kiddington, asked about resources from the health service and I want to ask about resources from the social services. While there is the transfer of patients or those in custodial care from residential care to the community, there are double costs. There is the cost of running a department and the cost of transferring the patient or person from custodial care. I am well aware, and congratulate my noble friend the Minister on the fact, that there has been an increase from £33 million in 1978–79 to £85 million in 1982–83 for joint financing. On 8th November my noble friend's right honourable friend said in another place (I have with me a copy of Hansard containing this quote) that there was to be a grant of £2 million to the social services for intermediate treatment. Nevertheless, having said all that, may I ask my noble friend the Minister whether he is really quite happy that there are the resources in the social services for good care in the community? Are there going to be extra resources or will local authority social services departments have to draw off their present budgets and perhaps put aside other things on which they might have spent the money? That is my first question, which is very much the same as that asked by the noble Baroness, Lady Robson of Kiddington, except that it is from the social services point of view.
My second question is, what are the mechanics of community care in relation to the voluntary sector? If a local authority social services department does not have the resources to fund, for example, a case, is it not likely that it will leave the patient in hospital rather than arranging for the patient to be cared for in the community? I have known this to happen. As your Lordships know, I serve Barnados, and, for instance, in the Yorkshire area skilled care and vacancies are available for mentally handicapped children who are now in hospitals. The noble Baroness, Lady Masham of Ilton, will know this because she has visited one of these very good places in Yorkshire. But what are the mechanics of a child transferring from a mental hospital into very good community accommodation? Which authority applies? Who pays? Who takes the first step? I wonder how the mechanics of this are going to work.
The British Association of Social Workers in their reply to the consultative document which I have studied are so worried over the position of resourcing care in the community that they would prefer an annual payment or lump sum for community care. While I understand the association's concern, I am bound to say that care in the community is also a shared responsibility as between doctors, health visitors and social workers—and this should never be forgotten. My last point on this part of the Bill is to ask 749 my noble friend the Minister whether there is to be a monitoring system on the effectiveness, speed and commitment of the work of the joint consultative councils? Too often we pass Acts of Parliament in this House and years later find that they have not been implemented. I would ask whether there is to be monitoring of the work of the joint consultative councils.
I now come on to Part II, which concerns the abolition of regional planning committees for accommodation for children. I have two questions to ask my noble friend the Minister. From my own experience I am sure it is wise and right that regional planning committees should now cease to exist. They have served their purpose and have done some good work, but I believe there is now no call for them. But there are exceptions. For instance, London is one place where I wonder whether we would be wise to abolish regional planning committees. Last week and the week before I visited two community homes for education run by Hillingdon Borough Council. They give a very good service. When I asked to look at their registers I saw that there were at those homes children from different boroughs of London. I believe it would be very unwise not to have a regional planning committee in, for instance, London and that it would be unwise to do away with the London boroughs' regional planning committee.
I would like to ask my noble friend the Minister what is the position with regard to the voluntary sector, which I think works very closely and happily in partnership with the statutory sector. A number of voluntary organisations run children's homes to meet the special needs of special types of children. Almost inevitably, local authorities are going to keep open their own homes and not use the homes of voluntary organisations even though it would serve a child far better and meet his needs if that child could go to a voluntary sector home. This is something which is very worrying as a number of good voluntary homes have had to close because local authorities are not using them, preferring to keep open their own homes. This is very understandable and natural, but at the same time they are not really meeting the needs of their children, because not every local authority can offer a wide spectrum of homes to meet the needs of many different types of children.
I now pass to Part III, which concerns the Central Council for Training and Education in Social Work. Rather inevitably to me as a social worker, this part of the Bill relating to the training of social workers is central to the social services of this country—both its statutory and voluntary sectors and also to the self-help groups. The council and particularly the staff have had since 1970 a difficult, demanding and almost impossible assignment.
The staff have worked hard against fearful odds. First of all, it has not always been easy for the council to attract staff with long and wide experience because the salary scales have not been commensurate with those of senior staff in local authority and voluntary organisations. Under the Local Authority Social Services Act 1970 many duties were by legislation laid upon social services departments. To meet this challenge there were not enough trained social workers, and those who were experienced were moved 750 to managerial posts. This also was experienced, I think, in the health field, and in some cases in the field of education. Therefore, there has been an explosion of training courses up and down the country.
There are on the council 64 members. When the council was set up this may have been advisable. I do not, however, think that it is a practicable possibility for 64 members all to work out a policy in detail; there are too many diverse views. I therefore applaud the clause in the Bill reducing the number to 25. There are varying views concerning the composition of the new council. After 1971, when the Council for Education and Training in Social Work was established, the method of appointment was altered and the majority of members of the council had been appointed directly by the organisations listed in the schedule to the Local Authority Social Services Act 1970.
I believe that the smaller council of 25 members should be a strictly professional body drawn from social services and education, and chosen for their calibre and relevant experience. Some have said that the employers' associations should be represented, as they have been in the past. I certainly think that their advice should be sought and that they should be consulted. Other professions do not have a wide range of representation of employers: the General Medical Council, the councils responsible for the training of architects, accountants and teachers, all of whom work in local government. Those serving on the council should surely be those nearest to the day to day work and the educationists responsible for the teaching of social work and work in the social services.
My Lords, I may be straying slightly from the Bill, but has the time not come to set up a working party to review the training of social workers and those in the social services, and, most important, the financing of that training? The quality of training courses for social workers, partly because of the explosion to which I referred earlier, is uneven throughout the country and there is a lack of consistency as between the courses. Some courses give a first class training, and their tutors and staff are of a high calibre with practical experience. But, my Lords, it falls to me to say that there are other courses which fall short of the standards set by the courses which produce the good social workers.
The tendency of some of these courses is to concentrate on ideologies and structures of society to the detriment of social work practice. Many disabled people—and I look at the noble Baroness, Lady Lane-Fox—have told me of social workers' lack of knowledge of resources. Judges and magistrates have been concerned about social workers who have not known the relevant law or court procedures. In the Mental Health Act it was necessary to make provision for approved social workers. Some social workers have not acquired the knowledge and depth of understanding of the dynamics of emotional tension in homes. Of course social workers must be involved in the structure of society, but I contend that this interest should stem from their experience, sensitivity and awareness of the needs of the most vulnerable with whom they work. The structure of society is not in itself and by itself the sole role of social workers.
My Lords, the residential day care services are to be commended for the service which they give and their sensitivity and care and kindness to those in their care, but there is a massive training backlog. There is an 751 imaginative scheme, called the Gatesby Project, which could make a substantial contribution. One of the reasons why I ask whether the new council should set up a working party to look not only at the training of social workers but also the funding of social work, is that the present funding is certainly not satisfactory; it depends on the various different local authorities. Some local authorities support training; others do not. Why does the social work world have to be funded in a different way from any other of the departments of the local authority? I would wish very much that a new concept, a new way of funding the training of social workers, could be looked at, could be considered and discussed. What I would say is that if we are going to have care in the community, if Her Majesty's Government are going to give money for this care, it cannot be adequately done without social workers who are committed and who are trained.
Therefore, my Lords, I support the smaller council. I support the council appointed by the Minister, of people of calibre and experience, and I very much hope that, whatever else this Bill does, it will make a contribution to a better social service in this country.
§ 5.17 p.m.
§ Baroness Stedman
My Lords, I, too, would like to thank the Minister for the care with which he presented this Bill to the House. From this bench we see Parts I to III and VI to VIII more as tidying up measures which were expected and are probably based on many of the earlier consultations that have gone on. We have some reservations and some suggestions t; put forward on Parts I and IV, which I will deal with first; and we have rather more serious reservations on Part V, which I shall come to later.
My Lords, Part I of the Bill provides for the joint funding of the community services. It has its origin in the departmental document Care in the Community, which invited proposals for transferring long-stay patients from institutional care into community care. We welcome the proposals for extending the joint financial arrangements to include housing and education authorities, in addition to local authority and voluntary social services. But we regret that no provision is made in the Bill for voluntary agencies or housing or education authorities to be represented on the joint consultative committee which will play such an important part in the allocation and transfer of resources. My noble friend Lord Kilmarnock regrets that he is unable to be here this afternoon, and I am sure that he may want to refer to this again at Committee stage.
My Lords, the extension of the joint finance towards district councils and local education authorities is accepted in principle by the Association of County Councils. But the danger is that with limited growth of joint finance in total, anything allocated to those other services will reduce the amount available to the personal social services, for whom, as you know, joint finance really has been a lifeline in recent years. In general, we on these Benches feel that community care has to be viewed rather more as a social goal in its own right than as just an opportunity to cut costs. Supplying a wide range of services to meet the individual needs of hundreds of thousands of elderly 752 people is not likely to be cheap. Evidence to the Social Services Committee of another place earlier this year indicated quite clearly that additional funds will be needed. We shall want to monitor these new and more flexible arrangements very carefully once they are in operation.
Again, the Association of County Councils has misgivings about the way in which the Government propose to implement the powers in Part I. It thinks that it is vital that the transfer of resources should be related to places rather than to patients. It is very desirable that people in hospitals who do not need to be there should be moved out into the community. It is just as important that people who do not need to go into hospital in the first place should never have to go there, but should be cared for in the community from the outset of their need. As we understand the Government's present proposals, this point has not yet been met.
We believe that there is a need for more co-ordination between the health and the personal social services. This could be done if more financial incentives were provided and if the health authorities could be encouraged to place contracts for community and other services with local authorities. In those cases where the cost of such care is less than the cost in National Health Service institutional care, local authorities could also be encouraged to place contracts for services with voluntary bodies where such bodies can perhaps provide a more effective service. Any controversy over the Green Paper Care in the Community, recommending the transfer of patients from hospital to community care, is not over the mechanism dealt with in the Bill but over the Government's refusal to acknowledge that additional resources are required. The local authorities are anxious for speedier procedure by which they can initiate the closure of an unneeded controlled or assisted community home. Even in this Bill that process is not exactly quick.
As regards Part IV, we welcome the proposals strengthening legislation governing the registration of the private and voluntary homes. However, we believe that the legislation would be stronger and that items which may be included in a code of practice need to have legislative backing. Like the noble Baroness, Lady Robson, we are convinced that the interests of residents and staff in residental homes would be served by a national registration agency. We regret that no such provision has as yet been made in the Bill. There is much that a national agency could do. It could take the responsibility for the registration of all the homes, thereby removing the residential/nursing home division. It could maintain a register of all the registered homes, of all the owners and managers who have had their registration cancelled or refused. It could provide inspectors and advisers. It could act as a forum for information and discussion, and perhaps for the training of inspectors and the staff of homes. It could also provide specialist advice to appeals tribunals and help to plan and co-ordinate the overall residential accommodation in an area.
The arrangements for tightening up registration and deregistration of private old people's homes are badly needed, but—here I am on one of my regular hobby horses—why does the Secretary of State have to 753 prescribe the fee that local authorities can charge for this service? Is that not something which could be left to local authorities?
The attempt to define a residential care home is welcomed, but the definition is still not very precise. Old age, for example, is not defined. Does it include all those people requiring such accommodation who are above the minimum state pension age? An attempt to define personal care is made in Schedule 3, but between "assistance with bodily functions" specified in the schedule and full nursing care there is a whole range of requirements, particularly for the elderly, mentally infirm residents, which requires further clarification.
The Bill proposes to abolish the exclusion from registration of homes already registered under the Nursing Homes Act 1975 and providing residential care other than nursing care. This, too, is welcomed. But clarification is required on the legality of the residential homes which also provide nursing care. We believe that legislation should provide that residents should be issued with a detailed brochure setting out the terms of residence, charges, the special facilities available and a list of regulations which residents choose to disregard at their own risk. Legislation should also include a formal complaints procedure, details of which could be issued to residents and staff. A record of formal complaints, and how they are resolved, ought to be kept by the home for inspection by the registration authority.
The Bill gives the Secretary of State the power, by regulation, to prescribe the frequency of inspections in the homes. We believe that the legislation should provide for the yearly inspection, as referred to by the noble Lord, Lord Trefgarne, but with at least one other annual visit, without notice, as a statutory minimum. The registration authorities should also be legally obliged to set out their criteria for judging premises or staff as being fit or unfit.
The noble Baroness, Lady Faithfull, has referred to some of the fears of the British Association of Social Workers. Has the Minister seen the proposals from that association for mandatory grants for residential and day care social service staff for training? Does he support the proposals? Will he also be willing to look at the association's comments on an advisory body to be concerned with the general aspects of child care? These are two important suggestions which ought to be taken seriously.
Finally, I come to Part V. The establishment of separate family practitioner committees is unwelcome. We believe that the family practitioners should be managed by the district health authorities. Clause 9 and Schedule 5 contain proposals to make family practitioner committees into special health authorities separate from the district health authority. Like the noble Baroness, Lady Robson, on these Benches we think that is a retrograde step which will not assist the National Health Service in planning or providing integrated primary care services. These committees have tended to be dominated by their professional members—doctors, dentists, pharmacists and opticians—and they have become remote and somewhat inward-looking bodies. There is an urgent need to redirect and reshape the primary care services, of which the family practitioner service is a key element, and to take account of the current problems 754 of today's National Health Service. The NHS is still far too fragmented, and boundary disputes between hospital and community care are all too prevalent. The real need today is for integration, not fragmentation.
The Royal Commission on the National Health Service argued forcibly that family practitioner committees should be abolished. In Scotland and Northern Ireland, they do not exist and the functions carried out by the family practitioner committees are handled by committees of the health authority. This arrangement could be adopted in England and Wales, too. The vested interests of the professions and the family practitioner committees are strong and it looks very much as if they might have won and persuaded the Secretary of State to give in and allow them to keep their independent kingdoms. But this is no way to put primary care and community care in a suitable position to tackle the very real problems. It confuses professional interest with public interest and, in the National Health Service, we must be very careful to afford public interest its correct priority.
In Committee we will be seeking to reverse the provisions of Clause 9 or, failing that, to introduce amendments that will make the family practitioner's involvement in planning and co-operation with health authorities a meaningful reality. We believe that the provisions for co-operation with joint consultative committees are too weak to ensure operational collaboration. We will also seek to ensure that the family practitioner committees are obliged to consult openly and widely on their own activities regarding primary care services. I look forward to the Minister's reply to this debate and to the further discussions in Committee, when I hope that my noble friend Lord Kilmarnock will be here to lead from these Benches.
§ 5.31 p.m.
§ Lord Hunter of Newington
My Lords, I too should like to add my congratulations to the Minister, and also to congratulate him on the delicate degree of unanimity which he attached to several of the proposals. The reorganisation of the health service and rhetoric about the optimum mix of the public and private sectors has diverted attention from the fundamental problem of finding ways in which to control or moderate costs and services and make the optimum use of resources.
The Minister of Health has said recently that he wants to take forward Government initiatives to improve the management of the resources available to the health service. In Part V, which deals with the family practitioner committees, we have before us proposals to change the status and constitution of those committees and grant what has been called in a distinguished journal the "GP's charter". The Government are convinced that this is a suitable base for forward planning. Previous speakers have made reference to the functions of the Bill and to these joint consultative committees which are to be set up. The family practitioner committees will be responsible to the Secretary of State, who will also appoint the chairmen and the members. So the Secretary of State will oversee family practice in this way, the responsibility for which, under the 1973 Act, was at least in part vested in the area health authority.
755 Again, as has been said by previous speakers, Recommendation 110 of the Royal Commission on the Health Service recommended that family practitioner committees should be abolished and their functions assumed by health authorities as a step towards integration. I believe that the Royal Commission thought that this would produce a more effective service and would also conserve resources.
Is the proposal before us the best arrangement to get effective medical care, to plan for the future and to conserve resources? While recognising that this arrangement may be highly satisfactory from the point of view of the present generation of family doctors, is it really the best arrangement on which future changes can be based? For example, it looks as though attempts to integrate practice closely with the hospital service are being made more difficult, if not abandoned. It also seems certain that any administration will be done by the doctors themselves and they will be entirely responsible for the expenditure of resources. So with the exception perhaps of extreme prescribing excess, a range of expenditure can be incurred without question. Moreover, attempts to create new primary care teams involving other professions will depend on these doctors, and if other professional people are to be included in the team they will have to accept the system of how family practice works.
The system will surely result in a continued isolation of family doctors from hospital practice, from which most new technology comes. General practitioners who will continue to serve on the district management teams may think that the effort is not worth while and not really connected with their every day problems. Such people anyhow do not represent their colleagues or their authority in any way. They are in the curious position of being financially penalised for attending because, of course, they are private contractors with the health service.
Prior to 1973 there was increasing contact between doctors in practice and local authority medical services, in particular the personal medical services. The key figure in all this was the medical officer of health, who also promoted contracts with the hospital service. He was often a man of authority and great influence with his local authority and he conducted the orchestra on the local front and was, of course, in almost daily contact with the Department of Health. He had an important management role and a responsibility for the expenditure of resources.
When the National Health Service Act was introduced in 1946 certain local government functions were transferred to the National Health Service, but the Minister of Health remained responsible for all health and many other local government functions. In April 1974 the National Health Service and the local government reorganisations transferred local authority personal services and the School Health Service to the National Health Service and the statutory post of medical officer of health was abandoned. Some of the environmental responsibilities of the medical officer of health were given to a new officer—the chief environmental health officer. Medical advice was to be provided to the local authorities by the area medical officer's staff. No longer did the local authority have a single doctor who 756 was the focal point of responsibility for the medical aspects of all its services including industrial ones, and the link with the Department of Health was broken. Experiences since have not been very satisfactory. Wider health responsibilities, both locally and centrally, have become more and more diffused.
Since 1974 communicable disease immunisation and the like have been dealt with by the area authorities—now, presumably, the district authorities. Outbreaks of food poisoning and communicable diseases, so important to the general practitioner, have generally been well handled by the environmental health officer.
One cannot but have serious reservations about the proposals before your Lordships, although they may be the best that can be achieved in the present climate as it exists between the family doctors and the Government. My anxieties are the following. First, that family doctors will continue to be peripheral to the health service which will be focused on the hospital service. Secondly, are consultative committees between the family practitioner committee, the health service and the local authority of any use? Thirdly, the grave deficiencies arising from the lack of the medical officer of health continue to exist. Fourthly, will developments of new methods of primary care, involving collaboration with other professions and new technology, be made any easier? Fifthly, general practitioners will more than ever feel that the district management team is not relevant to their problems. Sixthly, many aspects of medicine in the community are, I am sorry to say, in danger of being neglected. Finally, the lack of effective, tightly controlled personal and local health services—substantially those parts of the health service outside the hospitals—is continuing to guarantee a less effective use of resources, including manpower.
§ 5.39 p.m.
§ Baroness Lane-Fox
My Lords, the provisions which the Government are seeking to introduce in the Health and Social Services and Social Security Adjudications Bill were described by my noble friend the Parliamentary Under-Secretary and I am very glad to contribute to this debate. It is so good to note that the main intention of the legislation is to develop methods for caring within the community, rather than in hospital, for people who are physically or mentally handicapped. I believe that your Lordships are agreed that, generally speaking, disabled and handicapped people are better able, so far as it possible, to lead a full, useful and active life if living among families and friends. So it is good that the extension of the joint financing arrangements in Part I of the Bill should encourage further progress in the great work already taking place in that direction.
From the number of policy statements on community care issued by the present Government, your Lordships can hardly have been unaware of their commitment to this principle. Those statements have been followed up by positive action, as my noble friend Lady Faithfull has said. Since 1979 moneys available for joint finance have been increased by 35 per cent. and the Government have just announced a further £6 million to be added, be this a small beginning.
757 My noble friend the Parliamentary Under-Secretary of State referred to last July's announcement by the Secretary of State for Social Services and the Secretary of State for Wales on the Government's decisions, following consultations on the document, Care in the Community. He spoke of administrative action already taken to develop the financial arrangements which, incidentally, are being further improved by provisions in this Bill.
There are some improvements which do not depend on the Bill, but nevertheless I very much hope that they will be introduced soon. These may meet some of the points of anxiety raised by my noble friend Lady Faithfull and by the noble Baroness, Lady Robson. For instance, I shall give three; payments for extended periods to cover projects for moving people out of hospital; increased maximum periods during which such payments can be made; and centrally financed pilot projects in community care. All developments of this kind boost the progress in this work, and I feel sure that your Lordships will join me in encouraging my noble friend and colleagues along this road, making all speed in implementing the necessary legislative changes introduced by this Bill.
The noble Lord, Lord Wallace of Coslany, expressed concern that proposals in Part VII—Clause 12—of the Bill may operate to the disadvantage of the users of important services—services such as home helps, meals-on-wheels and/or aids to daily living. The noble Lord appeared to fear that this would place intolerable burdens on some people. My hope and belief is that he may perhaps have overreacted a little. As I understand it, provisions in Clause 12 are in no way intended to place new burdens on users of the services. The trouble is that, with such technical provision, it is not always easy to disentangle the precise impact of amendments to already complex provisions. But I am sure that my noble friend can clarify in this case.
Certainly Clause 12 aims to ensure that, if charges are made, they shall not be more than a person can afford. At present some authorities can make charges for these services; some do and some do not. The scene and practice varies from one authority to another. Where they do charge, at present there is no duty on the local authority to take account of a person's available income in making that charge. Clause 12 imposes just such a duty and, as such, I believe that it will be a welcome improvement. I think that there should be a recognised level for the assessment, fixed at a very reasonable rate. It so happens that when, some years ago, my home authority made adaptations to my flat—widening the door into my kitchen and making it and the bathroom accessible for my wheelchair—an assessment was made of my income. This struck me as a fair way of getting me essential help for which I could not otherwise have paid without assistance. Here I salute the resolve to get the greatest help to the greatest need. It is easy to tell heart-rending stories. What is needed is action to direct assistance to those who are worst off. Where at the moment charges are not made by local authorities, it does not seem to me that the situation will change. This is at their discretion, as always, for I cannot see that that is in any way affected by the provisions of the Bill.
Before I close, I would ask my noble friend the 758 Minister whether Part V—Clause 10—gives any hope that those great centres of excellence, the teaching hospitals, may be rescued from the effects of regional financing based on population. The trouble is that, where population in the region is declining, growing numbers of patients who wish to be treated reside outside the region. As the whole future of medicine in this country depends so much for its thrust and brilliance on the ability of our teaching hospitals to scrape through the present extraordinary circumstances, may I hope that this brief reference to them is designed to help them to solve their problems? Perhaps my noble friend will be good enough to explain that point.
§ 5.46 p.m.
§ Baroness Masham of Ilton
My Lords, I thank the noble Minister for his introduction, even though it is now rather blurred by steel and oil. If I were not a canny Scot now living among proud, independent Yorkshire people, I might not be speaking on the debate in your Lordships' House today. There are parts of this Bill which I should be grateful if the Government would explain further. I am curious to hear why some aspects have been changed in the Bill. There are many people who think that the priorities of the health service are for those people who work in it and not for those whom it is meant to serve. In the Bill there is protection for the salaries of general practitioners, but there is penny-pinching means testing for some of the most disadvantaged members of our society—those people who are unfortunate to be blind, deaf or crippled.
Last year I was given an honorary fellowship of the Royal College of General Practitioners, an honour that I greatly appreciate. It is an excellent college and they encourage good standards in medical care. They are an independent body with an excellent lobby. Today I speak for those people—the sick and disabled—who cannot go on strike, who cannot rid themselves of their handicaps and who cannot withdraw their services. They are at the mercy of Parliament and society. Unless some safeguards are put into Clause 12 of the Bill, there is a risk that some families will be degraded and humiliated.
I should like to ask the Government why there has been a change of wording to:having regard to his means",in Clause 12(1). The Bill proposes a different definition from the one in subsection (5) of Section 29 of the National Assistance Act 1948. It is still permissive and does not require the local authority to charge, but there is this new introduction of the right to means testing of all services provided by a local authority. We know that local authorities differ throughout the country in the way in which they treat disabled people. Some have very poor records.
Where there is severe disability in a family, there is always extra stress, strain and expense. Surely the criteria for aids and adaptations to houses should be based on need. There should not be waste. The correct need should be professionally assessed and the families guided, advised and shown how to use a device correctly. If a means test is applied, the administration of it may cost more than the supplying of an aid.
759 Very often people who have served the community well, such as a nurse, teacher or secretary, who have never married, never used state benefits such as free education, and always paid taxes, may get some cruel disease such as multiple sclerosis in middle age. Such persons will have lived carefully and saved a little money. These are the people whom the means test will hit most. Also, the poorer people feel humiliated and put off coming forward for help as they do not like to be singled out and identified. Even though many people are poor they like to preserve their dignity and do not want to be seen to go begging to the social services.
Some people feel highly embarrassed if they have a bladder and bowel problem. They need practical inducement to come forward, and kind, thoughtful advice and help to be given. The supply of a stair lift or bath aid may make the difference between a family coping and keeping their disabled member in the community or their backs giving out and having to place the disabled person in residential care.
The giving out of aids in this country has never really been efficiently run. Some aids come from appliance centres, some from social service departments, and some from health authorities. Often these departments are not co-terminous. There has been waste as the wrong aid has sometimes been given out by an untrained social worker. The aids sometimes are not serviced, and are never monitored and recalled when there is no longer a need for them. They are wasted. There should be joint funded regional centres with local depots. Occupational therapists and physiotherapists should be involved. This has been a sore point with physiotherapists, who sometimes know more about a mobility aid than anyone else. A civilised country like Canada has found that it costs more to administer the means test than it does to provide the service. It does not have means testing of its disabled people.
Like many other people, I welcome the Government's initiative on joint funding in Clauses 1 and 2. Disability and handicap merge over all the departments of health, employment, residential care, social services, education and housing. I should be grateful if the Minister would give us some details of how this will be organised. Will joint funding also mean joint consolidation all the way through and joint running? I hope it will not mean that the health authority has to hand over money and then lose any say in the running. It would be wrong if it meant an increase of paperwork. This has reached crisis point. But it should mean working together to get the services running well with the correct support and advice.
There has been difficulty in getting some medical people working together. It is necessary for doctors to co-operate—such as the paediatrician, the community doctor (school doctor) and the general practitioner. There have been some recent reports by these bodies. They have spoken a different language on integration, with different recommendations. Integration of child health services is very important. Will the Government be putting out some national guidelines? Clause 15, Part VII of the Bill, appears to introduce measures to prevent the disposal of assets by a person availing himself of Part III accommodation before entry to accommodation with a view to his not making any 760 contribution, which he is at present required to do on an existing means test. It would be interesting to know how much evidence of this abuse is available, and how the Government are going to implement this clause.
With the pressure of the elderly who need care I hope that the Government will do all they can to see that all residential homes are kept up to a decent and acceptable standard. Homes, like everything else, vary considerably. Elderly people in need of care are a very vulnerable group. How often, and by whom, will residential, licensed homes be inspected? I hope that there will be spot checks. The aim for more care in the community is an admirable one, but the expertise and funds must go with them, as stated so clearly by the noble Baroness, Lady Robson. It is a pity that the voluntary organisations which have so much knowledge of the needs have not been included in this Bill as far as joint funding is concerned.
I hope that the Government will look very carefully into this. What is worth doing, is worth doing well. I ask the Government whether they do not think that, in making general practitioners responsible to the Secretary of State, with DHSS funding, they are not divorcing them from the local scene. What will be the position of the regional health authorities? We must preserve the best of our hospitals. Teaching facilities must not be run down. For years many of us have tried to get the Government and the DHSS to see the merits of national funding for specialised hospitals such as the spinal unit at Stoke Mandeville Hospital, and St. Mark's Hospital in the City Road, where patients come from all over the country and from the armed forces. This makes sense to me, but I shall listen carefully to what the Government say about the general practitioner service.
I conclude by saying that the Government could have tried to solve the problem of the millions of pounds which have gathered in the bank accounts of mentally handicapped people who have been given the mobility allowance and cannot use it. When they die this money goes to some undeserving relative. I say "undeserving" because they have not looked after the handicapped relative in the community. Surely this needs solving. It gives great concern to many community health councils. Perhaps it is not too late to do something about it in this Bill.
§ 5.57 p.m.
My Lords, I think that my name would have appeared on the speakers' list as the first speaker below the line rather than the last speaker above it had I not feared that another engagement on other public business would have compelled me to be absent for the opening speeches. My fears proved well grounded and I was not able to hear the speech of the noble Lord, Lord Trefgarne, in explanation of this Bill. I am quite sure that he explained it in his usual lucid and clear manner, and I would merely assure him that I shall read his words with great care; but I should like to apologise to him in advance if I ask him any questions that he has already answered. Nor did I hear the noble Lord, Lord Wallace of Coslany, and I apologise to him also and assure him that I shall read his words, too.
I heard the second half of the speech of my noble friend Lady Robson of Kiddington. I did not hear the first half, but I do not think there is much risk that I 761 shall say anything that is in sharp contradiction to anything she said in her earlier remarks. After all, in this matter I could say that the noble Baroness had a long period of highly professional and very able service as a distinguished chairman of a regional health authority, in which she acquired immense professional expertise in these matters. In the lower echelons of the health service I worked first as a surgeon and then, for more than 30 years, as a general practitioner in the health service in which I, too, I think, acquired a certain professional knowledge of the service, so we take the same point of view in that sense. However, sitting on these Benches I think I should be right in saying that we both believe that the interests of the patient in this matter are absolutely paramount. Therefore, I am sure that we speak with one voice.
Having offered those words of professionalism, perhaps I should say to the noble Baroness, Lady Masham, that as a general practitioner it never occurred to me that the health service existed for my benefit. Nor, frankly, did it seem to my patients that it existed for my benefit. I want to make it absolutely clear that they thought, as I thought, that the health service existed for them. So it did and so, I hope, it always will do.
I shall try to be brief—speaking above the line rather than below it—and I come first to that part of the Bill which, as other noble Lords have said, is at the heart of the measure; namely, Part I and those clauses which seek to do something to spread the financial burden of domiciliary health care between local authorities and central Government. This is a long-standing problem, one about which I made speeches from 5th July 1948, when the health service first started—speeches to doctors, health service administrators and politicians and never did I find any disagreement with the general view that there had to be some kind of integration as between the health service, the hospital service and the domiciliary services.
The problem in those days was more acute than it now is because a larger proportion of the resources of local authorities came from rates and a smaller proportion from rate support grant. It automatically meant in those days that the enlightened, forward-looking local authority which took the trouble to provide good domiciliary care—in the form of residential homes, day care centres, health visitors and so on—saved a lot of money for the hospitals (because people could be discharged home instead of being kept in hospital and others could remain at home instead of being sent to hospital) but of course they were kept and cared for at home at the cost of the ratepayer and local authority, and there was no provision in those days for any transfer of funds.
That situation was somewhat exacerbated in the early 'sixties when, some noble Lords will recollect, Mr. Enoch Powell, as Minister of Health, published his 10-year hospital building plan for Britain, a plan which, at a stroke, as it were, transferred the responsibility for many things which hospitals had been doing automatically, and almost overnight, to the local authorities. Rightly, more patients with mental illnesses of one kind or another were to be cared for in the community instead of in hospital, but cared for in the community by local authorities at the expense of the ratepayer. More patients—orthopaedic cases were 762 quoted—would go to local treatment centres for physiotherapy and treatment of that kind, treatment centres which, in those days, it was envisaged would be set up by the local authorties and therefore would save the hospital authority money in providing extra beds, and those patients would be taken to and from those centres by ambulances which, in those days, were provided by the local authority and paid for by the ratepayers.
Since those days we have had a gradual understanding of the need to do something about the problem, and it is right to say from these Benches that Governments of both complexions and colours have taken steps in that direction. Mr. David Ennals, as Secretary of State, did a great deal with joint funding arrangements between local authorities and hospital authorities and with the Ministry and voluntary bodies. The present Government, especially under a comparatively junior Minister who appeared to have considerable responsibility for financial matters at that time, Sir George Young, took great strides and took a lead in the department which has led to some of the things which we now see in the Bill because he was clear that we needed to move in some of these directions. I am saying, therefore, that while the intention to do such things is clear in the Bill, perhaps the means and detail are not entirely clear.
§ Lord Davies of Leek
I too apologise because I also arrived late, my Lords, and am anxious to make a point about my experience of the Department of Health and Social Security in regard to the British Legion and the relationship of the public health services to our wounded, who are growing older, who need artificial limbs and so on. Something more should be done in that matter, but there is nothing in the Bill to indicate such toleration and understanding.
My Lords, I am grateful to the noble Lord for making that point and perhaps we can return to the question of the voluntary bodies shortly. The noble Baroness, Lady Faithfull, said my noble friend Lady Robson had said that what was being proposed was a good thing to do because it was cheaper.
§ Baroness Faithfull
My Lords, I certainly did not mean that, if I said it, because in fact it is not cheaper.
Very well, my Lords. My noble friend actually said that some people said it was cheaper. I am one of those who say it is cheaper. The noble Baroness, Lady Faithfull, says it is better. I am one of those who say it is better as well, so I say it is both better and cheaper. So far as cheaper is concerned, perhaps at this point I might give a brief example of something that is going on here and now; and in giving this example I must stray to the area of the family practitioner committees, to which I had intended to refer in any event.
I wish to speak briefly about a present method of saving money which is actually costing money to the public purse. Hospital authorities are, very properly, 763 trying to save money and are looking at all their costings with great care. They look at their drug bill to see what they can do to cut down the cost of drugs within the hospital. It is right that they should do that, and it is right that we should all look at the drug bill; perhaps much money is wasted in terms of the drug bill, and while I do not want to go into detail on that, it is the case, and that is not a criticism of the pharmaceutical industry, but there is scope for saving.
The hospitals have decided that they should cut down their costs. One of the methods by which they are now doing that, as the noble Lord, Lord Trefgarne, will know, is that hospital authorities are telling consultants not to prescribe for out-patients. Perhaps he is a consultant with a continuing clinical responsibility for an out-patient; say, a cardiologist or haematologist who is seeing a patient for regular adjustments to his dosage of an anti-coagulant drug, or perhaps a consultant psychiatrist who is having constantly to modify different drugs being given to a certain patient over a very long period of time, and the patient is attending regularly. The consultant is being told by the hospital authorities in many areas, indeed in most areas, not to prescribe for out-patients. Consultants are being told, "When the patient comes, merely give him two tablets and tell him to go along to see his general practitioner and get a prescription".
The patient does exactly that. He goes to see his general practitioner, who first of all has not had a letter from the consultant and therefore does not know what the drugs are. Then he telephones to try to find out and he has great difficulty in getting the consultant. Meanwhile, the patient must pay another visit to the general practitioner, an unnecessary visit, and in the end the general practitioner gives the patient a prescription for the drugs, which he then gets under the provisions approved by the family practitioner committees, who, noble Lords will know, are responsible for the general medical services, the general dental services, the pharmacy services, the optical services and so on. It is a fact, however, that the cost to the public purse of dispensing a prescription through the family practitioner committee services is much greater than dispensing the same drug in the hospital by the hospital dispensary.
Occasionally I have put Questions, oral and written, to the Government asking them to tell me the relative cost of an identical prescription, first being dispensed by the hospital pharmacy and, secondly, under the family practitioner committee arrangements. I am told that the Government regret that that information is not available in the form in which I have requested it. It is high time that information was available because the Government will find that certainly the hospitals are saving money by doing this, but in saving money for themselves they are actually costing money to the public purse by inflating the drug bill so far as the family practitioner committee arrangements are concerned. I am sorry to have digressed with a somewhat lengthy example, but it serves to illustrate the fact that we need to look jointly at the financing of these things, rather than be looking at them as entirely separate pockets in different pairs of trousers. It is all the same pocket in the same pair of trousers, and these 764 are matters I shall want to look at further when I come to later parts of the Bill.
As the noble Lord, Lord Davies of Leek, suggested, we need to hear rather more about the arrangements for the financial support of voluntary bodies of one kind or another, bodies which do so much to maintain the domiciliary services. I refer to bodies like the Spastics Society, the Richmond Fellowship, MIND, Mencap and many others who do an enormous amount to provide day care and residential care which itself saves the community a great deal of money. Although there are mentions, I should like to hear a little more about the financing of the voluntary bodies, who will be responsible on a continuing basis, and I should like to hear a little more about the role of the voluntary bodies and voluntary societies in the planning of the various services in which they are so deeply involved.
I now wish very briefly to say a few words about Clauses 12 to 18 of the Bill, regarding charges levied for certain services—matters referred to by the noble Baroness, Lady Masham of Ilton—and in particular Clause 15, which concerns the recovery of money from elderly and other patients in residential homes. These are people who have disposed of assets by means of gifts or otherwise. It might be entirely right that steps should be taken to claw back (if that is the appropriate phrase), or to do something about an elderly person who has deliberately reduced his or her means in order to qualify for a free place, rather than have to pay. But I am just a little uneasy about the way in which it will actually be implemented. I accept wholly that the noble Lord, Lord Trefgarne, would operate such a procedure in an entirely sensitive, sympathetic and understanding kind of way. But we have seen examples in which—I do not use the term in too pejorative a sense—bureaucrats at a level of society very much lower than that of the noble Lord sometimes wield such powers without quite the same degree of sensitivity.
Let us take another parallel example of the capital cut-off rule in relation to supplementary benefit. I know that I am wandering from the point, but I think that it is relevant here. We know that there are now many people—the long-term unemployed—who after 12 months suddenly cease to be entitled to unemployment pay and have to fall back on supplementary benefit. They receive the supplementary benefit only if their total savings do not exceed the figure of £2,000. Now we have people lower down the line looking at an insurance policy, which a careful, prudent, and thrifty person has paid for years, finding out the surrender value and more or less compelling the individual to sell the policy at a giveaway price in order to qualify for any kind of support when unemployed. All right, I accept that that is a digression, but it is an illustration of the way in which a well-intentioned rule of this kind, as outlined in Clause 15 of the Bill, could perhaps be applied without the necessary degree of sensitivity; and if that were to happen, it would be a matter for regret.
I should like briefly to say a few words about the new arrangements for the family practitioner committees, which apparently are about to become area health authorities in their own right. Again, that might be correct in principle, but in practice at the later stages 765 of the Bill, I should want to explore a little further the way in which the members are to be appointed by the Secretary of State. Surely the representatives of the doctors, opticians, or others ought to be elected by those whom they represent, rather than be appointed by the Secretary of State. I should like to hear a little more, too, about the lay element on the newly-established committees, the role of the community health councils, and so on. Further, I should like to explore a little more the dangers of a separation of the domiciliary services under the family practitioner committees from the area health authorities and from the hospital authorities in general. I believe that there are dangers along that route that we shall need to look at with care.
Finally, I hope that the noble Lord, Lord Trefgarne, will read carefully the words spoken by the noble Lord, Lord Hunter of Newington, regarding the disappearance of that well-known functionary of the past, the medical officer of health. I consider that in this matter the noble Lord, Lord Hunter, speaks with great experience, and, if I may say so, the noble Lord, Lord Trefgarne, would benefit from studying his remarks very carefuly. With that, we welcome the Bill at the moment, and will gladly give it a Second Reading, but we shall look very carefully at certain parts of it during later stages.
§ 6.14 p.m.
§ Baroness Jeger
My Lords, I thank the noble Lord, Lord Trefgarne, for the skilful way in which he presented the Bill and for his courtesy in promising to place in the Printed Paper Office Notes on Clauses. We shall certainly need them! Seldom have I seen such a mixed-up gallimaufry—
§ Baroness Jeger
G-a-l-l-i-m-a-u-f-r-y of a Bill before your Lordships' House. I propose to be very brief tonight because we shall have to come back at Committee stage to many of the things that concern us, and most of what I have to say will be in the form of questions to the noble Lord the Minister. I do not expect all of them to be answered tonight, but if he could perhaps refer in correspondence to some of my queries, that would help us in framing the amendments which we must put down for the Committee stage.
My first anxiety arises from what is stated on page iv of the Bill under the heading "Financial effects of the Bill". It is stated:There will be no additional public expenditure".What are we talking about if we are to have this great leap forward into community care, this integration of services, while in the Financial Memorandum of the Bill it is stated,There will be no additional . . . expenditure"?We have heard about some pilot schemes that are to be financed by the Government, but as an old civil servant I go by what is in the Bill; and in the Bill it is stated thatThere will be no additional public expenditure".I believe that that gives the whole Bill a terrible setback from the start, because it is the absence of funding in some of the vital spheres that we have been talking 766 about that causes so much unhappiness and poverty in our community. So I hope that if not tonight, at a later stage, we shall be told that perhaps that statement on page iv was an error, and that it does not in fact represent the Government's intentions.
I was very concerned, as were many other people, about the provisions relating to the family practitioner committees' present setup being ended and changed. The Royal Commission wanted them to be more integrated, but I feel that they are being disintegrated because they are being separated from the local authority and the personal health services. I should like to repeat the questions asked by the noble Lord, Lord Hunter of Newington. What control are they to have over their own expenditure? What about the other professions in primary care? How are they to get closer to the hospital services?—because that is one of the most important dichotomies in the National Health Service at present.
I must also ask what kind of territoriality is to be given to the committees?—because in line 30, at the foot of page 12, it is stated:An order under subsection (3) above shall be an order specifying a locality for which the Committee are to act".Does that mean that a locality of the family practitioner committee could be different from that of the area health authority, or the district health authority, or whatever it is? This is something that has very much hit my locality—if I may use the word used in the Bill. In Camden we are going through the most absurd territorial separation whereby our borough has been divided between two hospital authorities, which means that everything has to happen twice. When there has to be any communication two hospital authorities have to write to the borough council. Surely there should be some meeting up of boundaries between the family planning—sorry, that is Freudian—the family practitioner committees and the other authorities concerned.
With regard to Part VII, I am very worried, as are other noble Lords, about the charges. In Clause 12, on page 15, there is the phrase:. . . having regard to the means of the person from whom they are to recover them, in the circumstances of any particular case".We need something more than that to go on. Judging the means of a person involves a very subjective decision. People have different standards, different desires, different wishes. People want to live in different ways. Some want to spend their money on cigarettes, others on something else. Some people are more concerned about other aspects of their life in general. Does the phrase mean that any local authority can quite arbitrarily pick a figure out of a hat and say, "That is what that person can afford, that is what we consider his means allow him to pay"?
I wonder whether the Minister has it in mind to give some guidance on this matter; otherwise, we could have local variations going from one extreme to another. I do not think that Lambeth and Bournemouth, for instance, would take the same view of what was within a person's means; or even Camden, I am glad to say. I am much more concerned to know what the Minister is going to do about grants to local authorities, which would help them to decide what charges they will have to make.
767 Then I want to ask the noble Lord about the registration of homes for the disabled and elderly. Here I support noble Lords who have suggested that there should be a national register, because people can go from one area to another. Having run an unsatisfactory home in one area, it seems to me that, as the Bill stands, they could just "up stumps", go somewhere else and do exactly the same thing. On the question of the adjudication officers—these are now important people under this Bill—I recognise that there is a need to try to streamline these services, but, again, I have some anxieties, and I put it no further than that. We understand that the chairmen are to be legally qualified and that the clerks as well as the chairmen are to be appointed. Unless I have misread the Bill, it looks to me as if trade union representatives are to be dropped from appeal committees. I think it might well be—the noble Baroness, Lady Robson, referred to this—that applicants coming before these appeal tribunals might well feel that both the chaiman and the clerk are Establishment figures and they have not (as it were) a prisoner's friend at court because of this change. Excellently though these officers will, I am sure, do their work, it is very helpful for someone who has been working on a factory floor all his life, perhaps, to feel that he can take along with him a shop steward or someone who knows what it is like—what the noise has been like in that particular factory, what the strains and stresses are, and so on—and that he is not just confronting two appointed officials. It may be that the Minister has an answer for me on that point, but I hope that in any case he will be sympathetic to it.
I also query the amendment in Part V which will repeal the designation "teaching hospital". I merely ask why we are doing this. I know that many of my friends in the teaching hospitals have the most sinister ideas as to the Government's motives, and feel that they are trying to stop their special recognition—and, of course, I know that this is at the heart of the problems of the National Health Service in the financing of hospitals. That is because of that terrible thing that I think a previous Government introduced called RAOR—regional allocation of resources—which was an attempt to spread the money around the country. That, in theory, was a very good thing, but what was not taken into account was the fact that patients from around the country tend to come to the special areas, to places like Great Ormond Street and the Royal Marsden, and to the teaching hospitals in London. That has now put a terrible burden on those hospitals in caring for those people for whom they could say, if they were logical about the regional allocation idea, they had no responsibility.
That leads me to another query to the Minister. When we are engaged in this great enterprise of getting people out of hospital, especially long-stay mental hospitals, and into the community, which we all want to do, are they supposed to go back to the areas from which they came, to be the responsibility of those local authorities, or are they all supposed to come out of the gate of the hospital and be the responsibility of the area in which that hospital happens to be situated? Because, again, this makes for a very unfair burden, especially as some of our long-stay mental hospitals are so enormous in size that one district is perhaps going to 768 have an enormous number of patients coming out, whereas the next-door area will have none at all just because the hospital does not happen to be that side of the boundary. I very much hope that there will be some consideration given to this, so that in trying to allocate these funds as between health and social security we will take on board this difficult problem of the districts and the geographical accident of where a hospital happens to be.
I must ask the noble Lord the Minister whether I am right in finding no right of appeal as regards housing benefits in this Bill. We have been through that very complicated Bill about the changes in housing benefits and the resultant changes in social security claims, but I cannot find anywhere a reference to a right of appeal. I share the concern of other noble Lords about Clause 15 and the rather harsh references to people's resources, including the possibility of selling their houses, and so on. I hope this will be administered with great kindness, and I hope that the Minister will tell us that he will be issuing regulations for serious consideration wherever possible.
The trouble in respect of this clause is that many people may not want to go into Part III accommodation permanently. To have to go through all this business of whether they should sell their houses, whether they should sell their life policies to make sure that they have not got £2,500 in the bank, and so on, could be very cruel to someone who was hopeful of coming out of Part III accommodation—and there is nothing more destructive than robbing people of hope in this sort of situation.
Then a quick word about children, Clause 13. Again, I cannot quite see how the parental contributions are to be assessed. It seems to me that this Bill does away with the present arrangement whereby there is a period of a month in which the parents are allowed to consider and agree the charge with the local authority. May I ask the Minister for an answer to this question, if not tonight then perhaps at some other time? Will the parents who have children in care and who are themselves on supplementary benefit or in receipt of family incomes supplement be exempt from making payments for their children in care, or has the Minister in mind some sliding scale that might involve even these people in making payments?
Then about young people in care—16-plus young men and women who might be on a YOP scheme or on other courses. What disposable income will be left to them if they are still in care while they are on a course, or will they be exempt from payments if they are on an approved course? Because since November 1980 young people over 16 in care have been able to claim supplementary benefit; and I hope we can clear up that point.
My last point—I apologise for it, but I feel that if the Minister can give us some further guidance it will help at the Committee stage—is that I understand there are about 2,000 children in long-stay hospitals at the present time. We are supposed to be getting them out, but my information is that we are still putting them in. Only two regions have really taken any effective steps positively to stop or reduce admissions; and in most parts of the country—it may be because this Bill is awaited—there has not been a firm decision taken 769 locally not to admit any more children. Of course, one cannot lay down rules about this because there are about 8,000 admissions to these hospitals every year, and some of them may be desperately urgent and important. However, I very much hope that, even while this Bill is going through the House, the authorities concerned will be encouraged at least to start their plans and at least to begin to stop taking people in as well as trying to start getting them out. I apologise to the Minister for asking so many questions, but this is a very important Bill and I can assure him that we shall be coming back with plenty more problems.
§ 6.30 p.m.
§ Lord Trefgarne
My Lords, may I first take the opportunity to thank all your Lordships who have contributed to the debate today. If I may say so, it is very helpful to Ministers at this early stage in a Bill's progress to hear the reactions of noble Lords and to have suggestions as to how the provisions of the Bill might be strengthened or improved. I have listened very carefully to the points raised this afternoon. Some of them I will attempt to answer in a moment; others may require more time to think and work out, and I promise to write to the speakers concerned as soon as I have had a chance to consider with care the issues that have been raised.
I now turn to the points put forward and shall deal with as many of them as I can. First, the noble Lord, Lord Wallace of Coslany, referred to a number of points. In particular he asked me whether subsection (4) of Clause 1, which provides that a payment must be recommended by the joint consultative committee, was not a rather negative procedure, as I think he felt it to be. He felt that not all authorities were as forward-looking as he would wish, and I think he was disappointed that provision for direct funding of voluntary organisations was not included and that those organisations should have been represented on the JCCs.
The main purpose of the joint finance scheme is, of course, to promote collaboration and joint planning between health and local authorities. That is why all payments have to be recommended by the statutory body which is charged with furthering such collaboration, namely the joint consultative committee. I do not think it would be appropriate to appoint voluntary organisations to those committees. Subsection (4) of Clause 1, of course, repeats a provision under the existing Section 28A(3). Voluntary organisations can be supported from joint finance when they are providing services similar to those of the social service committees of local authorities and are taking part in collaborative schemes. It is therefore appropriate that the JCC should make representations on payments to them also. In many circumstances voluntary organisations are already closely involved with the statutory authorities in providing community services. We wish to encourage that and we are considering ways of involving the voluntary organisations as fully as possible, particularly in the "Care in the Community" initiative.
I know that this matter was also in the mind of the noble Lord, Lord Winstanley, who wondered about the financial support for voluntary organisations. Of 770 course we accept that they have a vital role to play in this context, and indeed I hope that the statutory authorities will involve them to the full in the planning of services and that voluntary organisations may be able to put forward constructive and imaginative proposals for projects. Indeed, a good many of those proposals come across my desk and I am happy to be able to authorise them and indeed provide financial assistance for them in appropriate cases.
The noble Lord, Lord Wallace, also suggested in connection with the registration of homes provisions that the homes should be registered for only a finite period of, say, three years. We decided that with the steps being taken to tighten up the inspection arrangements it would be unnecessarily bureaucratic and a burden both on the proprietors of homes and indeed on the registration authorities to move to a system of registration for a limited period. However, we certainly agree, as I said in my opening remarks, that the homes should be regularly visited at least once a year on what I imagine will be a comparatively formal basis. Also I have no doubt that there will be other informal visits, including possibly lightning visits, as somebody suggested, without a great deal of prior warning.
The noble Lord, Lord Wallace, also asked me about children's regional planning. This was certainly a subject which was in the mind of my noble friend Ladv Faithfull. The noble Lord thought it would not be in the interests of efficient administration for local authorities to withdraw from children's regional planning committees where they still had a job to do. I think that thought was also in the mind of my noble friend, Lady Faithfull. It is not obligatory for local authorities to wind up these regional planning committees if they do indeed still have a job to do. They can continue if the constituent local authorities so choose; but the point is that there is no longer an obligation for these planning committees to continue, and I think that that would be acceptable to my noble friend.
Turning now to the question of family practitioner committees, the FPCs, the noble Lord, Lord Wallace, suggested that this was a victory, I think, against the advice of all other bodies, for the medical profession. I referred in my opening remarks to the wide consultations which the Government undertook last year on their proposals for the change in the status of these family practitioner committees. A clear majority of those whom we consulted favoured the solution we eventually adopted, and the support for our proposals was by no means confined to the professions to which the noble Lord referred.
The noble Lord also referred to the difficulties which might arise from lack of co-terminosity, as it is called, between the FPCs and the DHA boundaries. It is the case that there is to be no requirement for the territorial areas of the new FPCs to be co-terminous with one or more of the DHAs, but in practice most will be, and we do not see this as likely to give rise to any problems. Where a DHA or a group of DHAs has a different boundary from its AHA predecessor, the FPC will still be administering the original area under agency arrangements. Most, if not all, of these committees are likely to be given formal responsibility for the areas they are actually administering.
771 The noble Lord also referred to the provision in Clause 10 which will remove the word "teaching" from the names of the designated health authorities. This was in the mind of my noble friend Lady Lane-Fox as well. It is a purely technical provision, which in no way indicates that we intend to reduce the number of teaching hospitals. The noble Lord, Lord Wallace, was mistaken if that is what he thought; but perhaps it was because I did not explain it properly. My honourable and right honourable friends and I are fully aware of the valuable contribution which these teaching hospitals make to the National Health Service, and I can assure your Lordships that this role will continue. However, some of them, as my noble friend, Lady Lane-Fox, said, also provide for certain regional speciality services and that also will continue.
Perhaps I may touch at this moment on a point made by the noble Baroness, Lady Jeger, when she referred to the difficulty which I have been asked about at Question Time almost every day for the last week or so—that is, the problems of certain hospitals which take patients from all over the country and sometimes from even wider than that. The famous RAWP formula, to which the noble Baroness referred, in fact provides for what are called "cross-boundary flows". I have to say that the RAWP instrument is a somewhat unsophisticated one. It is complicated enough, in all conscience. It would no doubt be possible to refine it further—for example, by making special provision for the kind of problem to which the noble Baroness referred. This is something that we keep under fairly continuous review; but, evey time you think of a good idea for refining RAWP, you find that the proposal produces as many anomalies as solutions, and so the way forward is not always immediately obvious, and in a time of financial stringency, proposals which call for additional resources always present a special difficulty.
I turn now to the question of charges, which was raised by the noble Lord, Lord Wallace. If I am dealing at particular length with the speech of the noble Lord, Lord Wallace, that is because, to be fair to him, he touched on a number of points which have interested other noble Lords and Baronesses as well. So, if I deal with the noble Lord's speech at some length, I shall cover many of the points that others have raised.
The noble Lord criticised what he described as the introduction of a means test and, at the same time, the variability of local authorities' charging arrangements, which I think was very much in the mind of my noble friend Lady Masham and several others, including the noble Baroness, Lady Jeger. At present, there is a variety of powers under which local authorities may make charges, some taking means into account; others only on the cost of the service provided. The purpose of introducing a standard formula requiring authorities to have regard to means is in order to make for greater consistency. It does not oblige local authorities to make charges where they wish to waive them, but it does mean that any charges which are made cannot disregard a person's ability to pay.
The legislative and administrative package which was agreed with the local authority associations in 1980 included advice by the associations to their member authorities about assessing people's ability to 772 pay for day and domiciliary services. We are discussing this approach with the local authority associations. Therefore, I say in answer to the noble Baroness, Lady Jeger, who raised a point about what regulations or guidelines would be provided, that the answer is that we are discussing this matter with the local authority associations and I think they will certainly be issuing guidance to their member authorities.
Returning to the speech of the noble Lord, Lord Wallace, who felt, also, that the abolition of the Advisory Council on Child Care and of the Advisory Committee to the National Radiological Protection Board would leave serious gaps in the provision of advice to Government in these important areas, I would say that the abolition of both bodies stems from the more critical attitude towards the creation and continuation of quangos, following the review by my right honourable friend the Prime Minister in 1979–80. The Advisory Council for Child Care was allowed to go into abeyance when the Personal Social Services Council came to an end in 1980, because we saw no need to retain such a body. Since the Advisory Council was established in 1948, there have been enormous advances in child care. There are now a considerable number of bodies, many with widely representative membership, concerned with the interests of children—for example, the National Children's Bureau, the British Agencies for Adoption and Fostering and the Pre-School Playgroups Association. We maintain close links with these bodies and receive valuable advice from them. We consider that a permanently constituted council reporting to the Government can no longer be justified.
The functions of the Advisory Committee to the National Radiological Protection Board were to bring to the notice of the board the practical aspects of applying in the United Kingdom current knowledge and methods of dealing with radiation hazards. It also advised the board about international agreements and standards on radiation hazards and informed it of matters where research by the board, or the advice of the board, was needed. After consultation with the board and other interested bodies, we concluded that its functions could be carried out more effectively by the board itself and by its direct consultation with the relevant interested parties and the public. The board's expertise has, therefore, been widened by appointing additional members with experience of the environmental sciences, economics, radiation, biology and trade union matters.
The noble Lord, Lord Wallace, and many others, including my noble friend Lady Masham, referred to the problem of charges for residential accommodation and the provisions made in this Bill in respect of them. I have noted the views expressed by the noble Lord and by my noble friend about those clauses, particularly Clauses 15 to 18, which are concerned with local authority charges for this accommodation. Perhaps now is not the time to go into this subject in detail, but I certainly hope that during the later stages of the Bill I shall be able to allay some of the fears that have been expressed.
Turning to the speech of the noble Baroness, Lady Robson, she referred to the danger in extending the periods of joint financing, so that most of the available funds would then go towards extending the joint 773 financing of existing schemes. It is our intention that the extended proposals for joint financing will apply only to new projects for enabling people to move out of hospital. Both the existing legislation and Clause 1 provide powers to lay down conditions governing these arrangements.
The noble Baroness again raised the question of the registration of homes and proposed a national register of homes to avoid undesirable people, having lost their registration, moving to a new area and opening up there. This was in the mind of the noble Baroness, Lady Jeger, as well. We think it is right that local authorities who have experience of running homes themselves, and whom we want to enter into partnership with voluntary and private homes, using places in those homes where appropriate, should inspect and register the homes in their area. But we are aware of the point raised by the noble Baronesses and we are considering proposals, in conjunction with the local authority associations, on how best to keep a record of the sort of undesirable people who have been mentioned.
The noble Baroness, Lady Robson, also raised the difficulty, as she saw it, of the situation where an FPC has more than four district health authorities within its boundaries and may not therefore, have all the districts represented on the committee. We certainly intend that the new FPCs should have as their localities the former health authority areas, and it is the case that this will mean that some FPCs will have examples of more than four districts within their localities. But, in that case, the Secretary of State will have power, under the wider powers that he has, to appoint additional members so that all the DHAs will, indeed, be represented.
The noble Baroness was also worried about the tact that the clerks to the social security adjudication bodies, which we were discussing, would be DHSS employees. Social security appeal tribunals are intended to be informal, not adversarial. The role of the clerk would be purely administrative, and he would certainly not be providing advice. The presidential system will help to clarify the clerks' role and to ensure their independence. The president will be consulted on the appointment of clerks and may make representations for example, requesting their removal.
The noble Baroness also asked how many full-time chairmen there would be. The intention is to appoint a president and six regional chairmen. The number of additional full-time chairmen to be appointed has not yet been decided, but is under consideration at the present time. But there will certainly be at least six, plus the president.
The question of housing benefit appeals was raised by the noble Baroness, Lady Robson, and indeed by the noble Baroness, Lady Jeger. There is a right of review on housing benefit to a review board in each local authority. Since local authorities are running the housing benefit scheme and local councillors are responsible for it, it seemed appropriate that councillors should be involved in a review of decisions taken by their officials.
I turn now to the remarks of my noble friend Lady Faithfull, who was anxious that social services departments should have the necessary funds to provide good community care. The aim is to enable 774 health authorities to transfer matching resources with the patients. Joint finance, including the announced increase which was referred to, will help with the transitional costs. My noble friend also referred to her concern that local authorities are withdrawing from the use of voluntary homes in order to maintain occupancy of their local authority homes. I share my noble friend's concern if there are, indeed, local authorities who are withdrawing from the use of specialised and highly valued voluntary facilities in order to maintain occupancy of their own homes. But, as I am sure my noble friend is aware, it is now generally recognised that residential care may no longer be the solution to the social problems of children and their families which was once thought to be the case. This must inevitably mean that there will be some reduction in local authority use of voluntary homes.
The noble Baroness, Lady Stedman, was concerned about the position of voluntary organisations. I dealt earlier with that difficulty. The noble Baroness also referred to the absence in Scotland and Northern Ireland of family practitioner committees. It is, I understand, the case that in Scotland the family practitioner services are administered directly by the health boards. This has been so since 1974, when they discontinued the executive councils. It is also true that in Scotland they have no regional health authorities, either. The explanation is one of scale. In the rural areas, the relative sparseness of the population would mean that unless committees were impossibly remote from the population they served they would be too small in terms of staff numbers to constitute a viable separate unit. In such a situation, integrated administrative arrangements may well be the best solution, but it would be unwise to attempt to draw conclusions in respect of England, with its much larger numbers of patients and practitioners and generally higher population densities.
The noble Lord, Lord Hunter of Newington, complained that some of our FPC proposals are contrary to the Royal Commission recommendations. It is the case that the Royal Commission on the Health Service favoured integration of the functions performed by FPCs with those of district health authorities, but, as the noble Lord will have gathered, this was not a recommendation which the Government felt able to accept. This is a specialised area of administration of contracts of self-employed practitioners, which, since the inception of the National Health Service, has been a function separate from that of the service. It is right that it should remain so. The practitioners themselves attach great importance to this, and it has served all of those concerned pretty well. Successful collaboration rests not so much on administrative structures as on people and organisations with mutual interests working freely together in a constructive way.
I have dealt, I think, with the point raised by the noble Baroness, Lady Masham of Ilton, about means testing, although I doubt whether I have heard the last of it. The noble Baroness also raised a technical point on the wording of Clause 12. Perhaps she will forgive me if I do not go into it now, but again I shall be happy to look at the point with her at the Committee stage.
Finally, may I touch on the point made by the noble Baroness, Lady Jeger, about the financial 775 memorandum: that there will be no additional expenditure as a result of the Bill. We have made it clear from the outset that the changes we are proposing have to be achieved within planned resources. What we are seeking to achieve is a change in the way that the resources are used. Transfer of patients from hospital to community care needs to be accompanied by a matching transfer or resources from health to local authorities. Care in the community is about making the best use of the resources we have to provide the most appropriate form of care for each patient.
The noble Baroness referred to children in long-term care, particularly mentally handicapped children. I can assure the noble Baroness that the Government take this matter very seriously indeed. I have been pressing health authorities, district health authorities and others very strongly indeed on this matter. We are determined that children should go into long-term care only in the most exceptional circumstances and that, generally speaking, they should be more appropriately accommodated in the community.
I hope that I have answered, or undertaken to provide answers to all the questions which have been raised this evening. In conclusion, I find it encouraging that this debate has not highlighted the vast areas of controversy about the Bill's provisions but rather has served to identify significant middle ground where most noble Lords share similar objectives. There are always minor differences of opinion. We shall try to iron out many of these differences as we debate the provisions in detail in Committee.
§ On Question, Bill read a second time, and committed to a Committee of the Whole House.