The Infirm Elderly: Care in the Community

HL Deb 01 February 1989 vol 503 cc1168-201

8.14 p.m.

Baroness Cox rose to ask Her Majesty's Government what measures are being taken to ensure satisfactory standards of care for the infirm elderly in the community.

The noble Baroness said: I am grateful to have the opportunity to discuss the care of the elderly in the community because a number of issues need urgent attention. I am most grateful to all in your Lordships' House who will be contributing to the debate.

In opening the debate I wish to do three things. First, I wish to highlight the growing scale and scope of the problem of providing adequately for elderly people who need some form of care; secondly, I shall point to current discrepancies between need and provision, discrepancies which will increase in the years ahead unless realistic measures are taken now; and, thirdly, I ask Her Majesty's Government what steps they are taking to remedy present problems and to forestall unnecessary suffering in the future.

First, there is the vast scale of the challenge. It is a matter for rejoicing that thanks to improvements in the standard of living and health care many more people now live so much longer. However, the demographic trend, which will have implications for the provision of care, is a change in balance between the relatively young, fit and indeed spritely elderly and those who may be termed the elderly, who are inevitably more prone to infirmity. According to Social Trends, although the total number of people over retirement age in Britain will remain at about 9.5 million up to the end of the century, the balance between the younger and more active element and the older more infirm group will change considerably. The numbers of those 75 and over, for instance, will increase by 21 per cent. between 1989 and the end of the century, while those who are between retirement age and 75 will decrease by 11 per cent. during the same period.

As the numbers over 75 and, particularly, over 85 increase dramatically. so does the rate of dependency. There will be a sharp increase in those with physical infirmities and those suffering from failing mental capacities. For example, among those over 75, 21 per cent. suffer from various forms of dementia requiring 24-hour nursing care. A simple extrapolation shows that there will be between 80,000 and 100,000 more elderly people suffering from dementia by the turn of the century as well as those requiring other forms of care.

Before turning to care in the community, it is important to remind ourselves that now almost half the acute beds in hospitals are filled by people over the age of 60. One concern arising from the White Paper on the National Health Service is the extent to which hospitals which may choose to opt out of the district health authorities may be subject to such financial pressure that they will prefer income-generating patients to less remunerative longer-stay patients such as the elderly.

I therefore ask my noble friend what steps the Government will be taking to ensure adequate provision in hospitals for elderly persons needing care and what measures will be taken to avoid premature discharge into the community, especially while there is a shortfall of provision there. Community care provisions are already often inadequate in quantity and quality. Looking ahead, the Royal College of Nursing estimates that there will need to be an extra 10,000 residential and nursing home places opened every year for the foreseeable future to cope with increasing need. That assumption is based on the extrapolation that only 4 per cent. of our elderly will need such care. That percentage is lower than that in any other comparable country and is therefore probably an underestimate.

Conversely, the rate of growth of such provision has already begun to slow down. In 1985–86, 14,000 new places were opened, but in 1986–87 those opened dropped to about half that number, and so my second question to my noble friend is: what provision will the Government make to ensure that enough places will be available outside hospitals for the care of the highly dependent elderly with either serious physical or mental problems? With the steady closure of large-scale long-stay institutions, where will such people be cared for with appropriate staff and facilities? Already, as I have pointed out, the acute hospital sector cares for many. While they are acutely ill, that is appropriate, but many others have to remain in hospital in an inappropriate setting for long-term care because of a shortfall of alternative provision.

That leads directly into questions concerning community care. While the ideals are commendable, the reality is often very different. The community can be a lonely place and many people suffer from social isolation and physical neglect. Therefore, as a framework for further specific questions I should like to raise three interrelated issues: first, the need for more carers, more support for those carers and appropriate education for them, and, secondly, the need for more facilities to meet the varying needs of the elderly and the families and friends who care for them.

Thirdly, there is the question of the organisation and administration of services and staff. Given the increase in the number of infirm and/or confused elderly in the years ahead, we know that more people will be needed to care for them. Many will be providing care alongside other family and occupational commitments. The great majority are likely to be women.

In 1972 Professor Pinker highlighted some of their problems: The fact is that the theory of community care was never based on any substantial body of evidence regarding the capacity and the willingness of ordinary citizens to play a major and continuing support role in the care of their sick or dependent relatives … Under the aegis of community care we may now be about to embark on another version of the domestic system, in which the bulk of hard, day-to-day support and care will be undertaken by women in their domestic lives, usually after a day's paid work in other occupations", and often alongside other family commitments. Experience is proving Professor Pinker's prescient anxieties well founded.

Moreover, in addition to family responsibilities many people—sometimes themselves elderly —are having to look after infirm or confused elderly neighbours. I know, for example, one elderly lady—herself well into her eighties—was driven nearly to distraction by her elderly neighbour who was tragically demented. She used to walk down the street in her night clothes on dark winter nights, leaving saucepans boiling dry on her cooker. She could not be admitted to residential care because no places were available. That is not an isolated example. Professional colleagues know of many similar tragedies because of a shortfall of residential care.

There is therefore already an urgent need for more carers and for more practical support such as more back-up laundry facilities for elderly people who are incontinent; more twilight nursing services to help with the demands of evening and bedtime care: more help with the physical aspects of care, such as lifting and bathing elderly people with mobility problems, some of whom may be partially paralysed, very heavy and very difficult to move with dignity and without risk of bad injury for the carer. There is an urgent need for more clinical help as back-up, such as chiropody services; more help with transport. Many elderly people are virtually imprisoned at home because of a lack of appropriate transport. A final example is the need for more direct help in the home such as meals on wheels, which at the moment are not available at weekends. Therefore the third question for my noble friend is: what policies do the Government have in mind to alleviate the practical problems already being experienced by many cares?

My fourth question also concerns carers. Do the Government have any plans to provide carers with more financial support? At present many provide care at great personal and financial cost. Will the Government consider reimbursing them so that they are not unfairly exploited?

My fifth question concerns respite facilities. Many people willingly and gladly care for those whom they love. But because such care is often very demanding, they need some respite. Often this is provided in the form of admission of the elderly person to residential care while the carer takes a holiday. So far so good. But much more needs to be done. For example, day centres which are often very helpful during weekdays remain unused at weekends when they could give much needed respite to carers. Or they could also be used for night care. One enlightened place which I think is the first in Europe is the Crest Hospital in West Lambeth. That offers an excellent service at night for elderly people. They come in at suppertime and can go to sleep if they wish to. Or if they prefer to remain active, they can stay up with staff to keep them company. They can go home after breakfast. This is a particularly valuable form of care, as it is often broken nights which families find most exhausting when caring for elderly relatives.

Such an arrangement gives the elderly person security at night and the family a good night's sleep. It also makes maximum use of the capital assets of the centre, which is used 24 hours, around the clock, instead of lying idle for half the time. That is a path breaker; it is the first in Europe and we hope to see such facilities developed. Another helpful development would be more readily accessible clinics, either geographically, in the form of travelling clinics, or in terms of time, being open at weekends when working people can take their elderly relatives without having to take time off work.

A final point concerning carers is that many people who find themselves caring for the elderly have had no training for this demanding role. Given the physical and psychological competence needed to provide appropriate care, some educational support would be invaluable, such as the excellent course by the Open College, called "The Carers". My next question is to ask the Government whether they would consider offering financial support to carers to enable them to take a course such as this, which would enhance the care they provide, might help them personally and, if we are thinking of groups such as community service volunteers, might help them vocationally, as it brings with it a City and Guilds qualification.

Clearly all these provisions require resources. Sir Roy Griffiths acknowledged in his report that most of the submissions he received indicated that: care in the community is not a cheap option". My next question is therefore to ask my noble friend whether the Government will take account of the extra costs which must he incurred if community care is to be adequate and humane?

This leads to my final theme: the organisation and administration of community care. While agreeing that it is most unsatisfactory for responsibility for community care to remain fragmented, I must draw the attention of my noble friend to widespread concern among health professionals over the proposals in the Griffiths Report that the social services departments should carry the primary responsibility and be the gatekeepers for the organisation of community care. That concern is based on anxiety that social workers lack appropriate clinical knowledge to assess the physical and psychiatric needs of infirm elderly people who may also he suffering from dementia. I am not lacking in appreciation of much of the excellent work done by many dedicated social workers, but their training does not give them clinical diagnostic skills necessary for preventive and prophylactic care, to enable them to discover incipient problems before they become acute.

The condition of the frail elderly can deteriorate very rapidly. Regular visits by trained health professionals can be invaluable in detecting clinical clues in time for remedial action to be taken before their condition deteriorates. Social workers are not trained for this and are therefore not equipped to be the first point of contact or the gatekeeper of care, as envisaged by the Griffiths Report.

Finally, there is deep concern over the ability of some local authorities to provide sufficiently high and consistent standards of care. While some do a very good job, the track record of others makes it doubtful whether they would be the best agencies to provide care for such immensely vulnerable groups as the elderly. Organisations representing the health professions, such as the Royal College of Nursing, believe that the right way forward would be not to follow those recommendations of the Griffiths Report, but instead to invest responsibility in a multidisciplinary primary health care team, including all the professionals involved with community care —GPs, community nursing staff and social workers. Examples of such good practice already exist, as in the Oxford District Health Authority.

A further point is that health authorities should maintain comprehensive registers by age. They allow effective monitoring and preventive care. Social services do not have that facility and must therefore wait for problems to present themselves rather than taking preventive measures.

I conclude by asking my noble friend two remaining questions. First, can he give an assurance that serious consideration will be given to the concerns of many in the health professions that local authorities are not appropriate as the primary agents with responsibility for community care? Secondly. will the Government consider the possibility of establishing an inspectorate to monitor and assess the quality of care provided in the community? This could be similar to the DES inspectorate and would be especially desirable, given the inherent vulnerability of people now being cared for in the community. Also, could such inspection include three-bedded homes, currently immune from any inspection? In this connection, will the Government realise the importance of such inspection being undertaken by people with clinical competence?

I finish by saying, as I have said on previous occasions, that a society can be judged by the quality of care it provides for its most vulnerable citizens. That judgment applies to individual citizens as carers and also to government. Many citizens are already setting a magnificent example in the way they are caring for elderly relatives and neighbours. Many health care professionals and social workers are also carrying out their responsibilities with great dedication, sensitivity and imagination. It is now essential that the Government develop a policy and provide resources which enable those who care to continue to do so to the highest possible standards and to meet the growing challenges ahead with all the necessary support and facilities to ensure that our elderly citizens in need of care can enjoy the best possible quality of life, with self-respect and dignity, to the end of their days.

8.30 p.m.

The Earl of Longford

My Lords, I am sure we are all grateful to the noble Baroness, Lady Cox, for raising these vital matters in such a sympathetic way. We are also grateful for the way she put all these questions which the noble Lord, Lord Hesketh, will have the pleasure of answering in about two hours from now. I am sure the noble Lord's brain works much more accurately than mine. But unless he has been given advance notice, he may have quite a task in front of him to keep up with the issues raised.

I am not sure whether the noble Baroness, Lady Cox, is better qualified than I am to discuss the infirm elderly. No one is less infirm or elderly than she is. I believe that after this debate she will go and play a game of squash. About 60 years ago I might have done that myself. On the other hand, I claim the severe advantage of being elderly, and of course, infirm. That may be more obvious to other people than it is to me.

The noble Baroness talked with deep sympathy of the infirm elderly. But, if one is among their number, one understands their problems in a different way. I think I am the only person taking part in this debate who is genuinely elderly. I do not count anyone as elderly until they are over 80 years of age. So I think I have a priority on the tee, as one might say.

I do not underestimate the qualifications of the noble Baroness for raising these matters. She has been a nurse. That is certainly more than I have been. That may be more than anyone has been who is taking part in this debate tonight. The noble Baroness is full of charming eloquence. We understand she has a unique influence with Mrs. Thatcher. That is an advantage provided it is a one-way influence and it is influence exercised by the noble Baroness on Mrs. Thatcher and not the other way round. If it were the other way round, that would he disastrous. I am afraid that Thatcherism is regarded as a deplorable phenomenon for the social services by non-Thatcherites. So the noble Baroness has advantages and disadvantages as regards discussing these matters.

We should not treat the infirm elderly as necessarily tragic figures. This morning I paid a call on the noble and learned Lord, Lord Gardiner, who was formerly Lord Chancellor in this House. He has suffered from a distressing illness for a number of years. He has not been to the House for 10 years. But there he was, looking as elegant as ever, with his charming wife beside him. The noble and learned Lord, Lord Gardiner, is aged 89 and his wife is 83. So they could be called infirm elderly. The noble and learned Lord asked me to send a message of good will to the House tonight. I am sure that would be reciprocated. The noble and learned Lord is a lovely example of serenity and dignity in old age.

I have been visiting a great friend in hospital during recent weeks. He is over 80 years old. He is getting on very well and will soon be out of hospital. Like the noble and learned Lord, Lord Gardiner, he will be well looked after. So it is possible to be infirm and old but to be well looked after, to be happy and to lead a good life. But the people who are in our minds tonight are not in those comfortable circumstances. I have been in touch, as others may have been, with that splendid organisation Age Concern. There is no organisation in this country which does as much for the old as that one. I have some notes from Age Concern, and some of the points that are raised are similar to those made by the noble Baroness, Lady Cox. The idea of an inspector, for example, is mentioned by Age Concern. The organisation states: we have campaigned for many years for the introduction of some form of independent inspectorate for all locally provided services, closely linked with a well-publicised and carefully defined complaints procedure. I am sure that suggestion from Age Concern has the support of the noble Baroness, Lady Cox.

Generally speaking, Age Concern shares the desire of the noble Baroness to see services much better integrated. That rather horrible word "multidisciplinary" comes into all these discussions. Age Concern supports the noble Baroness in that regard. I am not quite sure whether the noble Baroness agrees with Age Concern in desiring to see a radical reform of the law. It considers there should be a new statutory duty placed on local authorities. I do not know whether the noble Baroness agrees with that. But that is one of the organisation's ideas.

I shall deal with just one aspect of the points that Age Concern has placed before me. As I said, I have been visiting a hospital quite often recently to see elderly people. One thinks about those elderly people who will not have a good time and who will not be looked after when they leave hospital. I think of them particularly tonight. Age Concern states that if those old people cannot find care for themselves, they must hope to find a residential home within social security limits. That, as I understand it, is the crucial point in the minds of those who are most concerned with the elderly. Age Concern thinks that the limits must be raised if it is going to be possible for old people, when they leave hospital, to find some kind of residence within their pocket. That means more money.

I am sorry if I have to speak in what may sound to the noble Baroness a party way, but Thatcherism is no use in this connection. Thatcherism means less money. We are told that the point of the new health reforms is that we are going to save money and somehow or other improve the condition of patients. Whether we are thinking of the infirm elderly or just the elderly, in my opinion we cannot save money at their expense. The social security limits will have to be raised. By and large, we cannot help these people on the cheap. I say that bluntly to the noble Baroness, Lady Cox.

8.37 p.m.

Baroness Seear

My Lords, I shall be brief as many of the points I intended to make have already been covered by the noble Baroness, Lady Cox. I found myself in agreement with most, although not all, of her points. This evening I wish to speak not so much about old people themselves but about carers. I am the president of the Carers National Association. That body has recently been formed out of a merger between the National Council for Carers and their Elderly Dependents and the Carers Association. It is now undoubtedly the largest body dealing with the problems of carers for old people.

The issues are, of course, closely related. If carers are not adequately looked after, the chances of old people being properly cared for—unless they are in an institutional organisation—are very slight indeed. But it is the issue of carers to which I wish to direct your Lordships' attention.

It is reckoned that in the region of 1.7 million people are responsible for caring in this country. That is a very considerable number. Of those people, two-thirds, we are told, do not get help from anyone else. They are caring single-handed. I suppose that most of us, at some time or other, have been involved in looking after sick people. Anyone who has been disturbed night after night knows that it is not possible to go on and to maintain any kind of standard of care for people when one's sleep has been interrupted in that way.

If one is caring single-handed for an old person the burden is terrific. Old people get progressively more difficult to look after. They become more confused and, because of that, often very irrational. Something like 42 per cent. of the people doing the caring are themselves over retirement age. That places an additional burden on them because they themselves have to bear some of the problems of ageing along with the burden of the older people they are looking after.

Many people provide such care because they passionately wish to maintain the home in which those older people have lived. In so doing they are not only helping the older person who undoubtedly, in the vast majority of cases, wants to stay in his or her own home. They are also saving the state a great deal of money which would have to be spent if the old person were in an institution. It is therefore quite unreasonable to he cheese-paring in our attitude towards the needs of the carers.

People are living longer and therefore the years for which caring has to be undertaken are getting longer. If caring is to be a possibility there must be good community care. Good community care does not come cheaply. Let us not pretend that it does. At the moment, except in a few cases, community care is a mockery. It does not exist. As the noble Baroness, Lady Cox, said, carers need respite care. They need the ability to put the older person in an institution—often very much against their will. Old people are not all sweetness and light and can he extremely awkward as they get older, which increases the burden. Carers desperately need to get away from them and have a break.

It is therefore a great pity that the Government have been disposed to cut down on the number of small hospitals. If one wants good community care one must have a cottage hospital available where there can be day centres. With any luck the old person would have known that institution in the past, would be familiar with it and would know the people running it. Such local hospitals are well known and very much loved by many people. Old people would be willing to go into such hospitals for respite care for a short period to give the carers a very necessary break.

The noble Baroness, Lady Cox, made a further point which I should like to emphasise. Day care must allow the carer to continue in her work. That is highly desirable. The Carers Association has always fought for facilities to enable the carer to stay in employment and in social contact for as long as possible. Very early in the work of the association, years ago now, we asked people what their major anxiety was. We expected that it would be isolation, loneliness or their own ill-health. It was not. They asked what would happen to them when they were older because they had lost their jobs and their pensions and had used up their savings. They also suffered from isolation. It is therefore of the greatest importance that they should stay in employment for as long as they are able to do so.

Today, when the Government are anxious to get women back into employment, it is ridiculous to create circumstances in which women who have been in employment, often in very responsible jobs for which they are highly trained, have to give those up because the conditions under which they have to provide care make it impossible for them to continue their work. It should surely be a high priority to enable the carer to live as normal a life as possible. That includes the possibility to continue earning for as long as they possibly can.

There are of course other important services. Perhaps because I am a remarkably bad housekeeper myself, I have always felt that no social service is as important as the home help service. The ability to have someone to help with the cleaning up that inevitably has to be done for an elderly, often semi-senile and not very able-bodied person is of the greatest importance. Yet the Government have cut back on the home help service.

As a result of pressure a previous government paid the invalid care allowance where the carer had to give up employment—and that should be a last resort. The allowance is still only £24.75 and is paid only where someone has given up work. Someone drawing the allowance is not allowed to work for more than 12 hours. Is it not possible for the Government to look at the size of that payment? It is a very small contribution to make to people who are carrying a very heavy load, in many cases at great financial sacrifice, and who, in so doing, are saving society a great deal of money. Therefore we ask the Government to accept that there are a great many people who need to be cared for; to accept that the present provision is totally inadequate; to accept that we do not want, individuals do not want, and families do not want old people to have to go into residential institutions; and to accept that good community care is absolutely central.

I shall cross swords with the noble Baroness, Lady Cox, on one point. I should he very sorry for an argument to grow up about who should be the responsible authority. We are having difficulty enough in getting the Griffiths recommendations seriously considered. The Griffiths Report has recommended that the local authority social services department should have responsibility for community care. Of course it has to be a collaborative exercise between the people in the health service and the people in the social services. Griffiths came down in favour of the social services: I think that that is right.

The needs of old people are not only health needs. They have a variety of social needs. Once we improve their training, the social workers working with the health services, but not under them, should be in a position to see what is necessary and to call in expert help in the areas where they lack the appropriate expertise.

Responsibility for this work must he in the hands of an elected local body, and that is the local authority. We talk about neighbourliness; we talk about individuals making their contribution—the good citizen that we hear about, and all that. But those things have to be organised through the ordinary democratic processes of elected authorities. Will the Government please accept that Griffiths did a great deal of work, that he got the right answers and that the problem brooks no further delay.

8.49 p.m

Lady Kinloss

My Lords, it is very timely that the noble Baroness, Lady Cox, should ask this Question about the measures being taken to ensure satisfactory standards of care for the infirm elderly in the community. I wonder whether the Minister who is to reply knows what unease, if not anxiety, there is within the community on this subject.

Already in the late 1970s and in the 1980s the pressing problems of an ageing population began to be apparent. As the noble Baroness, Lady Cox, has already said, almost half the acute beds in hospitals are filled by people over the age of 60.

One of the concerns not only of people who need support to live in the community but of their relatives is the need for home helps. Home helps are provided by social services departments, but if departments have their grants cut it means that they may have to make higher charges for the home help service to the detriment of their clients, that is, those who pay.

In many areas home help is changing to home care with staff attending to the personal needs of their clients. Thus the popular home help service which involves some cleaning and shopping is disappearing, leaving a considerable number of elderly and infirm people without essential domestic assistance. The maintenance of home help care is of the greatest importance to the elderly and so too is the meals-on-wheels service.

Does the Minister agree that health authorities and local authorities joint funding should have a special allocation for community care? That would enable them to plan in advance for their rehabilitation programmes for returning suitable elderly to their own homes?

In York the City Hospital cares for the infirm elderly. With a complete change of outlook on nursing and with rehabilitation programmes, there is a greater turnover of elderly infirm patients. With the necessary back-up support where it is available, they are able to return to their own homes. The City Hospital offers respite care for the families or carers of those elderly people. There is also a small cottage hospital in Easingwold north of York, near where I live. It is vitally important to quite a large area of the rural community. It takes patients who live at home and are cared for by their families or by a carer in order to give them a break —in fact, the respite care which in many cases is urgently needed. There appears to be more and more need for small cottage hospitals of that kind. Help the Aged find that Part III places for respite care are rare. There is obviously a great need for more respite care places.

There has still not been a ministerial response to Griffiths. If there were, it would open the way to better co-ordination of care in the community. Yesterday, in answering questions on the Statement on the National Health Service, the Minister said: The interaction of health and social care in the field of community care needs further study. That work is well in hand and the results of the review will help to advance it further".—[Official Report, 31/1/89; col. 1010.] In regard to community care can the Minister say that the work is well in hand? How soon will that he completed? Will it be quite soon or in the distant future? Should not there he some guidelines set down nationally on targets and standards of services for the local social services to achieve? What measures are being taken to disseminate good practice? Local authorities need to know what others are doing. I understand that York has a good record. Are the Government taking a lead in promoting good practices so that the good quality services do not depend on where one lives? Does the Minister agree that the problem is that there is no one agency with responsibility to ensure the development of adequate services for the elderly? That often leads to confusion, duplication and waste. That point was also raised in Sir Roy Griffiths' Report.

The Royal College of Nursing is increasingly of the view, which has been reinforced by the wide discrepancies in the levels of provision made by local government social services for the mentally ill, mentally handicapped and physically disabled—as shown in the report of the Audit Commission—that a national service must be established under a Minister. Does the Minister agree that some form of co-ordination nationwide is what is needed?

The Family Policy Study Centre feels that the way ahead has to be clarified and responsibilities specified both centrally and locally. Without such a response both health authorities and local authorities face a planning plight. Help the Aged say that voluntary organisations such as Crossroads, which supplies care attendants to families who have elderly infirm in their own homes, are experiencing difficulties. This is because of transfer from the Manpower Services Commission to the new Employment Training Scheme. Under the MSC they had a block grant which they used as they wished but under the new ETS, they take on staff who are to be paid what they would receive from social security plus £10 for each individual. So the voluntary organisation has to find its own finance for management.

I should like to thank the noble Earl, Lord Arran, for his letter in answer to my supplementary question on expertise in the field of community care, in view of the recently published OPCS survey into the incidence of disability in the community. The survey has revealed that there are 4.25 million disabled people with varying degrees of disability who are over the age of 60 out of a total of 6,202,000 disabled adults over the age of 16, again with varying degrees of disability.

Those figures are larger than the original OPCS survey revealed in 1969. That is because the earlier survey only covered physically disabled adults in their own homes. These latest figures mean that 454 people out of every 1,000 over the age of 60 have some kind of disability. Of course some of them may be living in residential care rather than in the community. It has been found that many infirm or disabled people have to keep up a sustained fight to obtain the services that they need. The younger ones will probably succeed but the elderly or very old will not have the energy. The older people may also feel that they are in receipt of charity and good deeds. They may feel that they should not ask for the services to which they are entitled.

A comprehensive and easily understood pamphlet of information on services should be made available to all the people who need them, as they are unlikely themselves to ask for the available information, as is their legal right. There is also an urgent need for all information to be in the languages of ethnic minorities as well.

No new proposals are needed to improve community care; nor do we have to pass legislation. It can be improved simply through the implementation of the remaining sections of the Disabled Persons Act 1986, and Section 7 in particular. which concerns people who are discharged from hospital. Can the Minister confirm that I am correct in believing that this section is to be implemented this year?

RADAR believes that the needs of elderly infirm or disabled people are insufficiently recognised and catered for. I hope that that is not so.

8.56 p.m.

Viscount Brentford

My Lords, I too am very grateful to my noble friend Lady Cox for introducing this subject, which, like other speakers, I consider very important. It is important for a number of reasons. One is obviously the increasing number of elderly in the community. I gather that it is expected that between the years 1985 and 2001 the number of elderly people over 80 will increase from 1.8 million to 2.4 million, which is another 600,000. A large proportion of those people will doubtless fall within the ambit of this Question; namely, the infirm elderly.

The subject is also important because of the economic issues involved and in particular between the questions of home care, residential care and hospital care. I have tried to discover reliable figures which are averages for those different types of care and I keep coming across different figures. As a generalisation I should like to suggest that it costs at least 50 per cent. more to look after somebody in residential care than it does to keep that person in the community with individual care.

It appears to me that having someone in hospital care costs at least double what it costs to keep him in residential care. The figures for maintaining an infirm elderly person in a hospital seem to be double those for keeping that person in residential care. From the Government's economic point of view it is therefore very important to look at the significance of community care, which, while it is not a cheap option. is cheaper than the other options.

The third point that I should like to make about the importance of this Question is the improved quality of life for the individual who is able to stay in his own home, in his own bed and with his own things around him, with friends not only in his house but also in the street. For those reasons I believe that this is a very important Question we are discussing this evening. Speaking in my capacity as chairman of a small research group called Family Base, which is looking into this issue at the present time, I should like to say that we are hoping to set up workshops in which we can draw together individuals, churches, voluntary organisations and statutory bodies to discuss the setting up of support for the carer, who is someone we feel is greatly neglected.

As a solicitor I am quite often asked whether an infirm elderly person ought to stay in the home, whatever the cost in terms of the time and energy of the people around might be, or whether he should be moved into residential care. I also see the system from that point of view.

We ought to be looking at an elderly infirm person not only as an individual but also as a member of a family, where there is a family. Many people have family relationships that will benefit by keeping an infirm elderly person in the home. That is a matter that cuts two ways. In that connection I should like to refer to the 1981 White Paper entitled Growing Older. It states: The primary sources of support and care for elderly people arc informal and voluntary. They spring from the personal ties of kin, friendship and neighbourhood". It is very important for us all to remember that.

Let me next turn to the question of carers generally. Until very recently the scale and scope of the contribution of family carers—who are often called the forgotten army and were so called by the Family Policy Study Centre Report of 1984—were often unknown. Last year, however, the Office of Population Censuses and Surveys published some timely and startling statistics on the extent of informal care. On the findings of the general household survey of 1985 I shall quote some percentages, for which I apologise, but I believe that they are helpful. As many as 19 per cent. of households contained a carer who was typically looking after one elderly relative. Of those carers looking after someone in the same household, 45 per cent. devoted at least 50 hours per week to caring and more than half had had no break of at least two days since they first undertook the task.

Again, these co-resident carers had regular visits from health or social services or voluntary groups in only one-third of the cases. I believe therefore that we have a problem. We ought to be providing more help for carers. We also have a problem because the number of potential carers is declining. The numbers in the lower elderly age group have already been quoted as falling. There is a lower birth rate, as we know. A factor that has not yet been mentioned is that there is higher mobility today than there used to be. It means that families are breaking up. This is also causing a problem because one often has a situation where the younger members of the family have left the area where the infirm elderly person is residing.

We need to ask and to encourage local authorities to do two things. One is to look out for carers. I find that people who are caring for an elderly person often do not realise the back-up support that is available from local authorities. I hope that publicity can be given to that. When a local authority has found a carer it needs to assess the needs of that carer—whether it is respite, as we have already discussed, day centres, care attendance schemes, attendance allowance, or whatever. Every situation i differs. A careful assessment of what is needed is required by the local authority.

Perhaps I may ask some specific questions of the Minister about what I should like to see the Government doing. I believe that not only the local authorities but the Government should publicise the right of carers to contact local authorities. Are there any plans for increasing publicity for that?

The second question has already been touched on. Has the Minister any plans for delineating more clearly the responsibilities of the different government bodies? I mention the health service and the social services as examples. We lose a lot because of different people having different responsibilities with no central co-ordinating body. There must have been a need when the Griffiths Committee was set up. So far as I can see there is no less a need now. I do not know whether my noble friend will comment on the Government's attitude to the Griffiths Report recommendations. Is my noble friend accepting them or rejecting them? If he sets up alternative schemes, different from those recommendations, or if he accepts them, that will be good. But the one course that is had is for no action to be taken on the needs outlined in the Griffiths Report.

I know that the Minister will not want to hand out extra money. However, I should like to stress the need for better deployment of the economic resources that are available. I have already touched on the economic benefit of keeping an individual in community care—in home care rather than residential. What plans does the Minister have to ensure that there is sufficient cash to pay for the needs of carers so that the residential care is not needed? I look forward to his answers.

9.7 p.m.

Lord Carter

My Lords, I should like to join previous speakers in the debate in thanking the noble Baroness, Lady Cox, for putting down this Question and for enabling us to debate this very important subject.

Statistics have already been quoted. However, the key ones are worth repeating. It is estimated that by the end of the century the number of people over the age of 65 will have increased by half a million. The number over 85 years will double. It is also estimated that then each of the social service departments may have to cope with an extra 600 persons with senile dementia. The OPCS survey, Disability in Great Britain, which ***has been mentioned, reveals that of the 6 million people defined as disabled in the survey no less than 70 per cent.—that is 4 million —are over 60.

In the survey are a number of categories from 1, which is the least severe, to 10, which is the most severe. To illustrate the crude statistics, in category 2 is a man of 75 who often forgets what he is supposed to be doing when he is in the middle of something, loses track of what has been said in the middle of a conversation, forgets to turn off things like fires, cookers, taps and so on. It is estimated that there are 840,000 people with that level of disability who are living in private households and 16,000 who are living in establishments.

A women of 77 who is affected by old age illustrates category 8. She is so upset that she hits other people, injures herself and forgets people's names, and so on. It is estimated that there are 338,000 people with this level of disability living in private households and 58,000 in communal establishments. In those two categories alone there are one and quarter million people, of whom only 174,000 are in residential care and the rest are in fact being cared for in one way or another at home.

We can all agree on the answer to the problem. We need an easily-understood system which can direct help quickly and efficiently where and when it is most needed. We have had many recommendations and proposals, as has been mentioned. There have been the Griffiths Report, the White Paper in 1987 on primary health care, the 1986 report by Age Concern on the law concerning vulnerable elderly people, and all the other reports from the voluntary sector.

The response made to all this by the Government has been a deafening silence. Only yesterday we had the White Paper, the NHS review, which I fear poses many more questions than it answers. There is real concern about the effects of the proposed changes on elderly and infirm people. The only direct mention of the elderly in the White Paper is the proposal to give tax relief for private health insurance payments to those over 60. Immediately the question that springs to mind is: how much could be done in respect of community care for elderly people if the money proposed for this tax relief were to be used for that instead?

One might perhaps compare the proposal for tax relief in the White Paper with the actual problem of elderly people who are dependent on social security; and I will give just two examples out of many. The first is of a 75 year-old person living alone and in receipt of a severe disability pension. That person has an income of £93.20 per week and is saving the Government perhaps in excess of £6,000 on the cost of residential care. The second example is of a couple aged 75, one of whom is severely disabled and the other is trying to lift, carry, care and cook for the disabled partner. The total income of that couple is £92.05 per week: £1.15 less than the person who is living alone. That sort of anomaly shows that it is quite wrong that people in the evening of their lives should have a burden of that sort and that it should have to be carried by the people I have described.

I cannot help feeling that the resources which are to be devoted to tax relief for the eldely in respect of their payments for private health insurance would be better used to increase the income of old people such as I have described and to cure the anomalies in the social security system. As has been said by other speakers, these people are saving the Government enormous sums of money by staying out of residential care.

As a final point regarding the NHS review, we all know that the family GP is a very important point of contact for many elderly and lonely people. I wonder just how the GP's sympathetic ear will be costed in the new, cash-limited and budget-conscious general practice which is foreseen in the White Paper.

We all know the action that is required and which is being suggested, as I have said, in many reports and proposals made to the Government, and now the Government, as other speakers have said, must give the lead on community care. The whole community care movement in the public and the voluntary sectors is waiting for that lead. The provision must be needs-led and not resource-led, and the resources which are provided must be properly directed and managed. Infirm and elderly people should be cared for with understanding and, above all, helped to retain their dignity.

9.7 p.m.

Baroness Faithfull

My Lords, my respect and admiration for my noble friend Lady Cox know no bounds. However, in this debate which she has so ably initiated I find myself putting forward a somewhat different point of view. Perhaps that is to be expected.

In his report, as the noble Baroness has said, Sir Roy Griffiths recommended that the local authority should be the gateway for the organisation of community care, which of course includes the infirm elderly about whom I understand this debate is concerned. On the other hand, as the noble Baroness has said, the Royal College of Nursing recommended that the district health authority should act as the gateway and that a national service for community care must be established under the control of a Minister. Age Concern has called for a form of independent inspectorate.

The dictionary defines "infirm" as physically weak, especially for the elderly. "Sickness" is defined as incapacitated through illness. I shall not quote figures because they have already been quoted to your Lordships. It is true that the number of elderly is increasing, and that an increase in the number of the elderly means an increase of the infirm.

As I understand the figures—the noble Viscount, Lord Brentford, will perhaps know better than I—the elderly infirm are one-seventh of the elderly population. Therefore we do not want to look on the elderly as an illness problem. I am elderly. The noble Earl, Lord Longford, says that he is elderly. I am only a few years short of him. I feel very fit and I do not wish to be regarded as a medical problem.

The position in the population of the infirm elderly is a problem; but nevertheless we must regard the elderly as people in their own right wanting their own things in their own way. It is very important that we do not try to organise for them when they want to be people of individual independence.

I agree with all Members of your Lordships' House, and with the noble Baroness, that at the moment there is no strategy for the country as a whole. I suggest first that the district housing authorities and the housing associations should have a duty to offer the tenancy of a flat or, if they wish it, only a room to those in need of accommodation. One of the real problems is that in this country people do not plan for their old age. Some people remain in their accommodation which is sometimes quite unsuitable, and then when they get very old they do not have the energy to move. I believe that district housing authorities and housing associations should build in each area the kind of accommodation that people want so that they can be tenants in their own areas.

That presupposes that there must be a network of community facilities. Some noble Lords have mentioned meals on wheels; some have mentioned home helps; and others have mentioned carers. May I spend a moment on the carers which so many Peers have mentioned? There are two types of carers. There are the carers who arc relatives; and as the noble Baroness, Lady Seear, has said, they are people who sorely need help and support in the way that she suggested.

The number of people who came to me for jobs when I was working in Oxford as director of social services made me very sad. To fit them into a job after 20 years at home looking after somebody was very difficult. It was not impossible, but it was difficult. Therefore they are the people who need the kind of facilities that the noble Baroness, Lady Seear, and the noble Lady, Lady Kinloss, have described.

Then there are the carers who are employed by the local authorities. There is a scheme in Kent whereby the carers who are employed by the local authority are in groups of 20 and each group is, so to speak, organised by a senior carer who covers a district. So the district gets to know the senior carer who gives support and help and perhaps stands in for a carer if she is unable to go to a case. So it is vitally important that we develop the carer system throughout the country. Of course, as has been said by the noble Baroness, Lady Seear, they need training. Sometimes when I am visiting I find that it is the home help and the carer whom people welcome. The nurse is welcome, but she visits only once a week, once a fortnight or once a month. In most of the cases that I have visited, the doctor calls perhaps once every three months. However, the carer and home help visit every week. They may thread a needle for the half blind and carry out the tasks which are of value to the person in the home. Many people can stay in their own homes if their accommodation is in the area in which they are known, where they have relatives and have the supporting services of carers.

The housing authorities must supply wardened accommodation to enable those who are not so able to live on their own with the help of community services. The development of day centres is also vitally important. Residential centres are often built next door to day centres and therefore people attending the day centres become used to going to the area. When it is necessary to provide a rest for relatives or people looking after the elderly and infirm, they will go naturally and easily next door into the residential centre. That is most important, but it has only recently been carried out.

We are deeply indebted to and dependent on the medical and nursing professions. However, from the organisational point of view, the setting up of a network using volunteer organisations needs to be carried out by the social services. There must be a multi-disciplinary planning committee in each area. That requires the involvement of not only the social services and nursing bodies but also the housing departments. I also believe that there must be a multidisciplinary case committee to discuss where important cases must go. I agree with the noble Baroness that social workers need help to diagnose cases at an early stage.

I turn to the training of social workers. Your Lordships' House will become bored with me because every time I rise to speak I talk about the training of social workers. We must ask the Government whether they will ensure that social workers receive adequate training and are sufficient in number.

Although it is less expensive to have people living in the community rather than in an institution, good community care is expensive. That fact must be acknowledged and unless it is we shall never have a good system.

This would be an historic debate if the Minister made a statement concerning the recommendations contained in the Griffiths Report. Will those recommendations be implemented? There is at present a downward slide in social services and in the health service. It is now some time since the Griffiths Report was published. Even if the Government make the wrong decision we implore them to make a decision one way or the other. I profoundly believe that the social services should act as the key organisers and the gateway. We ask the Government to make a decision concerning the recommendations in the Griffiths Report so that the strategy can be implemented.

9.25 p.m.

Lord Pitt of Hampstead

My Lords, I too am very grateful to the noble Baroness for giving us the opportunity for this debate. It is very interesting that in this House the Question is being asked by one of our youngest Members and being answered by one of the youngest Ministers. What has already been said about the estimate of the number of people over 75 and over 85 is absolutely true. They are very important predictions for those who are planning the health and social services because the very elderly, whose numbers are increasing, also make the largest demand on statutory services.

It is estimated that health and social services expenditure on a person over 75—somebody like myself —is two and a half times that in respect of a person aged 65 to 75 and four and a half times that of the average covering all ages. Therefore, it is quite expensive in terms of the statutory services. What is more, it is estimated that a very high proportion of the over-75s find themselves needing 24 hour nursing care. That is also important.

Having said that, quite a small percentage of people of that age need care. The vast majority are living ordinary lives and should be helped and encouraged to go on living ordinary lives. I believe that the emphasis must be on trying to keep people in their own homes but, more than that, trying to keep them active and motivating them into being active. For example, I have never been too sure that it is wise to have a low limit—because the limit is rather low—on what people can earn when they become pensioners. They should be motivated to go out and earn and to keep active. The motivation should not be the other way round. I have never been sure about the wisdom of that. To allow people to remain at home and to help them to be independent enables them to run their own lives. It enables them to have the freedom and autonomy to structure their own lives in the way they wish.

Having said that, I come to the adverse side of the matter. The resources available to enable people to remain in the community are much too low and quite inadequate. It is necessary to face that squarely. The question we need to ask and that needs to be answered by the Minister is: what will the Government do about increasing those resources? We read about the money that is coming into the Treasury at the moment and the amount that is available to the Chancellor. In the next breath we are told that there is not the wherewithal to provide services for people who served the community when they were younger and who now need some support.

I am unable to understand what is motivating those who are responsible for dealing with these matters. I believe it is possible for us to do much more. What is more, although it is expensive to keep people in the community it is more expensive to keep them in residential care. However, the expense of keeping them in the community is high when they are first moved from residential care into the community. That is one fact not being properly faced by the authorities. They need to be prepared to spend much more money to transfer people from residential care to the community knowing that in future they will not have to spend so much because, once in the community, the cost is less. I do not believe that the planning takes that into account. I get the impression of an attitude that says, yes, one wants to make the transfer but at the same time keep expenditure at its present level. It cannot be done. And that important aspect needs to be faced.

Elderly people need to be treated as equal and ordinary members of society because that is what they are. They need to have their wishes, tastes and needs treated with the same consideration that other people expect. They need to be able to participate in the social, cultural and leisure activities of society. They need also to be fed, housed, and kept warm. I was glad to hear what the noble Baroness, Lady Faithfull, had to say because housing is one of the areas where problems arise from the approach that authorities adopt in dealing with the elderly.

Many old people are living in houses which are dilapidated and which they cannot repair. So another aspect that needs to be looked at is the extent to which we could provide much larger grants to owner-occupiers. The Government are pleased about the way in which they stimulate owner-occupation. Let us accept that there will be people who are owner-occupiers and ensure that there is provision for them to live in good houses, not in houses which are dilapidated. There must be proper grants. It should be possible to give grants which will enable houses to be repaired and modified to make them suitable. In many instances houses are not suitable for old or infirm people and the occupants do not have the wherewithal to make alterations. Therefore, adequate grants should be available to deal with that. Insulation is also important because old people need to keep warm.

I was glad to hear what was said about community care, volunteers and respite care. That is of the utmost importance. There is also the question of mobility. I have concentrated upon keeping people in the community in their own homes rather than in residential homes. But they also need to be mobile. Attention should be given to that point. I remember at County Hall, when trying to give Londoners free transport passes, we had to battle with central government—incidentally, a Labour government—to get them to understand that we were not seeking to take over the activities of the social services, which are the functions of boroughs, but trying to help the citizens of London to become more mobile. That was the basis of the scheme.

Finally, I must say something about Griffiths. As noble Lords have heard from previous speakers, Griffiths has suggested that care in the community should be the responsibility of local authorities under the direction of a Minister. We have heard from the noble Baroness that the nursing profession is not too happy with that. In addition, the medical profession is not entirely happy because, like the nursing profession, it also believes that the social services departments of local authorities have in the past not shown themselves to be quite capable of dealing with these jobs. They are not at all sure about this matter.

On the other hand, the General Medical Services Committee which is the committee of the BMA that deals with GPs, has agreed to accept Griffiths provided that the Government implement the Griffiths Report in its entirety. I shall read from the report because it comprises part of the GMSC's reply to the Government. I believe it is important that this should go on the record. Griffiths stated that: Merely to tinker with the present system would not address the central issues and would forgo the benefits that could be obtained from more concentrated action. The opportunity exists to create a partnership in the delivery of care—between central and local government; between health and social services; between government and the private and voluntary sectors; between professionals and individuals—to the benefit of those in need. The proposals as a whole—and no single one on its own—are aimed at enabling that opportunity to be taken". The GMSC is prepared to accept that. It states further that as the committee sees it, In practice, these very sound ideas (and the committee regards them as sound) demand universal implementation of the 'Primary Health Care Team' … concept with social workers attached to PHCTs by the Social Service Authority to act as 'care managers' for cases referred by the PHCT". That is relevant to the acceptance of Griffiths. The commentary continues by saying: Should the Government decide to implement the report piecemeal we should resist any attempt to amend the GP's contract, to make the GP responsible for informing the Social Service Authority of possible Community Care needs of any patients registered with him and for satisfying himself that the Social Service Authority had considered the case. Most GPs already do this anyway, though often with a sense of frustration at the lack of response from the Social Service Authority. The contractual responsibility should be that of the Social Service Authority". That is what Griffiths has recommended and if it is implemented in that way the GMSC will accept it. It will not accept it the other way round. The commentary continues: The GMSC considers that the report is a broad package of proposals and should be implemented as such, subject to discussions with the GMSC on the details". I believe that I should put this point of view on record. Your Lordships will know that I am quoting from the reply of the GMSC to Griffiths. I am sure that the Minister will not be able to tell us that the Government have accepted the recommendations of the Griffiths Report, but I hope that he will tell us how soon we can have an affirmative reply to them. As the noble Baroness, Lady Faithfull, said, there is great concern all around about what the Government are going to do.

9.40 p.m.

Lord Hunter of Newington

My Lords, I shall be very brief. First, I should like to congratulate the noble Baroness, Lady Cox, on two counts. She spent this morning dealing with social services in Europe and then she introduced this debate, for which I thank her. I apologise to the House for being absent at the beginning.

Personal social services were last reorganised 20 years ago. There is now general agreement that something further must be done for community care; but what? The Audit Commission has highlighted policy conflicts which exist in the impact of supplementary benefit payments for residential care on community care policies. In the 20 years I spent working in the National Health Service l felt that the health service should be the prime promoter of community care services. That was because I had a high regard for the activities of the medical officer of health and his social services associates. The good ones got the social services to develop naturally. The medical officer of health was the co-ordinator of things, and it worked.

The medical officer of health, as we knew him. disappeared in 1972, but there have been many partnerships embracing health authorities, housing associations, voluntary bodies and local authorities. They have important lessons for us now that we are looking at the situation. Some things have been tried and some lessons have been learnt. As David Hunter, King's Fund health policy analyst, said: Central government must take community care more seriously". It is suggested in the Griffiths Report that a Minister should give policy leadership and direction. It is suggested also that not the National Health Service but local authorities' social services departments should take the lead role within the guidelines specified by central government and in collaboration with other agencies. It is very significant that the starting point of Griffiths's examination of the problem was the need of the individual; in this case, the frail elderly. He did not start with territorial negotiations between the various agencies—the National Health Service arid voluntary agencies. I find myself very much in agreement with this approach.

The social services would design, arrange and regulate care and apply funds provided from different sources. But immediately there is uncertainty in the health service. Health service professionals such as nurses will no longer be the prime movers in the development of community care services. We have learnt of the concern among them in this regard. But central government will only provide guidelines and not dictate policy. If these proposals are successful local government and its social services departments will regain the central role in the care of the elderly and infirm people it was elected to serve.

There is a precedent in the United Kingdom for such an approach. It is the All Wales Strategy for Services for Mentally Handicapped People, introduced by the Welsh Office some five years ago. Under this strategy social services departments are the lead agencies for the production of joint plans with the health authorities. This has been a very successful experiment and should be studied by others.

But will central government be willing to delegate new responsibilities to local authorities? Are central government willing to provide central leadership and undertake the executive part of monitoring local plans? It is perhaps a job for the new social services departments. Will local government social services departments be able to cope and adopt new roles? Will it be possible to set clear boundaries around health and social care responsibilities? The answer to that question is no, it will not. Any guidelines will have to allow effective exchange between providers operating in the front line. The health and social services interface.

Doctors, nurses and others must become less insular. But the most important thing is the change of thinking and attitudes among those involved. Behind all that lies the dark shadow of the strained relationship between central and local government. Whatever the reason for that, one has to admit that it exists. There will be little progress in the community care of the frail elderly until there is a better and more sympathetic understanding on both sides. The significance of the creation of such an understanding extends far beyond the social services.

The creation of this new framework between local and central government is essential to success. The creation of a new framework for the National Health Service which is now proposed must facilitate that. This framework is also vitally important, and neither will be efficient and cost-effective without the research and development base as suggested for the National Health Service by the report of the Select Committee on Science and Technology of your Lordships' House on the subject of medical research.

Members of a range of professions will watch with interest and concern, and we hope they will co-operate. Perhaps in association with those developments there should be a new charter describing an enhanced role for many of the professions allied to medicine. Their contribution to the National Health Service and social services, outside the hospital service, will be a vitally important matter in the future. They include pharmacists and many others.

Radical proposals that there should be a combination of community health services and community care parts of priority care services, currently within health authorities, together with family practitioner services, do not commend themselves to me.

The Griffiths Report proposal could work quite well provided that there is tight financial control and good monitoring. It could be an important step in separating the proper responsibilities for medical and health care of central government from the provision of social and domestic care by the elected local authority.

9.47 p.m.

Lord Ennals

My Lords, I should like first to repeat what has been said by other noble Lords in thanking the noble Baroness for the way in which she introduced the debate. I often find myself profoundly disagreeing with many of the things which she says in the House; but every time she rises to talk about nursing, I agree with her. I think that she made an outstanding speech. I do not agree with the conclusions of the RCN about the Griffiths Report, but I profoundly agree there must be a decision. However, I shall say a word about that in a moment. The noble Baroness timed the debate very well, partly because of our feeling about the Griffiths Report, but also because it comes just after the release of the Government's White Paper on the new proposals for the National Health Service.

I must say that I am deeply concerned with the new style health service which has been put forward by the Government. My concern is that while some people may benefit, the principal losers will be the chronically ill and the elderly. My fear is that because such people are not in the bracket for the making of profits, either within the new independent-style hospital or within the independent GP practice, they will get a bad deal out of the health service. I see the noble Baroness nodding in agreement and I think that part of our task in the debate which follows is to ensure that that is not the case. If the health service is for anyone, it is for the elderly as well as for the rest of us.

Secondly, I agree most strongly with the views which have been put forward about the urgency for the Government to say something about the Griffiths Report. The Minister said last week in answer to a question from me that there would be an answer very soon. Tonight may be "very soon", but I have a feeling that I shall not have an answer today. The Government may not realise how much damage has been done by their failure to say anything for 12 months. A debate has been going on in the country, but it has almost died down. There is no doubt that the urgency to move forward has done great damage to local authorities faced with the uncertainty of where responsibility will lie and what sort of a lead agency there will be. The Government dare not allow the issue to wait much longer.

I agree with what the noble Lord, Lord Hunter, said: the relationship between local and central government has hit a low level. It is up to the Government to try, with all the support that the Griffiths proposals have, to ensure that a new relationship is established if we are to get community care right. It must be done in close co-operation with the health authorities and the social services departments. The lead agency needs to be at community level. It is a community service. It is at the level of the social services, not so much with the medical model, that we need the whole field of community care, and not just for the elderly.

The RCN said in its paper that until the late 1970s the debate on care in the community was dominated largely by the issues affecting the mentally ill and the mentally handicapped. That is true. In 1978 when I was Secretary of State I published a Green Paper called A Happier Old Age. I was much involved in it personally. I wanted to produce a document which did not present elderly people as a burden upon society. The Green Paper was written in what I thought was an up-beat manner. It showed that of course the community had responsibilities but that the opportunities for the elderly in our society arc enormous. They do not stop at 70. We can see from your Lordships' House how much of a contribution to national life can be made by people of an advanced age. I shall not look in any direction, but some of us begin to feel old about 20 years before some of the others seem to be old. When my noble friend Lord Carter talked about senile dementia, I began to think that I perhaps had some of the first signs, such as forgetfulness about names and other things that start one worrying.

The Green Paper put forward—I want to see a repetition by the Government at some stage—all the opportunities that exist for the elderly. How can we help them to play the fullest possible role in society? I was worried when I saw the Prime Minister's comments about wanting everyone to be paid to work and not to retire before they are 70. Old age gives people a great opportunity to enjoy their retirement. Many people will retire earlier. I am in favour of people retiring at whatever age they think best for them. Some people want to be at work at 70, others want to be in retirement. I hope that the Government's approach in the White Paper Growing Old—in rather a different mood from A Happier Old Age—will not be repeated.

The noble Baroness gave some statistics which I need not repeat. She said that there would be a need for an extra 10,000 residential and nursing home places. I wonder whether the Government accept that figure; whether they see the need; and whether they think that the need can he met. The noble Baroness referred to the drop in new residential places between 1985–86 and 1986–87. I wonder whether that trend has continued or whether there has been an increase in the number of places available.

The RCN is worried that in all the debates about future needs for care in the community there has been a failure to identify the scale of the problem among those people who cannot be cared for in the community. I refers to the over-75 age group and those with senile dementia. We were reminded in our debate on mental health a few months ago of the enormous and growing problem of those with senile dementia. I think it was mentioned in that debate that by the year 2000 there will have been an increase of 250,000 people in each of the age groups 75–84 and 85-plus since 1975. That is imposing a huge burden.

I was asked by the Alzheimer's Disease Society particularly to raise their concerns with the Government. With the growing number of elderly (and therefore the growing number of those with Alzheimer's disease) are the Government satisfied that they will be able to meet the residential and nursing care needs and domiciliary support which these people so desperately require? I hope that the Minister will be able to say something about that in his reply.

There seems to be a very broad acceptance of many factors: the size of the problem and the urgency: that the Government should give some clear recognition that as we have a growing elderly population there must be growing resources to enable us to meet its needs.

I think there is a wide measure of support in favour of the Griffiths recommendations. Certainly there is a great deal of support which I hear wherever I go on the need for the carers. I am glad that reference was made by the noble Baroness, Lady Seear, and the noble Viscount, Lord Brentford, to the fact that over 75 per cent. of elderly people are looked after by their own families. Almost always one woman, usually a daughter, sometimes a daughter-in-law or grandmother, has the burden of care for a physically or mentally infirm relative. The financial sacrifices involved are very considerable.

The response of Age Concern to the Griffiths Report was a very substantial and carefully thought out document. Age Concern argued, as did the noble Baroness, Lady Seear, that due regard should be paid to the costs of carers and that the level of the invalidity care allowance should be substantially raised. It is a problem which the Government must face. Age Concern also said that consideration should be given to the concept of a community care allowance as recommended by the Wagner review. At the same time as we arc waiting for a response to Griffiths, we are also waiting for the Government to respond to Lady Wagner's recommendations.

I think that there is a wide measure of support for the idea that there should he a Minister for Community Care. He would have very special responsibilities for the elderly and would be able to do for elderly people and others in the community who desperately need aid what Aft Morris was able to do for the disabled in his time when he was Minister for the Disabled, bringing together those responsible in all government departments.

I hope that in his reply the Minister will answer some of the very pertinent questions put to him by the noble Baroness. If he does not reply in the Government's response to Griffiths, then quite clearly we shall have to have a very early debate on the subject. I believe that the Government are doing great damage to the cause of community care and the needs of the elderly, especially the very elderly, by totally failing to give a lead. That is what we expect and need from the Government.

9.58 p.m.

Lord Hesketh

My Lords, the very first time I replied to an Unstarred Question in your Lordships' House was in regard to the National Health Service. As I rose on that occasion, all my notes fell to the floor. Your Lordships' House was very forgiving, as noble Lords received a very confused reply to an Unstarred Question from a very confused younger man.

We are all greatly indebted this evening to my noble friend for the opportunity that she has given us to discuss this matter of great importance to the wellbeing of elderly people. As many noble Lords will be aware, in common with many other industrialised nations, we are in the midst of an unprecedented expansion in the numbers of elderly people, particularly the very elderly.

As my noble friend Lord Brentford pointed out, on the latest estimates, by the year 2011 the number of elderly people will have increased by a million to about 8 million. The number of very elderly people will have more than doubled to well over 1 million. Those figures have profound implications, both in the amount of care that will be required for infirm elderly people and the way in which that care is provided.

Community care remains the cornerstone of our policies for the long-term care of elderly people. This has been the case for many years under successive Governments. I think I can say quite confidently that it will continue to be so. Most people want to continue living in a home of their own, in touch with family, friends and everyday life. I must add, of course, that the Government also recognise that there will be some people for whom care in a nursing home or residential care home would provide the best quality of life which they are able to enjoy. Our concern is that such homes should provide proper standards of care in an atmosphere which is as much like a person's own home as possible. It is important that a prospective resident should be actively involved in decisions about his or her future care and should enter the home, if that is what is decided, as a matter of positive choice.

Finally, if a frail elderly person does need to enter hospital, this should be for some form of active treatment or rehabilitation. Spells of inpatient treatment should be kept as short as possible and wherever they can still cope elderly people should be returned as quickly as possible to their own homes, as the noble Baroness, Lady Seear, pointed out.

But to come to standards, which is the subject of my noble friend's Question this evening, the Government are naturally concerned that whatever frail elderly people's care needs are and wherever and however they receive services to help them cope with daily living, they should receive the highest quality of care it is possible to provide within the resources available.

Before I go on to say something about good quality of care and the measures the Government are taking to secure it, let me show that I fully recognise that there have been well publicised failures in the past. particularly in the field of residential care. No one could be complacent in the face of some of the gross failures of care in all sectors which have come to light. I should, however, add that we believe that these failures are the exception and that in most homes a high standard of care is provided by caring and hard working staff. Nevertheless this Government are not complacent, as I hope the remarks I shall make in the next few minutes will show.

I should also like to say something at this point on the subject of resources. This matter was brought to your Lordships' attention by the noble Lords, Lord Pitt of Hampstead and Lord Ennals, and by the noble Baroness, Lady Seear. The noble Baroness said that care does not come cheap. The noble Earl, Lord Longford, said that the Government were trying to provide care on the cheap. I agree with the noble Baroness but disagree very strongly with the noble Earl.

We sometimes hear it said that if only the Government gave health and local authorities more money, there would be no problem about standards of service. The Government entirely reject that line of approach. Spending on both health and social services has never been higher. Gross spending on the National Health Service in England in 1988–89 is now 37 per cent. higher in real terms at £19.4 billion pounds than it was in 1978–79. The estimated local authority expenditure on personal social services in 1988–89 at £3.2 billion shows a similar real terms increase on local authorities' actual spending in 1978–79. Further real term increases have been announced for 1989–90. But securing good quality of services must also be a matter of making the best use of those resources already available. It should be the concern of all those who work in health or personal social services, especially those with management responsibilities.

I noted that the noble Lady, Lady Kinloss, had suggestions for special community care allocations. The joint finance scheme meets this need to some extent. The level of funding has risen by over 60 per cent. in the lifetime of this Government to over £110 million. That is in addition to the service developments planned for social services and health authorities from their own provision.

The financing of care is, of course, under review in the light of Sir Roy Griffiths' recommendations. I shall come to that later on. What are the basic characteristics of good quality care? First and foremost, it must clearly meet the particular needs of the person concerned. This means that care needs should be assessed on an individual basis.

Secondly, the people needing care and their families should be actively involved in decisions about the services to be provided. The Department of Health has commissioned two research projects to examine the information needs of elderly people and the outcomes where they are involved in care decisions.

The Government support a consumer approach to the provision of social services. We look to customer choice and competitive pressures to help ensure that standards are high and service is good. It is important for all providers of services to realise that the consumers include carers. I fully endorse the numerous remarks that have been made about the importance of respite care in meeting That need as an important part of a wide range of community care services.

The service provided needs to respect the dignity and automony of the elderly person concerned. The aim of any support service, from a home help to a place in a nursing home, should be to give elderly people as much freedom and control over their lives as possible.

Those are some of the characteristics of good quality care, characteristics which we want to see adopted by providers of care in all sectors. The position is that central government, through the Department of Health, do not provide any of those services themselves. For that we need to look to the statutory providers of care, health authorities and local social service authorities and to the growing number of private and voluntary providers, as pointed out by my noble friend Lady Cox and many other noble Lords.

We must also recognise, as my noble friend Lady Cox has poined out this evening, the invaluable service provided by informal carers. Informal carers hear a heavy and continuing burden and we are increasingly acknowledging the importance of providing support. We have for several years provided funding for voluntary organisations concerned with the needs of carers, with grant aid exceeding £1 million in the last financial year. My right honourable friend the Under-Secretary of State has just provided a three-year grant to the Carers National Association and Contact and Family for a project concerned with the training of carers.

The noble Baroness, Lady Seear, referred to carers. I recognise that they will be helped by patterns of service provision which take account of the needs of carers themselves, including the need to continue employment. I hope that local providers of care who are responsible for deciding the pattern of service will keep that firmly in mind. I am encouraged to hear from my noble friend Lady Cox of at least one case where that seems to have been done.

I have carefully noted what my noble friend Lady Cox and the noble Baroness, Lady Seear, had to say about the financial needs of informal carers. I can assure them that the points made will be considered carefully in the proper quarter.

Turning to social services provision, the Social Services Inspectorate within the Department of Health was set up to provide my right honourable friend the Secretary of State with professional advice and contact with field authorities, and to provide field authorities with help in planning and managing their services. The inspectorate has an important part to play in helping to disseminate good practice and in assisting authorities to provide services to high professional standards. To this end the inspectorate carries out detailed examinations of different areas of the work of social services departments and publishes reports. For example, recent reports on a sample of home care services indicated that policy towards home help services is often poorly formulated at local level, management both of individual cases and of staff is weak and resources tend to be spread thinly over a very large number of clients rather than being targeted according to levels of needs. Providing a sensitive home care service means strengthening management at all levels, better targeting of services on those in greatest need and efforts to improve and diversify services within available resources.

Those findings were confirmed by another recent report on first line managers in social service departments. That report recommended that first line managers of both domiciliary and day care facilities should be involved more closely in drawing up policy and should be made aware of the financial consequences of their decisions. The inspectorate will continue to work with social services departments towards the improvement of services.

The question of regulating standards of care in residential care homes and nursing homes is important. The Government have long recognised the need to ensure proper standards of care in homes of all types. To safeguard such standards the Registered Homes Act 1984 and its associated regulations were secured. These provide statutory control of voluntary and private homes through a system of registration and inspection with local social services and health authorities.

For each establishment the authority must satisfy itself that the statutory requirements and the conditions of registration are being met. It is crucial to establish the means of achieving good quality care as well as monitoring to ensure that those standards are maintained. This means good management and a trained staff. The Department of Health's social services inspectorate is undertaking a major study of the management of local authority homes which should help to enhance the quality of management. As regards training, the Government have introduced a programme of direct support towards the training of local authority staff working with elderly people. The programme covers £10 million of expenditure this year and attracts £7 million of government grant. It has enabled about 70,000 staff to receive training who would otherwise not have had the opportunity. For 1989–90 the programme will cover some £l0.4 million of expenditure including a government grant of £7.3 million.

I should now like to turn to improvements in health care for elderly people. Our discussion this evening has rightly revolved around the quality of care. The major improvements to the National Health Service which will result from the changes announced in yesterday's Statement are all designed to meet that goal. The Government are equipping the National Health Service to meet the challenges of the 1990s. And responding to the needs of elderly people will be a crucial part of that.

So what do the review proposals mean for elderly people? I can assure noble Lords of one thing: they do not just mean tax concessions for elderly people, as was suggested earlier this evening. First of all, they mean greater concentration on quality of care from everybody within the National Health Service: doctors, nurses and managers. We expect every health authority to institute a systematic programme of quality improvement, looking in particular to improve still further the personal service delivered to individuals. Noble Lords do not need me to tell them how important it is for frail, elderly people to be treated with the dignity and respect which they deserve. I believe that the systematic approach to quality which is now being taken will ensure that that is achieved.

Secondly, we are making improvements to the acute sector, in particular with an attack on long waiting times. Many elderly people, who are otherwise able to lead independent lives in the community, need acute treatments, such as hip replacements or cataract removal. The 100 additional consultant posts announced yesterday will be targeted at just such areas and, taken with the reforms in funding, will help to ensure that patients receive the necessary treatment as early as possible. This expansion will build on the significant progress already achieved through the waiting list initiative and the planned expansion of consultant numbers through the Achieving a Balance programme.

Thirdly, we are acting to strengthen the general practitioner service, often the main point of contact for elderly people with the health service. The introduction of the GP practice budget will give doctors greater freedom to develop a wider range of services to care for their patients. Such developments—for example, the employment of more practice staff to improve primary care—may well allow people to be treated in the community rather than visit hospital for out-patient examination. Let me make one point about these budgets perfectly clear. The level at which they are set will reflect the age of people on the doctor's list. The more elderly and dependent are the people on the list, the larger the budget will be. There will thus be no incentive whatsoever for GPs to refuse to admit elderly people to their care. And the improved management role that we are giving to family practitioner committees will ensure that any abuses are quickly identified and remedied.

Fourthly, improvements in management will benefit all patients, not least elderly people. We are looking to delegate as much responsibility as possible to the operational level to improve decision-making and management of resources. That lesson is just as relevant in the long-stay sector and community services as it is in acute hospitals. The arrangements for funding core services will protect these facilities and self-governing hospitals will he required to continue providing existing core services under contract where necessary.

I should like to make this one point. In yesterday's Statement the Government made it very clear that they were talking about the consumer. The fastest growing group of consumers in the health service is the elderly. We could not have made that statement unless we fully understood that that was the case because that was what we were talking about.

I have spoken at some length about the way the review affects services for elderly people because I believe that it is important to demonstrate how quality of care is at the heart of all our proposals.

Many noble Lords have today, as before, encouraged us to give an early response to the Griffiths Report. My noble friend Lady Faithfull went so far as to say that she would like us to make a decision, right or wrong. I believe it is very important that when the decision is made it is the right decision. We shall take full account of all the points that have been made this evening. In framing our own programme we remain committed to bringing forward our own proposals as soon as we sensibly can.

I fully appreciate that the noble Lord, Lord Ennals, will understand that when I said "shortly" yesterday, it did not mean that there would be an answer tonight. However, I listened with care to what my noble friend said about the possible role of primary health care teams, and I can assure her that the points are being carefully considered. Her remarks underline the fact that various options are available for the management of community care and it is right that we study them thoroughly before making decisions. Quality of care will be essential to our proposals when they emerge.

The remarks of the noble Lord, Lord Pitt, also show that there are different perspectives on community care from different professions. We need to weigh these views carefully. However, I should like to underline that all the caring professions have a contribution to make and co-operation will remain essential. There are many examples of such co-operation in action—for example, that cited by the noble Lord, Lord Hunter, in his example in Wales. Our proposals on community care will take full account of the need to develop valuable initiatives.

To return to the subject of residential care, I should like to take this opportunity to say something about the Government's reaction to A Positive Choice, the report of an independent review of residential care carried out by the committee set up by the National Institute for Social Work with the support of the then Secretary of State for Social Services and chaired by Lady Wagner. First, I should like to pay tribute to Lady Wagner and her team for their two years' hard work in producing the review of residential care. Their report was published in March and was widely distributed. We welcome the emphasis in their report on freedom of choice, protection of dignity, and personal life. These are matters to which the Government attach particular importance.

We believe that that is a valuable report and will prove to be of lasting importance. Many of the recommendations in the report are primarily for consideration by local social services authorities and other providers of local services. We hope that all agencies will give careful thought to these recommendations. By no means all of them have significant financial implications. Some of the recommendations overlap with Sir Roy Griffiths' Report on the financing and management of community care, to which I have already referred, and are being considered in that context.

Finally, there are the recommendations on which central initiatives may possibly be needed to carry them forward. The Department of Health has been considering what action might usefully be taken within the current legislative framework to promote action in line with these recommendations.

I am pleased this evening to be able to announce that my honourable friend the Secretary of State for Health has decided to launch a three-year centrally funded development programme and £0.5 million has been allocated for 1989–90. Funding for later years will be determined when the programme is further advanced. We aim to assist local agencies by exploring through the development programme the practical application of the recommendations in Lady Wagner's report aimed at improving the quality of life for residents. The aim will be to set up demonstration projects in several locations covering all client groups so far as is practicable and appropriate. Overall, the Government are keen to see practical solutions explored. It is on the whole not difficult to agree on broad principles. It is harder to turn those principles into worthwhile affordable service developments. That is where the effort now needs to be directed, building on the work of Lady Wagner's review.

In doing this the department will take account of the work of the development group set up by the National Institute for Social Work. This group is considering how certain of Lady Wagner's committee's recommendations might be put into effect. The group is representative of a wide range of interests. This is a valuable development with which the department is keeping in close touch.

I hope that what I have said has helped to show my noble friend that the Government take seriously the need to ensure satisfactory standards of care for elderly and infirm persons both in institutions and in the community. The task of caring for the increasing number of elderly people in the years ahead means that the search for cost-effective methods of providing good quality care must continue.

Although it is important to secure adequate provision to meet the care needs of elderly and other vulnerable people, it is equally important that quality is not sacrificed to quantity: the two must go hand in hand. That lies behind the work the Department of Health has in hand in many fields, some of which I have briefly described this evening.

I apologise if I have spoken for a slightly lengthy period of time. However, many important points have been raised this evening, and I am sure I shall be given the indulgence of the House; and I thank your Lordships for it. Many tasks, particularly those flowing from the Wagner and the Griffiths reports, are only just beginning. I am confident that when they come to fruition we shall have a range of both health and social services of a quality of which we can, as a nation, be justifiably' proud.

House adjourned at twenty-one minutes past ten o'clock.