§ 3.31 p.m.
§ Lord Carter rose to call attention to the need for a coherent and properly funded system of care in the community; and to move for Papers.
§ The noble Lord said: My Lords, the Motion in my name on the Order Paper calls for a coherent and properly funded system of care in the community. Coherent means consistent and well-knit. I believe that we can all agree that without proper funding the system will not work and could become a financial and demographic time bomb at the heart of social policy. It must be care in the community and not care by the community. Indeed, community care, although it is a phrase which we must use, is something of a misnomer. What we should be talking about is individual care, examining individuals' needs and planning the services required to meet them.
§ Every one of your Lordships who is to speak today does so with expertise and authority in a particular aspect of community care. But I know that I speak for all noble Lords when I say that no speech will be more keenly awaited than the maiden speech of my noble friend Lady Jay who comes to the House with great experience in the subject that we are discussing. Perhaps I may also say that I am very pleased to see the noble Lord, Lord Rix, in his place after his recent serious operation. I believe that he is in fact defying his doctor to be here today. That shows the very great interest which he takes in this subject.
§ Community care is such a vast subject that in opening the debate I shall try to set out a broad over-view while my noble friend Lady Hollis, in winding up from these Benches and with her great knowledge of local government and social security, will deal in detail with the financial aspects of the subject.
§ Your Lordships will know that the implementation of community care was delayed from April 1991 until April 1993. Whatever we may think about the reasons for the delay it did at least provide two more years to get the community care plans into place and well thought out. My first question to the Minister concerns the quality of the plans which have been prepared by local authorities. Are the Government generally satisfied with the quality and the depth of the plans? Do they have a mechanism for ensuring that the planning has been done properly? Will there be machinery in place after April 1993 to see that the delivery of community care matches the requirements which will be set out in the various plans?
§ Information from different areas of town and country indicates a fairly wide range of performance, at least in the planning. For example, the London Voluntary Service Council examined 17 London boroughs to see how far the local authorities concerned have taken on board the concerns of the voluntary sector. There was a wide range in the quality of the response, but a constant theme was that 1124 planning in its fullest sense has not really happened. Needs assessments did not reveal the full demand for community care and there was little commitment to change or to increase the service provision. What did become clear was that the users of services, the carers and the community groups, must be involved in identifying the local needs and designing the appropriate services. There was a very clear impression that what planning there was had been very much a top-down exercise.
§ The social services department of one county council which wrote to me gave what was quite an upbeat assessment of its progress in planning for community care in its area, which is largely rural, although revealing concern about funding levels. The community care involvement network in the same county gave a rather different impression. There was no money for preventive and support work to keep people in their homes. There was also a lack of resources which meant that people with learning disabilities were being asked to move from one supportive residence to a much cheaper one. This is a county where spending over the next 18 months is to be cut by £18.6 million to stay within the Government's spending limits. It is a county which is facing a sizeable increase in the number of elderly people and a dramatic increase in the number of very elderly over 85 years of age. It is also a county with over 6,000 people with some degree of dementia.
§ We can all agree that finance is clearly at the heart of the problem. We can all understand the current pressures on public expenditure. There seems to be a real danger that high expectations in advance of April 1993 will be disappointed because of the lack of resources. Without attempting to go into the detail of financing, it is clear that the funds made available to local authorities in the coming public expenditure round must be sufficient at least to maintain the social services at their present level. I can tell the Minister that there is at least a suspicion that Treasury sleight of hand will take away some or most of the benefits of the ring-fenced funds which have been allocated from the social security budget. I can tell the Minister that we will watch the details of the public expenditure round like hawks to expose that if it happens.
§ For example, there is already a substantial care gap, as it is called, between the fees charged for residential care and the support available to users. Arthritis Care puts it at £100 a week. Finding sums like that can put an intolerable strain on relatives and carers. It is estimated by the Association of Metropolitan Authorities that likely funds available will leave about 12,000 people in need of residential care, but unfunded in 1993–94. I am sure that the Minister is aware of that figure. Do the Government accept that estimate?
§ The Campaign for People with Multiple Disabilities, known as Challenge, has analysed the community care plans of 114 social services departments. It found that 56 per cent. of all community care plans do not have detailed, planned services for people with multiple disabilities; 42 per cent. of all plans do not even make reference to people with multiple disabilities; and 14 per cent. of plans, 1125 although they refer to people with multiple disabilities, do not plan to provide specific services to meet their needs.
Perhaps I may quote briefly from the excellent report prepared by Challenge and the words of the mother of a blind young woman with a hearing impairment and cerebral palsy:
In my fight for proper social worker care and support from my local authority I have had more problems with Social Services than my daughter will ever give me".
They say that if she was slightly less disabled, they could provide something, but … ".
It would be too easy to produce a litany of complaints but that would not be constructive. Implementation of the plans in the new system provides something of a culture shock for service providers with the change from a service-led to a needs-led system. If that change is recognised—there has been a valiant attempt to do so in some areas—the planning of community care with the users' needs paramount could introduce some rationality into a system which previously has certainly lacked coherence. But community care must be founded on planning which is based on participation and a sense of ownership of plans by users and deliverers.
§ What has also become clear is the paucity of standards which set out what should be expected. There seems to be no clear statement of the required minimum level of service. Where there are targets they are largely financial and do not much relate to the quality of service or expected outcomes. It appears that targeting is very often a euphemism for rationing. That is hardly surprising when we know that 50 per cent. of social services departments have had to cut their budgets in 1991–92 through fear of capping. The NCVO estimates that £44 million will be cut from local authority grants and contracts with the voluntary sector this year. That is before the full effects of the council tax are known.
§ The whole question of assessment, which is an essential part of preparing individual care plans, illustrates extremely well the dilemma of those preparing an assessment on the basis of needs, while being very well aware of the limitations on resources. I ask the Minister: once a user has been assessed as needing a service, does that user have the right to receive it? If the user has such a right, and resources are limited, is there a danger that assessment will subtly reflect available resources rather than individual need? As regards assessment, do the Government have any figures for the waiting times for assessment? We hear figures of up to 12 months or longer being quoted in some areas. Does the department attempt to monitor that in any way?
The full effects of, to use the jargon, a "user-friendly, and needs-led" system are now becoming apparent. Where planning has failed to recognise need, the results are obvious. As I said earlier,56 per cent. of community care plans have no detailed planned services for people with multiple disabilities. There is still a large area of unrecognised and thereby unmet need across the whole spectrum of community care. Mrs. Virginia Bottomley, who was then the Minister of State for Health, stated in the
foreword of the Government's excellent policy guidance, Community Care In The Next Decade And Beyond:
If implementation is to be effective, there must be close working links between all agencies social services departments, NHS bodies, housing authorities and associations, voluntary organisations and private sector service providers. These working links must take full account of the views and needs of those being cared for and their carers".
As users' needs become more clearly identified, so the lack of resources to meet those needs will become more apparent. The Government and the service providers will then find, I fear, that "their mouth will be where their money isn't".
§ Turning now to more specific points, although my noble friend Lady Hollis will deal with the detail of the financial aspects of community care when she replies to the debate, there is a very important point regarding the new ring-fenced funds which has been missed. Indeed, some of the briefings that I have received seem to have missed it. Can the Minister confirm that the money which is ring-fenced in each of the next three years drops out of ring-fencing in the following year; that is to say, does the amount that is ring-fenced in 1993–94 disappear into the revenue support grant in 1994–95 and the same happen in the next two years? In other words, the proposed ring-fencing is not cumulative.
§ This may seem like a rather arcane point on local authority financing, but its practical effect will be considerable. It means that out of a total budget of some £5 billion, barely 10 per cent. will he ring-fenced and protected by specific grants. Add to this the requirement that 75 per cent. of the total ring-fenced amount must be spent in the private sector, and this will mean that after meeting all the other costs of setting up the new system there will be virtually nothing left from the ring-fenced funding for local authority-provided care.
§ Perhaps the Minister can tell the House how sacrosanct is the requirement to spend 75 per cent. of the total ring-fenced money in the private sector? Are the Government prepared to negotiate on this point? If they laid down a requirement to spend 75 per cent. of some figure less than the total grant or less than 75 per cent. of the whole figure, that would give the local authorities much more flexibility when planning community care as, I am sure, the Minister is aware.
§ The Government claim that they want a "mixed economy" of care involving both the private and the local authority sector, but they are certainly not providing a level playing field at the outset. The balance of funding raises another important question. The private sector is not particularly good at providing domiciliary care, especially for the frail and the elderly. It is hard see how local authorities will be able to find the money to provide that care which is, in fact, a very good investment as it helps to keep people out of residential care.
Another aspect of ring-fencing is causing concern. What has happened to the ring-fenced money for the voluntary organisations that provide services for drug and alcohol misusers? I am sure that a number of your Lordships will wish to raise this matter, but as a curtain-raiser, perhaps I may remind the Minister of
the undertaking that was given in another place on 27th June 1990 by the then Secretary of State for Health, Mr. Kenneth Clarke, at col.404. Mr. Clarke stated:
That is why our amendment proposes that the Secretary of State should be able to make specific grants to local authorities for use in helping voluntary organisations with the services that they provide for people who are dependent on drugs or alcohol … that money will be ring fenced and local authorities will be able to spend it only on grants to such bodies".
I should like to ask the Minister whether that is still the case.
In the same speech—at the same column—the then Secretary of State for Health, also said that that was,
Alongside the commitment that we have already given to make specific grants for the services for mentally ill people".
What has happened to the money that was ring-fenced in 1991–92 for mentally ill people? Is that system still available under the new financing arrangements?
§ Lord Ennals
My Lords, will my noble friend confirm that that concession was made as a result of a vote in this House which called for the ring-fencing of all community care money, and that that assurance was given to this House as the response from another place?
§ Lord Carter
My Lords, my noble friend is absolutely right. In fact, my name was on the amendment which led to the agreement of this House to ring-fencing, but I was much too modest to say so.
I have referred already to the lack of a level playing field between the private sector and the local authority sector. This highlights an ideological problem that the Government have. Their commitment to the concept of the "internal market" sits rather uneasily in a system which is based almost entirely on a planning mechanism. The Government have already discovered with the Tomlinson report that the internal market has very little to offer when it comes to solving the problems of the health service in London. In fact, we know that Tomlinson has, in effect, recommended a strategic planning mechanism.
Tomlinson has also illustrated extremely vividly what happens when primary and community care are poor and the effect that that has on hospital services. It is clear that good primary care, linked to good community care, is both cost-effective and efficient. Talking to general practitioners, I find that there is still very little involvement or feeling of belonging among them in relation to community care.
The boundaries of responsibilities between health authorities and local authorities must be better defined. It is still unclear who is responsible for providing nursing care to residents in private homes. Professionals employed by the health authorities have a very important role in community care. I understand, however, that there is still confusion about who pays for them. Is a hospital able to discharge a patient who no longer needs hospital care if the social services department cannot provide the optimum community care support? The British Medical Association has calculated that providing 1128 only two weeks of respite care for those carers who spend over 20 hours a week on their care responsibilities would require 100,000 hospital beds.
In their policy guidance, the Government have set out the need for close liaison between all the bodies involved in both the public and the voluntary sectors. Health, housing, education, social security and the provisions of the Children Act all have direct effects on the demand for social services. Are the Government satisfied that there has been sufficient liaison between all the bodies involved in creating the demand to ensure that the supply of services is adequate?
Many noble Lords wish to speak in this debate and I shall not take up all of the time available to me but, even then, the time available does not allow me to cover all of the many aspects relating to the issue of community care. I am, however, sure that they will be covered as the debate proceeds. I should have liked to spend some time on the problems of carers, including the extraordinary situation whereby 10,000 children nationally are acting as a hidden work-force of primary carers.
The future of the Independent Living Fund is causing great concern. Is there still not time for the I LF, with all its expertise and experience, to act as the agent for local authorities in delivering the very specialised care to the severely disabled which it currently provides?
There is a very strong argument for allowing direct payments to disabled users so that they can manage their own care programmes. Have the Government taken a view yet on the Private Member's Bill of Mr. Andrew Rowe which seeks to solve this problem? I am sure that all these and many more aspects of this issue will be raised this afternoon.
I conclude with a most useful definition of community care which was provided by Kathleen Jones, the Professor of Social Administration at York University. She has said:to the political, 'community care' is a useful piece of rhetoric; to the sociologist it is a stick to beat institutional care with; to the civil servant, it is a cheap alternative to institutional care which can he passed to Local Authorities for action or inaction; to the visionary, it is a dream of the new society in which people really do care; to the social services departments it is a nightmare of heightened public expectations and inadequate resources to meet them. We are just beginning to find out what it means to the old, the chronically sick and disabled people".One must hope that the implementation of community care in April next year is not a nightmare but will exemplify what was said by Mr. Roy Griffiths in his seminal report which led to the changes in the Government's plans. He said that,caring for one's neighbour is a 2,000 year-old moral imperative".My Lords, I beg to move for Papers.
§ 3.50 p.m.
§ Baroness Cumberlege
My Lords, in thanking the noble Lord, Lord Carter, for initiating this debate we can begin on a point of agreement—that we need a coherent and properly funded system of care in the community. That is precisely the Government's goal. We wish to see care provided in a way which enables 1129 people to live as normal a life as possible in their own homes or in a homely environment in the local community. This will he achieved by providing the right amount of care and support to help people retain maximum independence, and by giving them a greater say in how they live their lives and the services that they need to help them do so.
The policy of caring for people wherever possible in the community rather than in institutions has long been advocated and enjoys widespread and all-party support. One of the main visible manifestations of progress in this direction has been the increasing move within the NHS from reliance on outdated long-stay hospitals towards integrated local provision. However, care in the community in the way in which it is generally understood goes very much wider than this. It encompasses care and support in the community for all those people who need it, whether because of frailty, disability or illness.
It is also most important to remember that care in the community is by no means the preserve solely of statutory authorities. It is maintained by a network of very many different people in the statutory, private, voluntary and indeed volunteer sectors. Above all, it depends on the commitment of the millions of informal carers who from day to day and hour to hour look after their relatives, friends and neighbours.
Care in the community is not a construct of government, nor something that legislative or administrative action will by itself secure. However, there is a very important role for government in setting the framework within which it can develop and flourish. It was a concern with this framework that led to the Government's proposals set out in the White Paper Caring for People, published in November 1989. These proposals were given legislative force by the National Health Service and Community Care Act 1990 which, as noble Lords will remember, was the subject of detailed debate and consideration in this House.
The key objectives of the proposals are set out in the White Paper. They aim to give authorities the freedom and flexibility at local level to develop effective individual solutions. They place the emphasis of care where it rightly should be—on the proper assessment of individual needs of users of services and the design of a package of care that will meet those needs.
The Government's commitment to this policy is quite clear, and I do not think your Lordships require me to repeat it. It is true that implementation has not been to the timetable originally proposed. Nevertheless much of the groundwork in the White Paper has already been done, and we are on course for its full implementation from April next year.
In 1991 local authorities introduced new "arms length" inspection units and complaints procedures for users of their services. Both steps have improved the mechanisms for ensuring that users receive a service of the quality which they have a right to expect. Also in 1991 we introduced specific grants to local authorities to promote the development of community care services for people with a mental illness and for 1130 voluntary sector services for alcohol and drug misusers. In the current year these grants have risen to £31.4 million and £2.1 million respectively in England.
In April of this year local authorities published the first of their annual community care plans. This is the first time that authorities have been required to publish comprehensive plans for their community care services. Authorities are required to consult widely on their plans in order to ensure a coherent approach. It was encouraging too that many produced plans jointly with their partner health authorities. Perhaps I can address the noble Lord's point here. The Social Services Inspectorate is at the moment assessing and will continue to assess the quality of these plans.
April next year will see us put in place the final pieces of the framework when local authorities assume in full the responsibilities given to them by the 1990 Act. Their most important new responsibility will be the assessment of individuals' needs. People who need care and support will now have a statutory right to assessment by their local authority. These assessments should be carried out in collaboration with health and housing professionals as necessary, and should aim to determine the whole range of a person's need for care and support. In turn, these assessments will form the basis of packages of care that should increasingly be individually tailored to the individual needs of each person. These care packages will draw on what is available in statutory, private and voluntary sectors. I agree with the noble Lord that assessments should be undertaken promptly. We are urging local authorities to set standards which can be monitored locally.
The second major change to take effect in April will underpin this process of assessment and care management. From that date the primary responsibility for funding residential and nursing home care for people who cannot themselves afford it will pass to local authorities. Placements will follow assessment. Local authorities will as a result now have the primary responsibility for purchasing and arranging both residential and non-residential care for people. This will mean that all the options can now be considered as ways of responding to an individual's needs on an equal basis. The current system of higher rates of income support has created a perverse incentive for people to chose—or be encouraged—to enter residential care even though they might prefer to remain at home and could, with additional support, do so.
These are the outlines of the Government's policy for community care: co-ordinated services which meet assessed needs. I have made quite clear our commitment to this policy. Just as clear is the commitment properly to fund it and our record to date.
Since 1978–79 spending on social services has increased by nearly 67 per cent. in real terms in England. Similarly, between 1978–79 and 1989–90 hospital and community health services spending on care for elderly people alone has risen by £1.8 billion. Social security spending on residential and nursing home care has risen from £10 million to around £2 billion. The Government have made available specific grants to local authorities to develop services for 1131 mental illness, HIV/AIDS, and alcohol and drugs misuse. The grants for next year will be announced shortly. The specific grant for social services training in England has risen this year by £4.2 million to £29 million. We have provided over £2 million in support for national carers' organisations and carers' initiatives since 1990 and social security benefits for carers have risen from £4 million in 1978–79 to £213 million this year. The Department of Health has spent £2 million over three years on the "Caring in Homes" initiative to promote and improve quality of life in residential homes. In the housing field the Department of the Environment is providing nearly £3.5 million support to local authorities for 115 home improvement agencies in England.
For the future, our commitment fairly to fund new community care arrangements is a matter of record, and one by which we stand. We have always said that we would transfer to local authorities the amount that the Department of Social Security would otherwise have spent on supporting people in residential care and nursing homes. Earlier this month my right honourable friend the Secretary of State for Health announced the amounts to be transferred over the next three years. For Great Britain as a whole this will rise from £467 million next year to over £1.8 billion in 1995–96. My right honourable friend was also able to announce—in advance of the full local government finance settlement—a further £140 million for local authorities in England next year to enable them to take on their new responsibilities.
However, the policy's success requires much more than just simply money. At the heart of the provision of a coherent network of care in the community is close collaboration in the provision of services locally. If services are to be provided at the highest level possible then the resources of all involved need to be harnessed and co-ordinated. This includes social services, health and housing authorities, providers of all types of care in the statutory, voluntary and private sectors.
Ultimately, this co-operation and collaboration needs to be developed and pursued locally. The Government believe that it is only at local level that needs can be assessed and appropriate responses developed. Their policy is to give people at local level the flexibility that they need to do this.
In summary, therefore, I believe that we are on course to have in place next April new arrangements which will significantly enhance the further development of care in the community. That is neither the end nor the beginning of a process. Care in the community has been with us for many years and has the Government's fullest support.
§ 4 p.m.
§ Baroness Seear
My Lords, I must first apologise most sincerely for the fact that I have to catch a train at 8.30 this evening in order to attend a conference. Although I know that it is most undesirable for people to leave before the end of a debate, especially Front 1132 Bench spokesmen, I felt as president of the Carers' National Association that it was incumbent upon me to say something during today's debate.
Community care is an archetypal case of motherhood and apple pie. Everyone is enthusiastic about it, are they not? But the Government must be aware that that enthusiasm may well change to anger and disillusionment unless the plans that have been laid out before us are in fact properly carried out when at last the time comes for the full introduction of the community care programme. We were all disappoint-ed that it was delayed for a period of two years—with the exception of matters dealing with mental health cases. However, we hoped that those two years would mean that the preparations would be more full and more comprehensive and that we would then be able to embark on a really satisfactory programme of community care.
The Minister gave us some indication of what has been going on. But there are a number of points on which I should like further clarification. When the Griffiths report was being discussed, and during those long months of delay, we knew that there was considerable conflict between the Department of Health and the Department of Social Security as to where responsibility should lie. The Minister said—or, at any rate, she implied—that those matters have now been satisfactorily ironed out. However, I should like to know, at every level, what will be the relationship between the health service and social security. We all know that when it is necessary to deal with more than one government department one is likely to be in trouble very quickly. What has been happening at national level between the Department of Health and the Department of Social Security to ensure that community care really is effectively operated?
At ground level—that is the local authority level—responsibility is with the local authority. But it is vital that the nursing service for the whole of the medical service, but especially the community nursing service, should be so closely integrated into what goes on at local level that there is no question of a running in parallel and the right hand not knowing what the left hand is doing. There is evidence that that is still going on. It is vital that it should not do so. It is also vital that there should be a sufficient supply of community nurses to show that, when we have the collaboration, the people are there to do the very necessary work at local level.
Of course, not all people needing care need nursing care all the time; but, sooner or later, most of them will. A proper supply of community nurses working closely with the local authorities is absolutely essential if community care is not to be a mockery. Although we all want as many people as possible to be looked after in the community—and we have repeated that fact again and again—full residential accommodation will be available. But there have been many question-marks put over such accommodation: for example, who gets into it and why; who will bear the full cost and what will be the system of independent inspectors which will ensure that those institutions are properly checked and investigated and that continuous investigation and inspection takes place?
1133 People who find their way into residential institutions in old age are very ill-placed to take up issues themselves when things go wrong. Unless the inspectorate is well trained and adequate in supply then, indeed, there will be, as there has been in the past, very unsatisfactory situations in some of those residential institutions. I should very much like to know what the system of inspection is to be.
If we are to do what we say we want to do and have people looked after in the community, in the great majority of cases that means that they will be looked after in their own homes. As noble Lords know, I speak in no small part, although not entirely, from the point of view of the people who have to do the caring. Of course, both the people needing care and those doing the caring are of great importance. But, given current resources and the scale of the problem, there is no likelihood that the 6 million people who are undertaking caring at present are likely to be increased in number. It is surely much more likely that the number will be very considerably reduced. Unless those people are given adequate support, the whole scheme and the carers will break down.
I suppose that most people in your Lordships' House have had some experience of trying to look after people who are sick over a long period of time. I have been fortunate; I have only had to do it for a short period of time. However, I think that we all know that a caring task that carries on for 24 hours a day, seven days a week and 52 weeks of the year is a killer, unless real support is given to such people.
First and foremost, there must be adequate domiciliary care; that is, home-help care. What has happened to the home-help service? Some home helps have been upgraded to counsellors. For my part, I could manage without counselling if I had someone to do the washing-up and keep the floors tidy. It would make a good deal of difference if there was a good supply of home helps. But it is not unknown that if the daughter of the house is looking after the person in need of care, however heavy the demands upon her may be, it is regarded by local authorities as quite unnecessary to provide any additional help, because, "She can cope, can't she?"
It is essential for the person being cared for to be taken out of the house at least from time to time. Incidentally, it is essential for the person being cared for and absolutely vital for the person doing the caring. We need good day centres and respite care on an adequate scale. Why on earth have we been shutting down small hospitals which could be excellently used for day centres and respite care? I have visited small hospitals, loved—and that is not an exaggerated term—by people in the neighbourhood, which are threatened with closure. Small hospitals are ideal for the purpose of day centres and for respite care. Not all old people are sweet old things; indeed, they can be extremely tiresome.
§ Baroness Seear
Like us, my Lords.
In such circumstances, it is the carer in the home who has to carry the can all the time. Such people may refuse to go into respite care. But if they have been 1134 going to that small hospital to attend the day centre, then, when the opportunity for respite care arises, they may be prepared to take it if it is in the same place.
For all those reasons I urge the Minister to look again at what is happening on the ground and to look especially at the issues of respite care, day centres and home helps. Without that assistance, in reality, the task that we are giving, whatever the fine words, to the women and men—because men also undertake this work—in their own homes will be one which will, in the end, break them.
§ 4.8 p.m.
§ Lord Rix
My Lords, perhaps I may begin by saying how grateful I am for being allowed to speak so early in this most important debate. I should like to apologise to your Lordships and to the noble Lord, Lord Carter, as it is unlikely that I shall be able to last the full five hours. As the noble Lord explained, I have recently been in a theatre of a different kind from that to which I was accustomed: I had two cardiothoracic surgeons in the prompt corner rather than two assistant stage managers. I should also like to apologise for the fact that the anaesthetic seems to have had a deleterious effect on my short-term memory. Therefore, I shall have to refer to my notes perhaps more often than is acceptable or customary in this House.
As your Lordships may know—it was mentioned by my noble friend Lord Allen of Abbeydale in a supplementary question only yesterday—on Monday, MENCAP relaunched its image and restated its commitment to people with a learning disability, producing manifestos setting out its campaign agenda into the 21st century. Your Lordships will note the use of the words "learning disability", because these have now been adopted by the Department of Health to describe mental handicap. I know that the noble Lord, Lord Renton, also mentioned this yesterday in his supplementary question. The words "learning disability" are used even though many of us do not believe that the phrase encompasses the condition suffered by so many of our sons and daughters.
The purpose of the re-launch was to show people with learning disability in a more positive light, and to campaign for the full recognition of their rights in all aspects of life. How badly this focus is needed. In a survey of public attitudes which MENCAP commissioned for the re-launch, it is easy to see views reflected that may appall many noble Lords, because they certainly appalled those of us who are working in the field. Over half of those questioned believed that people with learning disability can be violent and unpredictable, whereas the actual numbers who show such traits are almost certainly less than in the population as a whole. One in four still believes that long-stay subnormality hospitals are the best places for the care of those with learning disability—a view that nobody who has visited our declining hospitals and seen the alternatives can possibly support.
These views, regrettably, appear not to have improved for at least a decade, in spite of all Mencap's efforts in this direction and taking into account that the majority of the media has been in the main 1135 reasonably helpful in the recent past; so let us never be complacent about the future. On Monday, at the MENCAP conference Tim Yeo, the Parliamentary Under-Secretary of State for Health, took the opportunity to produce a long-awaited circular on social care, as well as health service guidelines on health services for people with learning disabilities.
The circular and the guidelines are to be welcomed. They state essential principles of service provision and remind health and local authorities of their responsibilities, but they do not set standards and they do not deal with the problem of resources. Without high-quality standards being set, and then matched by funding, I fear that people with learning disabilities will continue to have the same halfhearted and often inadequate service that they have at present. I was interested to note that the noble Baroness, Lady Cumberlege, said at Question Time yesterday that,good practice is disseminated widely by the national development team".—[Official Report,27/10/92; col.1013.]That is true, but the noble Baroness failed to mention that whereas once the national development team could be called in free of charge by health or local authorities, now it must be paid for. In these recessionary times, how many authorities are going to bother to call in this expert team? Very few, I'll be bound!
However, two interesting points came out of the publications. The Government circular and the guidance reveal that there has been a tendency to underestimate the number of people with severe learning disabilities and to ignore the evidence that in all age groups severity of disability is becoming a major concern. I welcome, therefore, the Government's recognition that the number of adults with severe learning disabilities is between 120,000 and 160,000, and the number is growing as people live longer. MENCAP has been saying that for some time. But who are these people and what are their needs?
Let me tell your Lordships about Amanda, a 16 year-old girl with Retts Syndrome. She is very severely handicapped and can neither walk nor talk. She has just undergone surgery on her hip because her condition causes curvature of the spine. Amanda has to be dressed and undressed by her mother and changed regularly because she is doubly incontinent. Because she cannot chew or swallow easily or quickly, it takes more than an hour to feed her. She is only 16 and so she still receives full-time education, allowing her mother to work part-time. But what will happen when she leaves school?
Indeed, what happens to all the individuals living with parents all their lives when they finally leave school? Is it not shocking that in this day and age there are many hundreds of families with no services available to lessen the strain? And the hopelessness of the situation bears down on those concerned more and more as each year passes. Many elderly parents in their 70s, 80s and even 90s—often single and often alone—go to bed not knowing what will happen to their son or daughter sleeping in the next room if they 1136 go to meet their Maker during the night. Surely their plight, and the plight of all families without services, must not be ignored.
The Government guidance recognises, and I quote:Sometimes such difficulties can be overcome without additional resources; in other cases additional resources will be necessary to enable people with learning disabilities to use the services satisfactorily".So here we have it at last: the recognition that if people with learning disability are to benefit under community care, it will take money—new money. As the noble Lord, Lord Carter, also said yesterday, referring to the guidelines:Without new money, they certainly will not work."—[Col.1013].Extra resources are essential if parents are to be relieved of these pressures and if adults with learning disability are to have a chance to develop their own lives independently. I am greatly disappointed that the Government do not indicate any additional relief for these families. To date, about 2,000 new residential places have been created annually. This has just kept pace with the movement of people out of long-stay hospitals. What do the Government intend to do to address the much greater numerical problem of those people who live in the community now, not only with elderly carers but with parents, across a wide range of ages, income and housing?
The money being transferred in April from the Department of Social Security to local authorities does not take into account the large difference which already exists between levels of income support payments and the actual cost of residential care. Without extra resources, the gap between the real needs and the reality of service provision will be glaringly obvious. Ultimately, that may be to our benefit, but in the meantime people with learning disability and their families are caught between Scylla and Charybdis and continue to lose out daily. As was said long ago of the Athenians, governments recognise virtue but they are regrettably slow to practise it.
§ 4.18 p.m.
§ Baroness Jay of Paddington
My Lords, it is a very great honour to become a Member of your Lordships' House and I am of course particularly privileged to be here and to be welcomed in such a helpful and warm way. I had been led to suppose that I would be met with friendship but I was not prepared for such warmth and I am delighted by the way in which I have been greeted. Perhaps your Lordships will indulge me for a moment of family sentiment. As you can imagine, it is for me a particular privilege to have the honour and the opportunity to serve in Parliament with my father and noble friend, Lord Callaghan of Cardiff. It is, of course, a particular privilege that simply by being in this House as a Member I am contributing another unique record to his historic political life.
I have ventured to speak in the debate today, not to try to contribute to the masterly overview of all the community care issues which was provided by my noble friend Lord Carter, but to draw attention to the 1137 special needs of the growing number of people in this country with HIV disease; those who are HIV positive or who have AIDS. They have special needs for,a coherent and properly funded system of care in the community.We are now entering the second decade of the AIDS epidemic in Britain and we now understand far more about how HIV disease progresses and how it is most appropriately handled, both medically and socially. To date,6,500 people have been diagnosed as suffering from AIDS and it is authoritatively estimated that approximately 30,000 people are now HIV positive.
It is also now known that the average time between someone being found to he HIV positive and developing symptoms of full AIDS is eight years. During those eight years most people who are HIV positive will be, for most of the time, fit and well. But they will need the regular medical supervision and social and psychological support that, ideally, is provided by community care. Even when they go on, as many of them will, to develop the full symptoms of AIDS, they will need to be in hospital only at times of acute illness. They need the well-funded and coherent community care plan that we are discussing today. But, as yet, among those who are infected and affected by the virus, there is little confidence that many of the services can be generally provided.
Most of the people in this country who are HIV positive are young and vulnerable. They have little experience of dealing with statutory authorities. They are often unsupported by families or the informal network of what we describe as informal carers. Many lose their jobs and their homes when they are known to be infected, and become even more isolated. Their needs are deep and complex.
At the moment, the first port of call for most of those people is the out-patient department of an acute sector hospital. We find that the majority is still being looked after in London by the major teaching hospitals. At the risk of raising a controversial issue, I must say that if Sir Bernard Tomlinson's proposals for reducing London's teaching hospitals are implemented, the threat to HIV/AIDS services as they exist will he considerable. The HIV/AIDS situation illustrates precisely the general point about the Tomlinson plan: before it becomes any sort of reality—before it is implemented and not after—we must have new and extensive community-care provision to fill the service gaps caused by any hospital closures.
The London magnet for HIV care exists because many young people who are HIV positive, or who suspect that they may be, drift to the capital because they are anxious about the care that they may receive in their home communities. Every person who has an HIV positive diagnosis confronts not just a tragic health problem but often a crushing burden of stigma and prejudice. GPs may still resist looking after a patient with HIV. We have heard reports of home helps who refuse to visit people with AIDS or who will perhaps not go into the house; of people who will leave meals-on-wheels on a doorstep; or HIV positive expectant mothers who are delivered by midwives in 1138 so-called space suits. Sadly they are not stories from the dark days of the mid-80s but stories that I have heard and confirmed in the past year.
If a broad base of good community care across the country is to be established it will need to spread far beyond those teaching hospitals which have already established practices with local and voluntary agencies and the few metropolitan boroughs which have been in the vanguard of creating appropriate care packages.
The appalling situation in New York City, which I have seen recently, where homeless people with AIDS are literally dying on the streets has not happened here, but the community care net will have to be reinforced strongly to prevent even the possibility of such shameful tragedies.
Everyone in this country who has been involved with AIDS recognises the invaluable role that has been played by the voluntary sector. Organisations such as the Terrence Higgins Trust, Positively Women and the London Lighthouse have provided a wide range of care for people who may be intimidated by statutory services or who may need extra help such as "buddying" or alternative therapies. Those organisations are now alarmed by what they see as a serious threat to the AIDS support grant to local authorities in the coming year. They fear that if the grant is cut local authorities will concentrate upon their own services and reduce their grants to local voluntary organisations. I urge the Minister to ensure that the grant is maintained and that local authorities are monitored carefully to ensure that they spend at least the Department of Health's suggested 20 per cent. of the AIDS support grant on aiding the voluntary sector.
Voluntary sector work for people with AIDS has spread far beyond the organisations that were set up to deal with the issue. Just this morning I attended a conference entitled Women, AIDS and Social Change at which Her Royal Highness the Princess of Wales was present and at which the Minister spoke. That conference was organised partly by well-established women's organisations such as the National Council of Women, the Standing Conference of Women's Organisations and the Soroptomists.
There is an enormous reservoir of skill to be drawn upon from such organisations, and it will be critical, if effective packages of community care are to he created—here I echo my noble friend Lord Carter—that the whole voluntary sector should play a full and equal part with local and health authorities in planning and delivering that care.
In conclusion, I should like to draw your Lordships' attention to the global theme for this year's World AIDS Day which takes place on 1st December. The theme this year is "AIDS—A Community Commitment". I hope that in this country we will ensure that our commitment is both coherent and properly funded.
§ 4.26 p.m.
§ Lord Mancroft
My Lords, it is a great privilege to be able to congratulate, on behalf of your Lordships, the noble Baroness, on her maiden speech. One or two of us in your Lordships' House have followed our 1139 fathers into the House, but for slightly different reasons from those of the noble Baroness. Many of us will hope that our fathers are as proud of us as I have no doubt her noble father is today. Her speech showed the enormous expertise that she has in the field of AIDS and HIV which she has gained as chairman of the National AIDS Trust. The House will also be aware of the tremendous work she does for other charities and in the National Health Service. I believe that the whole House will join me in hoping that we shall hear a great deal more from her in the future.
§ Lord Mancroft
My Lords, I should like to thank, as other noble Lords have and no doubt will, the noble Lord, Lord Carter, for bringing this subject to our attention today. However, I am somewhat sad and perplexed that it has taken Her Majesty's Opposition to put down this Motion for debate today and not the Government whom I support. I should have thought that the Government would have been happy to share with your Lordships their new plans for community care. I am sad too that they saw fit to bring those plans forward in a Statement made a week before Parliament reconvened and not here on the Floor of the House, bearing in mind as I do the enormous amount of work that was put in on all sides of the House during the passage of the National Health Service and Community Care Bill. An enormous part of the work done to ensure that community care was viable and was a plan with which people could work was done in this House. It could even be described as a discourtesy to your Lordships' House that the Government did not see fit to debate the matter here before they made their announcement.
It will not surprise your Lordships to know that I shall confine most of my remarks to drug and alcohol treatment. It is an area in which I have an interest. I am connected with a variety of voluntary and commercial organisations which seek to provide that difficult area of care. In case your Lordships should think that I am biased in any way, I should say that in the past week or two I have spent a considerable amount of time talking to organisations with which I am not so closely connected to ensure that I have a full view of what they felt about the changes and how they would affect them.
It is worth looking for a moment at the plans for community care over the past two years. During the Bill's passage through the House we were able to convince my right honourable friend the Home Secretary who was at that time of course Secretary of State for Health that drugs and alcohol represented a special case. We managed to convince him to ring-fence the funding and to make, for instance, various other provisions relating to assessment. We managed to persuade him that drug and alcohol rehabilitation were low on the list of local authority priorities. He accepted that point. He made the changes. I should love to know what has persuaded the Government that he was so wrong and that my right honourable friend the present Secretary of State is so right.
1140 I am aware, of course, that under the new rules 25 per cent. of the grant must be spent on areas of care other than the care of old people. I am aware that of that 25 per cent. of grant,75 per cent. must go to the independent sector. The noble Lord, Lord Carter, is not happy that that will provide enough money for local authorities. I, of course, am not happy it will provide enough money for the independent sector. Certainly that matter needs to be more closely debated. My noble friend on the Front Bench has been in the Department of Health long enough—she was the chairman of a health authority before being appointed to the Front Bench—to know that the guidance to be issued is of no consequence as local authorities ignore or respect guidance as they choose. If that is the way that the Government wish to proceed, we shall need directives and not guidance.
We were assured that health authorities would contract out as regards the service we are discussing. So far only two have done so. Therefore that assurance did not come to pass. We were told that local authorities would consult over care plans, but my information is that less than 30 per cent. have done so as regards this area of care. Of those who have consulted, few have been included in the future care plans. The only issue that has been successful is that of extra contractual referrals—I congratulate the Government on that—although that matter is not strictly relevant to what we are discussing today. Extra contractual referrals have only worked because GPs have pushed for them, much against the will of various directors of public health in health authorities. Extra contractual referrals only work to a certain extent because the extra contractual referral budget is small and it runs out after about six to nine months of the year have passed. As that policy has been successful, I hope that the Government will extend it as it seems to be welcomed by patients and doctors.
The independent sector facilities that accept patients under the Department of Social Security will face various problems with the new plans as they are outlined at the moment. Many facilities accept patients, as there are so few of them, from many different areas. At the moment many of them are paid up to six months in arrears by local authorities. That is purely due to incompetence at local office level. In future the facilities will have to deal with up to 100 different authorities; indeed as many authorities as there are patients. One conjures up the vision of an administrative nightmare with facilities having to chase payments from many different authorities. That nightmare is too terrible and too inefficient to contemplate.
Further, funds for local authority budgets are to be assessed on the basis of the previous year's expenditure. However, currently the various independent sector facilities apply for funds in their local area regardless of where the patient has come from, and yet the budget will be assessed according to which authorities have paid for patients. Therefore many authorities which may have sent patients out of their geographical area for treatment—this applies to all 1141 fields of rehabilitation—will not be eligible for a share of the budget in future years. Such a process will make the whole scheme completely meaningless.
Another problem concerns assessment. I have a ghastly feeling of déjà vu when I talk about assessment. We spent long hours in this House, both in Committee and on Report during the passage of the community care Bill, discussing this issue. We came to a conclusion that assessment should be made in the facilities. We persuaded the Government to accept that conclusion. We decided assessment should he made in the facilities because the patients involved are difficult to get hold of and, once someone has got hold of them, they are likely to vanish overnight. The period between assessment, referral and admission must be as short as possible. If assessment is carried out by a local authority that period will be drawn out and patients will vanish.
Further, the Government accepted that all the expertise in this area exists within the independent sector and that there is relatively little expertise in local authorities. Clearly that position has not changed in the past 18 months. Therefore there is no reason for the assessment process to change. If local authorities undertake assessments, few patients will receive the help they need and, further, the assessments will have to be repeated when the patients reach the facility because most of the independent facilities do not trust the calibre or quality of assessment made by local authorities.
There is also a feeling in the independent sector, both voluntary and commercial, that the Government dislike the concept of residential care for those suffering from drug and alcohol related conditions. There is a case for saying that in future we need to provide more day care. We do not have enough day care provision and what we have does not offer great expertise and is not of first rate quality as yet. Day care provision will become better with time but it cannot be provided until it is backed up by good in-patient care. At this end of the market, as it were, many patients need to get out of their normal environments. Many of them have nowhere to live and many of them have no jobs. How are they to survive while they receive out-patient care? It is also worth noting that we are talking about 2,000 beds; that is one bed for every 122,000 of population. One cannot say that that figure constitutes surplus provision. The market is not flooded. Indeed it is safe to say that at the moment demand outstrips supply approximately four times over. I believe that I am right in saying that last year about 40,000 assessments were carried out but there was only provision for 2,000 beds. Therefore it is ludicrous to suggest that we have too many beds.
It must also be remembered that the price of care is based on the price of nursing home care, whereas the quality of nursing and expertise in the facilities that I am discussing is a great deal higher than that offered in nursing homes. Therefore the taxpayer is already getting a good deal. Like my friends in the voluntary independent sector I am unhappy. The Government have not produced a good reason why this sudden change should occur. I have no reason to believe that 1142 the new proposals will work. The Government should have the courtesy to explain in detail why they have suddenly decided upon this complete U-turn.
§ 4.36 p.m.
Baroness Darcy (de Knayth)
My Lords, I, too, wish to thank the noble Lord, Lord Carter, for enabling us to debate this huge subject. This is a wide-ranging debate as has been shown by the wide variety of aspects that have already been covered by noble Lords who have spoken. I am delighted that this debate has given us the opportunity to hear the most interesting, knowledgeable and thoughtful maiden speech of the noble Baroness, Lady Jay.
The noble Lord, Lord Carter, has given a wonderfully comprehensive outline of community care. I shall concentrate on three narrow issues that are particularly important to physically disabled people who cannot compete on an equal basis in society without control over their own personal assistance arrangements. There are problems which need to be ironed out so that they can lead their own lives successfully, happily and productively and thereby contribute to the life of the community.
The matter of direct payments has long been a thorn in the Government's side. I shall not bore noble Lords by giving many details about this matter as many noble Lords, and particularly the Minister, have heard it all before. The Minister smiles. She is relieved to be spared that ordeal. Basically the matter of direct payments concerns severely disabled people being provided with cash rather than services, if that is what both the local authority and the disabled person want. It does not require any further resources. The disabled person is assessed by the local authority as needing a given number of hours of personal assistance. Instead of the service being provided, cash is given to enable the disabled person to make his own arrangements.
A number of such schemes exist and work successfully. They are excellent examples of consumer choice, independence and equality for severely disabled people. In fact they constitute everything that the Government espouse in their community care proposals. The Minister outlined those principles clearly in her opening speech. The Government have said that the law does not allow such payments. However, it is not only disabled people who want the option of direct payments—one might say that they would want that option—but many local authorities also want them. At the end of September the Association of Directors of Social Services passed a motion that was unopposed calling upon the Government to empower local authorities to make the payments. Moving the motion Roy Taylor, the director of social services for Kingston-upon-Thames, said:The case for direct payments is overwhelming in terms of effective financial management, best community care practice, empowerment, coal-face quality control, on-site monitoring and sound common sense".One cannot put it much clearer than that.
The ADSS is not the only body of people pressing the case for direct payments. The British Association of Social Workers, the Audit Commission, the Prince of Wales Advisory Group on Disability, Members of 1143 the other place and Members of your Lordships' House of all political complexions including Government Ministers, have all praised these schemes. The Department of Health has been somewhat intransigent and blinkered in its approach. In the light of the ADSS Motion—it is after all the directors of social services who will implement the policy—will the Government now reconsider their position and ensure that the Department of Health takes a clear look at what is working well in practice and takes steps to ensure that such schemes are allowed to flourish for all those who wish to use them and are eligible to do so?
I turn to the Independent Living Fund which has already been referred to by the noble Lord, Lord Carter. The ILF has been a tremendous support to many disabled people. As the noble Lord, Lord Henley, put it in a debate on the ILF on 7th March last year:… the fund has been a success … not least because it has addressed a real need in the community in giving disabled people the opportunity to exercise control over their lives rather than having to submit to choices made on their behalf by experts. It allows individuals largely to choose the nature and extent of the care that they need in order to remain in their homes … ".—[Official Report,7/3/91; col.1504.]The decision to wind up the ILF was strongly opposed by people with disabilities. In their election manifesto the Government gave a commitment to retain some form of provision for new applicants. No details have as yet been forthcoming. When the Minister comes to reply I very much hope she will respond to the following points. But if she cannot respond to all of them because time will not allow it I would be very grateful if she could write to me about them.
The first point is crucial. As I understand it, the present fund is not taking any applicants after December 1992. If no new scheme is to come in until April 1993 what provision will be made for those people who become disabled between December and April? Will they be catered for? Secondly, what consultation has taken place with disability organisations? A number of people have written to the government department asking for details and to be involved and have received no reply. Thirdly, it is important that provision continues to come from a central source of funding that goes directly to the individual. It cannot be assumed that after April 1993 local authorities will meet all personal assistance needs. The fundamental principle for funding is that personal assistance is a basic human and civil right providing equal opportunity. No one should be disadvantaged by the need for personal assistance in taking part in the social, economic or political life of the community. I urge the Government to involve disabled people in decisions made on future provision for the Independent Living Fund.
My last point concerns the disability living allowance and bed blocking. If we are talking about a coherent community care policy it is important to ensure that all the strands are co-ordinated. The noble Baroness, Lady Cumberlege, talked about co-ordinated services which met assessed needs. 1144 Long-term hospital patients face a number of difficulties when returning home. For example, lack of communication and delays over alterations to their homes often mean that they have to stay in hospital longer than medically necessary.
A point that concerns a number of members of the Spinal Injuries Association is that in spinal units delays in processing DLA lead to delays in processing applications to the ILF because the latter body needs to know what level of DLA the applicant is getting before the claim can be assessed. That in turn leads to bed blocking in units as people are unable to go home until the ELF money starts to come through. The Spinal Injuries Association has asked that that be prevented by indicating on the DLA application form whether the applicant is awaiting a decision from the ILF. The benefits agency replied that that would not be possible. Is it really so difficult to do that? It would greatly assist people to get back into the community as soon as possible and free beds in hospitals. I realise that the DLA is a social security matter but it has a knock-on effect on social services matters. Will the noble Baroness, Lady Cumberlege, talk to her noble friend Lord Henley about it? Will the Government stress the importance of ensuring that unnecessary delays do not occur?
Those particular issues are but small grains of sand in the vast arena of community care, but they are very important to those concerned. They are exactly what community care is about. Enabling people to lead their lives to the full not only enhances the quality of their lives but enables them to contribute to the life of the community. It also makes financial good sense. The Minister not only cares but is very knowledgable about these issues. I very much hope that when she comes to reply it will be in a positive and encouraging way.
§ 4.45 p.m.
§ Lord Rea
My Lords, in order to pack as much as possible into my 10 minutes my speech will consist largely of throwing to the noble Baroness the equivalent of half a dozen Starred Questions one after the other. In mitigation I plead that I have at least warned her of most of them.
Coupled with the announcement earlier this month of the sums to be allocated to local authorities for residential accommodation—and many local authority spokesmen have said they are much too low—is a requirement that 75 per cent. of the money should be spent in the private sector. How does that proportionate split relate to the current division of homes run by local authorities and the private sector? For example, there are very few private homes within the boundaries of the inner London boroughs because of the high cost of staffing them and property. Where more than 25 per cent. of homes are in the public sector will those local authorities be required to close or dispose of those above the quota however popular or well run they are, or will they simply not be funded so that the local authorities will either have to fund the entire cost themselves or take the blame if they are 1145 forced to close them? These questions are widely asked, and I am sure that the answer of the noble Baroness will be closely noted.
The director of social services for Camden told me that only 10 per cent. of the funds allocated to him in this tranche can be spent on accommodation for those under 65. Is that a general rule? Some boroughs, especially the inner city ones, have a much higher prevalence of drug, alcohol-related and mental health problems (as well as AIDS and HIV sufferers as so ably described by my noble friend Baroness Jay) than the national average. These problems affect young adults. Young people with problems gravitate to the cities.
The policy of closing down large mental hospitals requires more hostels and sheltered accommodation. This is not keeping pace with the problem, as has been described many times in this House. As the noble Lord, Lord Mancroft, mentioned in more detail than I can, residential rehabilitation units for those with drug and alcohol problems will have very special difficulties. That was recognised by the Government as a result of the amendment passed in your Lordships' House. It was agreed by the current Home Secretary when he was Minister of Health that special mechanisms would he found for funding them. Many of these units accept clients from all over the country. Clients come from a variety of referring agencies. Only a minority come through local authority social services departments. Because many clients do not have recognised or fixed abodes, getting funding from many different local authorities will be virtually impossible. Unless special arrangements are made, surely many of the units will have to close. The problem of drug and alcohol dependence is increasing, not decreasing, and I think it would be very irresponsible of the Government not to fund those units directly in some way. I hope the noble Baroness will be able to announce that the Government's undertaking to this House and the other place two years ago will be honoured.
The British Medical Association, the Royal College of Nursing and myself are very concerned about the arrangements for auditing the quality of care which will be provided by residential units in the country. Perhaps the noble Baroness can describe the state of play in that respect. Many units provide high-quality care, but many do not. I will be grateful if she could remind us what is meant by "arm's length inspection". Who will be carrying out the inspections to check whether agreed standards are being achieved? How often will they be carried out? Will inspection teams always include a qualified health worker such as a nurse or doctor? How independent does the term "arm's length" make them?
In January this year the Royal College of Physicians and the British Geriatrics Society produced a very useful document entitled High Quality Long-term Care for Elderly People. It spells out in some detail, but in a very practical way, acceptable standards, and it suggests how they could be achieved and maintained. I expect that most noble Lords have visited old people's homes which are pervaded by the unmistakable smell of stale urine. In some of them it 1146 seems to be almost accepted that that is the norm. It is not the norm, nor should it ever be. This report shows how that and a variety of other indignities, which I shall not mention, can be avoided, and how a dignified old age can be assured even for very frail people through the use of the CARE system of audit, described in that document.
Does the Department of Health recommend to local authorities the use of that document when it sends out advisory circulars? It would be very useful for both inspectors of homes and the owners and managers of homes because it is phrased very clearly and in non-technical language. I have spent much more time than I meant to do on residential care, and that is only part of the total package of care in the community, the bulk of which takes place in people's own homes assisted by day care units.
Speaking of day care units, perhaps I may diverge slightly at this point. A professor of psychiatry in old age—a psychogeriatrician—in Nottingham (whose name I shall not reveal), when discussing day units for old people once said that the ideal model for a psychogeriatric day centre was the House of Lords—your Lordships' own House. For instance, he said, Members come to the House and come to believe that they are rather important people. They can make speeches and ask questions about almost any subject they want to raise in front of a virtually captive audience. They have one restaurant and bar to which they can bring guests and another in which guests are not allowed. Above all, they have a Library with comfortable chairs, where they can ostensibly read about urgent and important matters while in fact having a quiet snooze. Visitors of course are not allowed to witness it. I suggest that far from abolishing your Lordships' House, as has been suggested by some on these Benches, it is clear that every town and every county should have one.
Having dealt with day centres, I return to home care. As has been mentioned by a number of speakers, that is largely dependent on the nursing professions, district nurses and community psychiatric nurses, who assess the needs of elderly and mentally ill people in their own homes. They are the ones who draw up practical management plans for them. The GP may initiate the process but nurses undertake the continuing burden. It is ideally a team effort, very much helped if a health adviser for the elderly or a geriatric health visitor, who again is a specially trained nurse, can be involved. There is a great need for a close working relationship between social services departments and the local health providers of community health care. Many other speakers have mentioned that aspect. I shall not elaborate on it.
Finally, with special reference to London, what practical steps are proposed to upgrade primary care in line with the recommendations of the Tomlinson Report? Poor primary care has been mentioned as one of the main reasons why average hospital stays in London are longer than in the rest of the country. London's needs are greater than elsewhere, as Sir Bernard himself points out in his report. I quote from paragraph 61: 1147the proportion of people with psychiatric problems is greater because of the flow into London of vulnerable people with mental illness, drug addiction problems, alcoholism and multiple social problems … but the provision of accommodation for the former residents of large mental illness hospitals has not met demand, and community-based care has been undermined in many parts of London by a lack of trained professionals including psychologists, occupational therapists, community psychiatric nurses and social workers".I suggest that the £140 million which Sir Bernard recommends to be spent on improving primary health care services in London will hardly be enough. It is necessary not only to bring our primary health care services up to the national average level in London; but, in order to cope with the problems, they must be brought up to a higher level.
§ 4.56 p.m.
§ Lord Redesdale
My Lords, I want first to thank the noble Lord, Lord Carter, for giving us the opportunity to speak on this subject, especially as the three youngest Members of the day centre are present. The issue of a coherent and properly funded system of care is one of increasing importance because, as has been stated by the British Medical Association, unless the community care provisions are funded fully, the consequences for the chronically sick, their carers, the hospital service and general practice will be disastrous.
The principle behind community care is that people should be able to live as independently as possible in their own homes or in a homely rather than an institutional setting. In April next year, when the final sections of the National Health Service and Community Care Act 1990 are implemented, the opportunity will exist for that principle to be carried into practice. However, if it is to be properly instituted, community care will not be a cheap alternative. If carers in the community are to take on the task of caring, adequate funding will have to be invested.
At the recent launch of Caring Costs, an alliance of voluntary organisations which aims to achieve an adequate income for all carers, a number of carers described the problems faced at present by carers. There was a real sense of anger that the main social security benefit for carers—invalid care allowance—is only £32.55 a week. It is hardly surprising that 26 per cent. of all carers are living in poverty. That is an estimated 1.5 million people.
In a survey carried out this year,81 per cent. of carers between the ages of 18 and 34 had experienced financial difficulties since becoming a carer. There are 6 million carers in Britain, a figure that is set to rise with the growth in the proportion of older people in society. The idea that carers should have to cope with what, for a high proportion of them, is a demanding and full-time job while suffering financial hardship is unacceptable and unquestionably will have an adverse affect on the person being cared for.
In many cases, it is impossible for carers who work more than 35 hours a week also to go out to work. Many carers therefore subsist on the invalid care allowance or their own savings. It has been estimated that carers save the Government up to £24 billion a year. However, there is little remuneration for their 1148 work. Indeed some carers who spend many years caring for a sick relative find themselves in a position of not qualifying for a pension, with the further problem that if the person the carer is caring for suddenly dies, the invalid care allowance is withdrawn from that day, removing possibly the only source of income which that carer receives.
My own experience in this field is through volunteer work and residential holidays, where I have acted as a helper. It is only through such experience that it is possible to understand the intensity of such work. It is both physically and mentally exhausting. The residential holidays in which I took part were not only a break for the children but also, and perhaps more importantly, a break for their families left at home. Those holidays only lasted a week at a time. I am afraid it usually took me more than a week to recover. I therefore have the greatest respect for those who are carers in the community and fulfil the task of caring for 52 weeks of the year. Seven out of 10 people with mental handicaps or, as the noble Lord, Lord Rix, pointed out with a learning disability, are already living in the community in their parents' homes. The figure includes middle-aged adults who are now being cared for by parents in their 70s,80s and even 90s.
As MENCAP has highlighted recently in its manifesto on family life for people with a learning disability, increasingly more is expected of those parents as their sons and daughters become older, in particular when they reach the age of 19 when schooling stops. As many as a third have no jobs, no training, no further education and no day service of any kind. I have a friend who is handicapped. It was devastating for him when he left school because he had nothing to do with his time and no ability to do anything without help. At a time when most parents are able to begin to think of themselves again, parents of sons or daughters with learning disabilities find themselves having to care for and find stimulation for their adult offspring day in and day out.
The Government circular issued on 26th October emphasises the importance of the role of carers. However, assurances are needed that appropriate day service and respite care will be provided. Even when children are young, those with severe multiple handicaps require far more support than other children. The intensive care which children under the age of two demand does not end for those children and their parents. The usual milestones are never reached. Parents still have to feed and change the nappies of their 10,20 or 30 year-old sons and daughters. Is it right that a parent in his 70s is still providing total care for his children who may be aged 30 or 40?
Only 17 per cent. of the most severely handicapped children receive any respite care, with the figure for adults being too low to record. MENCAP has identified respite care as a top priority among its members. However, evidence suggests that rather than expanding to meet need, fewer respite opportunities now exist and those are continuing to decrease. As the figures illustrate, respite care provides a break for the parents/carers as well as introducing new experiences into the life of a person with a learning disability. That is especially important. Often for such a person the 1149 first knowledge of leaving the security of the home is when the parents die; and the ability to cope with that loss is intensified with the loss of familiar surroundings. Respite care is a first step to independence and it is hoped that it will lead to people moving out of the home before a crisis necessitates it.
MENCAP estimates that 4,000 new places in appropriate housing will be needed in each of the next five years. But the current provision is just 2,000, which barely covers the needs of those moving out of hospitals. The Government's recent announcement does not indicate any increase. For 60,000 adults with learning disabilities and their carers, community care will mean absolutely nothing unless their needs are properly addressed through honest assessments and the availability of resources to meet those needs.
The Minister states that it will need more than money to make care in the community work. However, without the money it will not work in the first place.
§ 5.2 p.m.
§ Baroness Fisher of Rednal
My Lords, I congratulate my noble friend on bringing forward the debate. It is a comprehensive debate with most speakers concentrating on a particular issue.
I remind the House that in the late 1980s it was the rundown and closure of long stay mental hospitals which formed the centrepiece of community care policy. How successful that policy has been I leave to noble Lords to judge. However, I wish to dwell upon that problem for a few moments.
Voluntary organisations in the community face an acute dilemma in being challenged to provide an increasing range of accommodation, containment and treatment for growing numbers of mentally disturbed, socially maladjusted persons. They do so without adequate resources of revenue income. Figures relating to that problem may easily be gained from the Salvation Army, as I know from my personal knowledge of the Trinity Centre, which operates in the Birmingham area.
Considerable confusion exists as to where accountability lies for people with aggravated and complicated needs. Have the Government a master plan? Have government policy documents been formulated? I am not aware of that, but the noble Baroness may be able to tell me that they exist. The problem has to be tackled comprehensively; we have to get to grips with it. The problems are there for all to see. They exist on the streets of London and of our major cities. Care in the community is not apparent. If the Government believe that community care is best for the mentally ill, they must provide adequate resources. Otherwise, as other noble Lords have said, the community programme will be exposed as a sham and a cost-cutting exercise, as we know that many of the exercises that the Government operate are.
For a number of years I have had a particular interest in the blind. People with sensory disabilities are found in large numbers in hospitals for the mentally handicapped. They have the greatest difficulty in achieving resettlement into the community. They wait for long periods. Pioneering approaches 1150 have been made. In that respect one has to compliment the organisation Sense which has been trying to maintain some form of accommodation in the community. Does the Minister agree with the necessity for service planners to make sure that they develop appropriate services for the blind handicapped client group which is a specialist group of persons?
The consultative document, The Health of the Nation, refers to psychiatric hospitals as providing an outmoded pattern of care. That might be so. If it is, what alternative forms of in-patient care do the Government expect to be developed by the NHS to provide sanctuary for those whose mental illness or learning disability (whatever we wish to call it) is too severe to be managed in the community? Are mental hospitals encouraged to use part of the land that is available around their hospitals to provide secure housing units in the small clusters which are much favoured, with perhaps a section being used for respite care for many of the schizophrenic patients who require their treatment to be regularly updated?
Proper community care can be provided but I do not believe that it will he cheap. It worries me that the Government's proposals will be for community care on the cheap. Community care needs family support, back-up services and financial support for carers. It needs to provide respite care. The Government must recognise that the provision of adequate housing must also form the basis of any successful care programme. Will the Minister tell the House whether the Housing Corporation is allocating special money to housing associations in order to permit the building of accommodation, which in many cases must be new? Local authorities are unable to use their money to build any houses.
My concluding remarks relate to young homeless people. I have a personal involvement at St. Basil's Centre, which is a well-known organisation catering for young homeless people. It is known in the department as being worthy of government support and receives support from the Inner City Partnership in Birmingham. It has a long history of helping those in need of short-stay and long-stay accommodation, thereby completely rehabilitating young people into the community.
It has been brought to my attention that serious incidents have happened during the past 12 months. Indeed, during the past two months there have been 10 attempted suicides by people under the age of 20. They have involved mostly wrist slashing and drug overdoses, but at present the centre is dealing with the serious case of a young girl who is determined to hang herself. Hostels for helping the young homeless do not cater for such people. The staff at the centre are all well-trained in counselling and so forth but they are not well-qualified to deal with the seriously emotionally disturbed young people who are now going to the centre. They can receive little support in the community. The duty psychiatrists and the social welfare departments offer help but only on assessment. The matter needs to be drawn to the 1151 Minister's attention because something is going wrong if young people are missing out on necessary psychiatric care.
I express my admiration for the positive work that is carried out in the community by the voluntary organisations and charities. Their contribution can be described as innovative; they are willing to try new solutions to problems and their staff are really involved in caring for young people. We are well aware of the many appeals for donations to such worthy bodies. That helps with capital projects but all those organisations face problems because the real costs occur in daily and weekly work and revenue costs. One of the problems that is holding back many voluntary organisations is that capital becomes available but often revenue is non-existent. That problem should be readily understood by the Government and some means should be found to allay the mounting concern involving revenue costs. The voluntary bodies will then be able to play an increasing role in care in the community in partnership with local authorities.
§ 5.15 p.m.
§ Lord Holderness
My Lords, when I visit friends in hospital and look around I wonder how some of the patients will cope when they are discharged. That is not a particularly intelligent question because I suspect that for every thousand people discharged from hospital, there are a thousand different needs. However, they will share some anxieties as regards their individual futures. They will hope to find a place to live that is physically suited to their condition after discharge from hospital, and I hope that they will be successful. All must be able, with or without outside help, to manage the ordinary tasks of life. Many will have to cope with loneliness and depression and perhaps the fear of growing old. Those conditions may be harder to overcome than the physical challenges which they must meet.
All those challenges have been given greater relevance by the added emphasis which the Government have given to care in the community. I have no doubt that that decision is right. At home, surrounded by familiar things, is basically where people belong. We all know of friends and relations who became confused and disorientated by being uprooted and put into institutional care. Indeed, many of us have seen comparable disorientation among men and women in hospital for only a short time. There appear to be other strong reasons for making a patient's stay in hospital as short as possible. In my opinion, hospital care of acute cases, often the gravely ill, is beyond all praise. However, the attention given to patients needing not acute care but that different and rare commodity "tender loving care" appears to be less evident. That further strengthens my conviction that people who need such care are better returned as soon as possible to their own surroundings.
In saying that I am well aware that the challenge to the services outside hospital will be enormous. The noble Baroness, Lady Darcy (de Knayth), made that 1152 almost horrifyingly clear. GPs will need all that the Government can arrange for them, particularly in the wake of the Tomlinson Report. An immediate need which is not at present met is for hospitals to tell GPs when patients are discharged and to provide them with details of the hospital treatment. Without such support, GPs cannot be expected to play their part—which in my view is an exceptional part—in the reorientation of men and women after leaving hospital. Many patients, especially those with a residual disability, will need information about the various agencies which will be able to help them to cope. It has appeared to me for some time that GPs, who are so closely and almost uniquely in touch with their patients, are well placed not to give the information sought for but to point the way to those well qualified to give it.
Responsibility for providing a suitable home environment is, and must continue to be, shared by many. I am profoundly distressed to hear of patients unnecessarily kept in hospital because the physical improvements which need to be made to their homes have not been carried out. While the necessary work may and probably will fall to the local authorities, the initiative must belong to the hospitals concerned if such disheartening delays are to be prevented.
I believe that my noble friend has already shown herself to be sympathetic as regards the question of quick assessments. I know that it is asking a great deal of whatever multi-disciplinary team takes charge of the individual case. However, if the future home environment is to be satisfactorily matched with the patient's needs, then an immediate assessment must surely take place as soon as possible after admission to hospital, leading to early decisions about the shape of those needs, in order to make possible discharge as soon as the acute care is over.
Others will speak with much greater authority than I can about the central role of carers in the community. Indeed, many noble Lords have already done so. I am glad to say that the Government seem rightly to recognise the carers as the foundation of the whole concept of care in the community. I hope that I shall be forgiven for entering a plea which is close to my heart for basic equipment essential to many leaving hospital and preparing to return to live at home. It is not an inspiring or exciting item of equipment but it is one which is used by more than half a million people at present and it is completely indispensable to a considerable proportion of that half million. The issue of wheelchairs is now broadly the responsibility of the district health authorities. Until next spring, part of the budget allocated to regional health authorities is specifically earmarked or ringfenced for that service. We have already heard about ringfencing in another connection. Thereafter, because of the end of ringfencing, the wheelchair service is less secure. Unless the Government can make certain that the service is maintained, any system of care in the community will be gravely handicapped.
I go further. Even though I understand that this is not a time for uncontrolled optimism, I ask for greatly improved funding for that service. Our whole concept 1153 of caring for the old and handicapped makes little sense unless we are prepared to provide the means to enable them to live as full a life as possible.
Finally, certain aspects of caring in the community—and my noble friend Lady Darcy mentioned the independent living fund—present a formidable financial challenge. However, there are other opportunities within community care which need cost very little. My concept of a civilised country and a relatively affluent nation, if this country can be considered to be both, suggests an environment in which individuals have the leisure to help other individuals, not in complicated tasks but in ordinary everyday pursuits which is what most of life is about. Hundreds of people are ready to help with those simple tasks, and although such an effort may be difficult to organise, I suspect that the main obstacle to its implementation is the suspicion and distrust which exists in certain quarters and a lack of confidence in those ready to give their time voluntarily.
I am encouraged to hear in this debate that there is already a certain amount of support for the suggestion that we should draw more deeply on that fund of available help, because many, including myself, doubt whether any financial resources available will be adequate for the National Health Service. The service always looks likely to need more than is provided and that is probably equally true for community care. While considerable expertise is necessary in both cases, certain aspects of community care offer wide opportunities to those without medical expertise. I do not believe that we shall succeed in reaching the objectives of the Motion moved by the noble Lord, Lord Carter, without being willing and ready to harness all resources, including those which hundreds of our fellow citizens are already offering, and which thousands more are pressing to imitate.
§ 5.25 p.m.
§ Baroness McFarlane of Llandaff
My Lords, the debate to which the noble Lord, Lord Carter, has given his name is extremely timely, particularly in view of the fact that final sections of the National Health Service and Community Care Act are to be implemented next April.
I wish to focus my remarks on the implications for community nursing to which the noble Baroness, Lady Seear, has already referred. I want to talk about four matters: the increasing importance of community nursing; the need for partnership in care planning; consideration of manpower needs and skill mix in community nursing; and consideration of the training needs of community nurses.
I also think it does well for us to have a sense of history as we enter the future. Many of the community nursing services had their origins in voluntary organisations. We remember respected organisations such as the Queen's Nursing Service and the Ranyard Nurses. We remember the advice that Florence Nightingale gave to William Rathbone on setting up community nursing services in Liverpool. Those of us who come from the North West delight in the fact that health visitors originated there in the Salford Ladies Sanitary Reform Association. I understand that in 1154 those days both doctors and nurses became what were called health missionaries and visited homes with sachets of carbolic and religious tracts!
One might imagine that we should move on in organisation and role from those days. Yet it is good to look at those origins of Victorian philanthropy and Christian ideals which have informed the community nursing service.
We remember how the voluntary organisation work was taken over by local authorities in their community nursing services and then became integrated into the health service in that rather ungainly tripartite service which we first had. Those of us who worked in that service can remember the difficulties of communication between the health services in the hospital sector and health services in the community sector, and particularly the difficulties as regards communications for effective discharge planning for patients coming out of hospital.
We would now expect the community nursing services to be subject to the same kind of scrutiny as to quality and value for money as other aspects of the service are subject. There can be no doubt that community nursing services are becoming more and more important in the care given in the community. We only have to look at the emphasis on early discharge from hospital and the increasingly intensive and often specialised nursing care which needs to be given in the community. We must look at the demographic trends and the number of elderly in the community, and we have already heard a great deal about that. We must look also at the Government's own papers on the health of the nation. It seems to me that within that and the need to promote health and prevent disease, the health visitor has a key role in the community's services of the future.
Under the Act the local authority will again take the lead role in the provision of community services. There will be a wide range of need. I believe that it is difficult to make strict demarcations between health care needs and social needs. It is necessary to emphasise the importance of partnership in planning for care. The district nurse and the health visitor come with the skills acquired through experience in hospital nursing and in further education in making assessments of health care needs in the community. It is most important that that should be married to the assessment made by social workers. The object is a seamless robe of service.
I see examples of some authorities which are making great strides in making their plans for partnerships in assessment and planning explicit. Regrettably I see other authorities that have not made their plans explicit. I believe that it is now a matter of urgency that those plans should be made specific if we are to provide effective partnership in planning. I understand that already some discharge planning is being interrupted by hospitals referring discharges directly to the local authority and bypassing any reference to the district nurse. It is that kind of anxiety that we must overcome.
I pass on to a matter of great concern; that is, manpower needs in district nursing and the skill mix that is required. I am disturbed by what I find to be an 1155 increasingly prevalent view that money can be saved on community services by cutting down, for instance, the number of health visitors and certainly cutting down on highly qualified district nurses—some from grades G or H have been made redundant. That appears to be a good way of liberating money to train and employ care assistants, but it obviously has the effect of diluting the skills of a community nursing service.
I understand that one region recommends cuts in student intake across the nursing specialisms and points to what it calls,gross over-training of district nurses in the past".I understand that the Value for Money Unit, having surveyed one area, estimated that the numbers of qualified district nurses could be cut by 60 per cent. The mind boggles at the effect that that would have on the quality of service. Yet there is another report just published, from the University of Leeds, that indicates that the quality of care and the outcome for patients is improved when there is a better skill mix with more rather than fewer registered nurses. I suggest that we need an assurance that before precipitate action is taken by purchasing authorities and provider units, there needs to be a national appraisal of manpower and skill-mix needs and how they affect the quality of care.
I turn briefly to the numbers of health visitors and district nurses in training. Health visitors and district nurses tend to be a relatively stable population. But when one looks at their age structure, they fall more in the higher age end of the nursing population than the hospital nurses. The number of district nurses and health visitors coming into training has decreased over the past few years. The intake to district nursing courses was down by 6.4 per cent. between 1985 and 1988. We need to look at the implications for the future of qualified manpower in the community nursing service, if that is to continue.
In summary, I believe that for those and for many other reasons it is necessary to rebuild the morale of community nurses who at the moment feel threatened by the uncertainty of the future and in some cases the lack of acknowledgment of the skills that they bring to that important aspect of the work.
§ 5.35 p.m.
§ Lord Murray of Epping Forest
My Lords, we were reminded several times this afternoon, not least by the noble Baroness, Lady Seear—to whom I am sure we all pay tribute as president of the Carers' National Association—that without carers in the community there can be no coherent system of care. I make no apologies for returning to that theme. For far too long these people have been taken for granted. The duties that they undertake are literally a labour of love—they care because they care. Many find in caring a deep fulfilment and satisfaction. But many, often the same people, are frustrated, tired and resentful. Because they are resentful they feel guilty.
The carers I refer to particularly are single people caring for one or more parents, couples caring for parents or parents-in-law, one of a couple caring for a 1156 spouse or, as we were reminded, single persons or couples caring for an adult disabled son or daughter. There are around 6 million such carers and around 1 million care for more than 35 hours a week. What is more, many carers are themselves getting on in years. For many people caring begins in the third age, between 50 and 74. For many the onset of caring means forced early retirement; for others, particularly women, it means that after bringing up children, without a break they move into caring for adults—parents or an in-law.
The noble Lord, Lord Redesdale, emphasised the case of younger carers. I want to emphasise the case of the older carers. A recent study by the Age Concern Institute of Gerontology undertaken on behalf of the Carnegie Inquiry into the Third Age suggests that nearly half of all carers (about 3 million people) are in the age group 50 to 74. The number of people needing care has increased and, as we have already been reminded, will continue to increase as the numbers in the third and fourth ages rise.
I am grateful to my noble friend, Lord Carter, for introducing the subject this afternoon. I join him and perhaps also my noble friend Lord Rea in declaring my own interest in the matter.
While there will be an increase in the number of people requiring care, there may well be a fall in the number of potential carers. The fact of more divorces will reduce care by spouses and children. The growing employment of women may well reduce their ability or even willingness to care.
It was suggested by the noble Lord, Lord Redesdale, that the cost of providing a public service would be up to £24 billion a year. I do not know how the statistics are worked out. It is not a particularly meaningful figure. Caring is a deeply personal service. No professional service, however devoted, can be an adequate substitute for personal care. The price paid by carers is extremely heavy. In the Age Concern Institute of Gerontology survey to which I referred two-thirds of carers felt that their physical and mental health, or both, had been affected. Many older people have great difficulty in caring physically for a spouse or a disabled son or daughter. Many carers suffer from depression; they feel trapped. In particular, caring frequently leads to isolation as a result of losing contacts at work and in social activities and leisure pursuits.
Having to give up a job is not the end of the story. Losing a job means losing pension rights. It means having to use up one's savings before reaching the normal age of retirement. As we have been reminded, disability itself creates special costs and increases ordinary costs such as heating, laundry and transport. So on the grounds of equity alone we must do more to relieve carers of some of their mental and physical stresses and financial worries. Even on the grounds of keeping down public expenditure—and one cannot find a lower motive than that—we should be spending a little more on enabling people to accept the responsibility of caring in the home and encouraging them to go on.
I do not wish to repeat what has been said, but this means more action by the Government to improve 1157 financial help. It also means more action by local government, health authorities and other agencies to provide services. Anyone who looks at the benefit provisions for caring at home and for carers must be totally bemused by the byzantine complexity of the system. Perhaps the first need is to provide better advice services than those available at present and to mount a take-up campaign to ensure that people actually receive their entitlement.
I shall limit myself to one glaring anomaly and to one plea. The anomaly relates to the severe disability premium. Many people who get through all the tangled hedges come up against a blank wall ultimately in that the premium cannot be paid to people who live with a close relative. That must restrict the ability of disabled people to live in the community. The case for removing that restrictive condition is overwhelming.
My plea to the Government is not to shoot themselves in the foot by insisting on transferring the Independent Living Fund responsibilities to local authorities, as has been said this afternoon. That fund is a real success story. I say with great respect that the Government have not got so many great success stories that they should wantonly throw this one away. I very much echo what the noble Baroness, Lady Darcy (de Knayth), said on that subject. This scheme has been enormously successful.
But from April 1993 new applicants are being transferred to local authorities. Reference has been made to the fact that in any event local authorities cannot make cash payments. I hope that that will be put right by the Government supporting the Private Member's Bill put forward by Mr. Andrew Rowe in another place. Even if that is done, local authorities are going to be very short of cash. Also it is pointless to make local authorities institute new systems of assessment and monitoring, thereby reinventing the wheel, when these measures can perfectly well be implemented through continuation of the ILF. I join with my noble friend Lord Carter, the Disability Alliance and other carers' organisations in begging the Government to think again. I ask them to maintain and extend the principle to other areas of caring.
Equally important—it has been so well emphasised that I do not need to go over the ground again—is the need to provide adequate services to carers. I underline the point of respite care. It means the difference between life and almost living death for many carers. Tributes have been paid to various organisations. I pay tribute to the noble Lord, Lord Redesdale, and to bodies such as Winged Fellowship which provide holiday respite care for disabled people. I underline the point that, whereas local authorities have been able to fund many of these activities in the past, they are beginning to make charges for many of the services such as meals on wheels, home helps and respite care. I echo what the noble Lord, Lord Holderness, has said in this context. If the Government will the end that people should be cared for in the community, they must will the means to make that possible.
Finally, there is the need to give more carers the chance to keep or to get a job. For some time now 1158 employers and unions have accepted the need to make better provision for working mothers. Solutions have been found to problems that were once thought to be insuperable. Now they should address their minds to helping other carers such as those we are discussing by the provision of more part-time work, job sharing, flexible hours, extra leave and access to a telephone, which is very important indeed. Older people should also be enabled to return to work after a period of caring. I hope that the Government will complement these measures by raising the earnings limit for carers' benefit payments.
Action on these lines, not only by the Government and other public bodies but by employers, trade unions and the rest of us, will demonstrate that we genuinely care about carers and recognise the value of what they do.
§ 5.45 p.m.
§ Baroness Masham of Ilton
My Lords, I thank the noble Lord, Lord Carter, for initiating this timely debate and giving us the opportunity to bring to your Lordships' attention some aspects of community care which are causing great concern to the users and providers of the service. I hope with an understanding Minister such as the noble Baroness, Lady Cumberlege, that she will be able to alleviate some of the anxieties.
When I heard this week that St. Bartholomew's and St. Thomas's Hospitals were on the hit list it made me think that the next two institutions to be mentioned in this light might be Eton and Winchester colleges. Is this what the classless society is all about? Are we no longer to aim for excellence? I mention Bart's and St. Thomas's in this debate on community care as one who lives in a rural part of North Yorkshire with few services. I have a GP trained at St. Bartholomew's hospital. The ripples from the medical school go far and wide.
At St. Thomas's Hospital there is a unique unit named after the late Lady Lane-Fox who raised so much money for the unit. It looks after high risk respiratory patients from across the country. There is a unique, highly-trained team, including technicians and a service of Danish au pairs who look after people in their homes, many of whom have to use iron lungs as a result of polio. That unit is a lifeline to these patients. They must now be feeling very frightened and vulnerable. I hope that the Minister will find time to visit this most interesting and vital part of our National Health Service.
I am sure that all noble Lords speaking in this debate applaud the principle of providing the services and support to enable people to live as independently as possible in their own homes or in a homely rather than an institutional setting. If there is to be a consensus that the needs of the user should be the driving force, then the help needs should be forthcoming when they are required. Many people go into a hospital for acute patients for an operation or they become disabled in their homes through injury or illness. The link with hospital and home, or alleviating incapacity in the home, can be helped by the advice 1159 and useful aids which come by having an adequate supply of occupational therapists and physiotherapists.
These professionally trained people are the vital link, but it is far from adequate at the moment because of the quick through-put of patients in hospitals. The physiotherapists and occupational therapists are overworked and overstressed. The slowness of the community services and the time it takes to assess needs are matters which I would like the Minister to address today.
I have letters from frustrated people with disabilities who have written to me as a last resort. I have letters from the North of Scotland, Wales and from all over the place. So often relationships have broken down because a generic social worker who does not really know what a severely disabled person really needs has been dealing with the case. Increasing the load on the community of people with severe disability without a massive increase of occupational and peripatetic physiotherapists is asking for trouble.
Academic achievement has been a priority for many therapists in recent years. While this is important for self-esteem and research, it is the basic grades doing the work in the hospital departments and in the community who give most benefit to the patients and enable them to live in the community. If an adequate, suitable house is available and the correct equipment can be afforded, such people will survive.
Yesterday I heard a rumour that local authorities might not be able to afford to keep some of their severely disabled people in the residential home at Putney. They have lived there for years and it has become their home. May I ask the Minister to look into this and to find out what the alternatives would be? These severely disabled people have to live somewhere. The so-called "community" is not a cheap option. They need care 24 hours a day. If local authorities panic and the money runs out, I shudder to think what may happen.
As a member of a family health service authority, I think it is important that people get to know and trust each other, that barriers are not put up and that everyone tries to do the best with what they have. It is difficult when local authority boundaries differ from those of the health authorities. Could the Minister say to what the community and district nurses will be attached? If they are working closely with general practitioners, should they not come under the umbrella of the FHSA? They need to belong to the community they serve. Highly skilled, expert nurses from hospitals could then resettle in the community patients who may have ongoing specialised needs and could also teach the community nurses how to cope. This is being done with community mental health nurses and in some districts works very well indeed.
There is no doubt in my mind that there is a need to teach the community at large, which wants to help, about the needs of the mentally ill and mentally handicapped. I sometimes wonder what one can do when one reads in the local press, as I did a few months ago in the Yorkshire Post, that 1160A Member of Parliament says he has no regrets for saying that mentally handicapped people should be evicted from a housing estate because they were causing house prices to plummet".An excellent group of caring, well-informed people have formed the Continence Foundation which is to be launched in Parliament shortly. The Department of Health has recognised the problems and has responded by carrying out a report on incontinence, the results of which were published in Agenda for Action on Continence, but it is of considerable concern that incontinence was left out of the Health of the Nation document despite the fact that it was included in the Green Paper. It is an easy area in which to establish targets. What is the reason for this omission?
A major concern is that continence services may fall between two stools under the new arrangements as there can be health service and social service interests. Is this an issue for joint planning? It is essential that users of services are involved in planning and monitoring them. There are going to be more people with continence problems living at home and in the community. If community care is to work in reality, continence services are a key element. Can the Minister say who is going to be responsible for providing the products that are needed'? Incontinent people need information, expert individual assessment and advice, access to specialist investigation when needed, treatment options and support to manage the problem.
Anyone working in the drug and alcohol treatment field knows how much opposition there is from local people when a residential rehabilitation home is set up. The work is not easy and addiction of various sorts is on the increase in our complex society. Drug and alcohol abuse damages family life. Children are put at risk and crime increases. Many dedicated and skilled people are striving to treat those who have decided to get clean and to live life within society.
It was with utter dismay and frustration that people learned two weeks ago that the Government had decided to go back on their word that the funds for this service would be ring-fenced, as was assured in 1991. It is the complex and difficult nature of collecting the funds and the high proportion of such people who are homeless that make this a special case. If the present residential homes have to close, the option may well be prison, which is expensive and has the added risk of encouraging the spread of AIDS because of needle sharing. The drug and alcohol treatment agencies have been thrown into crisis. I hope that the Minister will understand the misery and deprivation of this abuse. She has only to look at the success of the noble Lord, Lord Mancroft, who is shortly to become a father, to see what successful treatment can do.
An added concern is that since 1986 the number of UK alcohol research projects has declined by nearly 40 per cent. from 400 projects in 1986 to 253 projects now. To give an example of what is happening, an alcohol researcher from Oxford went to Copenhagen to work for the World Health Organisation and a researcher from Dundee is now a professor in Sydney. No wonder addiction is on the increase.
1161 Having attended the World Conference on AIDS in Amsterdam in July of this year I can assure your Lordships that HIV and AIDS are truly a world disaster. Our Government should be congratulated on the preventive measures that they have taken. Even so, it is estimated that between 25,000 and 30,000 people in Britain may be HIV positive. I hope that the Minister will ensure the confidentiality of such services as genito-urinary medicine despite cross-boundary accounting. AIDS sufferers need careful medical monitoring as there are many complicated conditions such as drug-resistant TB. I end by saying that some of the kindest and most generous volunteers work in the field of AIDS and need to be congratulated. They are an example to all.
§ 5.57 p.m.
§ Baroness Turner of Camden
My Lords, I welcome the opportunity to participate in this debate which was so ably introduced by my noble friend Lord Carter. I make no apology for returning to the subject of carers which has already been dealt with so effectively by the noble Lord, Lord Redesdale, and by my noble friend Lord Murray. I do so because I think that it is most important. I am closely involved with some of the organisations active in this field, notably, Age Concern, and I was for a number of years a member of the Equal Opportunities Commission, which has also worked on behalf of carers. I pay tribute to the work of the National Council for Carers and their Elderly Dependants, which is so ably led by the noble Baroness, Lady Seear.
I know that carers can be either men or women but, the way things are, the overwhelming majority are women. In the types of work where women predominate, that work tends to be undervalued and underpaid—and sometimes not paid at all. As we have heard this afternoon,1 million people in this country provide care and support for at least 35 hours a week for a relative or friend who is elderly or frail or who has a disability. Great sacrifices are demanded of the people who do this work. Many of them have had to give up any thought of a career at reasonable levels of pay or with good prospects—or often of any kind of work at all, even part-time, and we all know how badly paid and unprotected part-time work is. Their career becomes a matter of caring for their elderly or disabled relative.
Many are outside our system of social insurance, which is based on the concept of people working for an employer for a particular number of years, followed by retirement on a state pension, often supplemented by an occupational pension. Such prospects are not for the woman who spends a large part of her life looking after elderly or infirm parents only to find that when she herself reaches retirement age there is no one to look after her and that she has no pension entitlement due to her after years spent outside the labour market.
Of course there is some social security benefit—invalid care allowance, to which the noble Lord, Lord Redesdale, has already referred—but this is only £32.50 a week, the equivalent of about 12 per cent. of national average earnings. Even so, only 17 per cent. 1162 of full-time carers actually receive ICA Many thousands of older carers receive nothing at all to help with the extra costs of providing care and support in old age. In 1990 a House of Commons Select Committee recommended increases in the ICA, raising it to the level of state retirement pension. That would have been something—not exactly munificent—but nothing so far has happened.
There is no doubt at all, from the research undertaken by voluntary organisations, including my own organisation, Age Concern, that a very large number of carers currently live in poverty. A survey conducted by the Department of Social Security in 1991 found that two-thirds of carers reported that caring had an adverse effect upon their standard of living. It is not only a matter of elderly relatives receiving care in the home. There are children with disabilities, many of whom require a great deal of attention. I well remember the case of a former colleague of mine several years ago. He and his wife had a Down's syndrome child to whom they were absolutely devoted. The boy was quite badly handicapped. That couple had never had a holiday and one year they decided to have one. They were able to make arrangements for their son to be looked after in a residential home. When they came back, however, they told me that they would never go away again. They were distressed to find that the boy, removed from familiar surroundings, had pined, had refused to eat and had lost weight.
I refer to this because respite support is very necessary for carers, but it needs to be flexible and on a regular basis in order to meet the needs of' the carers and those being cared for. Proper respite care can he expensive. Nevertheless, it is absolutely vital if carers themselves are not to suffer from the enormous strain involved in daily caring for relatives who may need a great deal of' attention. Often—this point has been referred to by other noble Lords—such charges can become demanding and difficult. They are not all nice old things. Many carers themselves become ill with the strain of constant work and worry, added to which arc the concerns that inevitably arise when there is simply not enough money to meet normal needs, let alone the special needs of ill or disabled people.
People who have given their lives to caring for relatives in this way frequently feel that they have been abandoned. I was at a meeting recently at which a number of carers spoke about their experiences. One woman had spent a lifetime looking after a severely disabled child only to find that when she reached retirement age she had no entitlement to a pension in her own right. Others spoke of the constant strain involved in what they were doing and the hopelessness they felt because no one seemed to understand their plight. Yet, as my noble friend Lord Murray said, the work they do saves this country about £24 billion a year which otherwise would have to be provided by state institutions.
The Government's policy, as we know. is for "care in the community". The intention is to provide services and support to enable people to live as independently as possible in their own homes rather than in an institutional setting. It sounds fine. Who 1163 could disagree with that as an objective? But it is not at all clear that the Government have understood that community care is not a cheap option—it is very expensive.
In April 1993 local authorities will have the lead responsibility for ensuring that people needing community care services in their areas actually receive them. There must be adequate numbers of district nurses and health visitors. They must be adequately trained. I question whether this need is being addressed by those concerned. The Royal College of Nursing fears that without an increase in resources for community nurses the full burden will fall on informal carers—friends and family who will simply not be able to cope.
My own stepdaughter is a health visitor in the Brighton area. She is now actually in charge of the work in her area. I spoke to her on the telephone last night and told her that I intended to participate in this debate. She told me that she is very concerned that the number of trainees is diminishing, whereas, with the increase in the numbers of elderly, she believes that more health visitors are needed rather than fewer. That was confirmed in the speech of the noble Baroness, Lady McFarlane.
The BMA has said that unless community care provisions are funded fully, the consequences for the chronic sick, their carers, the hospital service and general practice will be disastrous. The BMA also demands more financial assistance for carers. There should be a safeguard, it says, that a carer is entitled to retain the benefit for a specified period if, after some years of caring, their relative dies or moves into residential or hospital care. I fully support that view. However, ominous sounds have been emerging from government sources about the need to cut public expenditure because of the recession. The Prime Minister has talked about going for growth. I support that and I support the call for more investment in capital projects. If it is a U-turn it is a welcome one, but not if it means that the disadvantaged and those who care for them are going to have to pay for it. This is perhaps not the appropriate debate to talk about public sector pay, but the professionals who work in the health and community services are by no means overpaid as things stand. Whatever is done in that area I hope that there will be no cuts in the pay of people providing those essential services.
My noble friend is right to put this matter down for debate at this time as community care is due to be implemented next April. Now is the time to say to the Government that they must ensure that it is properly funded and that the many informal carers are properly valued and paid.
§ 6.7 p.m.
The Viscount of Falkland
My Lords, I am grateful to the noble Lord, Lord Carter, for initiating this debate today. I shall confine my remarks to alcohol and drug care. I pay tribute to the excellent speech on this subject by the noble Lord, Lord Mancroft. He dealt with a great many points and he covered in detail some of the points which I would have found difficult 1164 to cover myself; for example, the way he visualises the difficulties of local authorities in coping with the new government arrangements.
During the progress in 1990 of the National Health Service and Community Care Bill I was among those noble Lords who argued, in exactly the same way as Members of another place argued, that in order to safeguard residential care services for those suffering alcohol and drug problems we needed specific financial provision. As the noble Lord, Lord Mancroft, pointed out, a great number of these sufferers are what one might call itinerant sufferers—that term has been used—many of whom are homeless and many are certainly without a fixed address.
We argued that the inevitable result of not reserving funds—I have to use the rather unattractive term "ring-fencing" because it has become common currency—would be the quite rapid closure of certain centres. This would bring hardship not only to addicts themselves but also to their families. It is calculated that for every person who goes for treatment—they are treated for relatively short periods, which is another complicating factor—there are perhaps up to 10 family members or friends who are affected by their illness, if I may describe it as such.
Such was the clear merit of our case and the clear support from all sides of the House that to our great delight, which has now turned to disappointment, the Minister gave assurances which we accepted in good faith, as always in this House, and we did not press the amendment to a Division. Indeed, it went further in another place as has been described. An amendment was produced by the Government which covered the very points we had argued and laboured over for so long and with such energy.
Perhaps I may briefly recap. What has happened now is that the Secretary of State has announced that all community care funds will be ring-fenced. Local authorities are to have total discretion for that ring-fenced amount and will, accordingly, arrive at their priorities. The overall principle of ring-fencing all community care funding is good news for many involved in community care generally. It is good to see that that money is safeguarded; but it is extremely bad news for those of us who are involved in the area of providing residential services for drug addicts and alcoholics. They, again, face the prospect of being left out of local authority priorities, which I can well understand with the pressing needs, the shortage of money and the inevitability of treatment centres being forced to close.
It seems to me that Ministers and departments have never really understood the actual nature of the problem of drug addicts and alcoholics or the problems of local authorities which have to deal with such people. They are often not able to provide services within their own area. There are many cross references and delays. Delay for people who have been compelled or who have volunteered to go into treatment is a dangerous thing, because such people may change their minds or all kinds of things can happen. It becomes increasingly difficult properly to deal with them.
1165 So we are back to square one. I am most eager to hear what the noble Baroness, Lady Cumberlege, will say on the matter. Unless the Government can be prevailed upon to change their mind before April 1993, I do not see how we can view with any optimism the future of patients and their families in the field. Indeed, they face a bleak future. The situation as I see it—and I am not an alarmist by nature—could be unparalleled in, at least, any developed nation. As I said, these people are by nature often homeless and distressed. Any delays would cause further problems and make it a very dangerous area. There is already a severe shortage of places for such sufferers. I believe that the noble Lord, Lord Mancroft, gave the relevant figure. Certainly somewhere in the region of three-quarters of all applicants are refused because of lack of space. Therefore, to further decrease the available treatment is absolutely counter to the stated objectives of the Government in The Health of the Nation. I shall be pleased to hear the views of the noble Baroness on that document, which was presented to us with a clarion call.
In summary, perhaps I may point out that the purpose of a spell in a residential home for a drinker—which is my principal area of interest, although drinkers and drug addicts overlap in terms of treatment and most often attend the same centres—is to relieve him or her of the stresses of a difficult family life or of the pressures of living daily with the problems of a drinking environment.
The options left to clients who are abandoned, as seems likely many will be if the Government's plans go through, is that they will end up on the streets, continuing to drink heavily. They will thus further damage their own health and possibly pose a threat to the health of others, with little prospect of returning to a normal life. We all know that they can be a public nuisance. That is one of the many reasons why many local authorities are not keen to deal with them in the first instance, quite apart from the constraints imposed by a shortage of money. That leaves the police in a very difficult position, given the pressures that are already upon them. We have spoken many times in your Lordships' House about the difficulties faced by the police in respect of those who suffer from alcohol abuse.
It means that those who still have a family—many are abandoned by their families but I have to say that many are supported by families whose fortitude is truly admirable—will find themselves in extremely difficult situations. Indeed, earlier this week we debated the topic of domestic violence. I took a rather critical view on one aspect of the document that we were discussing; namely, a report on domestic violence. I did so because that document of about 100 pages gave the causes of domestic violence, but there was no mention of the connection between alcohol and violence. I have information from organisations like Turning Point and Alcohol Concern which states that on a conservative estimate, in cases of domestic violence—that is, attacks on women by men, whether married to them or in other kinds of less formal relationships-40 per cent. are alcohol related. I find it extraordinary that when people get together to 1166 discuss such social problems they cannot bring themselves to acknowledge the fact that alcohol plays a very strong part.
We talk about denial, which is the term used by those who suffer from such problems and who cannot be brought to realise the illness that they have, but there seems to be a kind of denial in our society about such problems. That does not help. I very much look forward to hearing the Minster's response. I hope that she says something cheering to us, otherwise the prospect is bleak indeed.
§ 6.16 p.m.
§ Lord Ashley of Stoke
My Lords, this House has a proud record on the subject of community care. It has achieved a great deal. I should like to congratulate my noble friend, Lord Carter, on initiating this further debate. I should also like to congratulate him on his impressive and persuasive speech. Many speakers have concentrated on finance and I am very glad that they did so. That is the nub of the problem; without adequate finance—and I personally believe that the Government's provision is inadequate—we shall get nowhere and the people who require community care will suffer.
April 1993 is supposed to be the beginning of a new era for old people, disabled people and all those who need community care. It is supposed not only to give them care, but also to provide choice and dignity for them. If there is a shortfall in funds, there will be no dignity or choice and there will be inadequate care. The foundations of the structure will be damaged without adequate cash. It is rather like sending a rocket into space with an inadequate engine. It will just not get there if the funds are inadequate.
I hope that the Government will look seriously at the amounts of money being provided. Ministers seem quite satisfied with the £539 million which will go to local authorities next April for the newly old and disabled people who require help. But that satisfaction flies in the face of the opinion of many authoritative commentators and many organisations concerned with old and disabled people.
The Association of Municipal Authorities has said that the shortfall from the Government may well result in 12,000 people at risk of no care-I repeat, of no care. The association says that it is a "desperate situation". If that is so, it is a reason for very great concern. The Institute of Health Services Management says that at least £750 million is required to implement the reforms properly. That is £750 million compared with the £539 million allocated by the Government. The director of that institute has added that it is a,reasonable settlement in a tight spending round".Of course, it is not reasonable. We cannot have an estimated shortfall of £300 million and then say it is reasonable. It is very unreasonable, given that degree of shortfall. And it is not a marginal deficit, £300 million: it is half as much again. So it is a very serious shortfall, for which the Government are responsible. In my view, that shortfall makes all the difference in the world between care and neglect. I think it is the difference between responsible change and the 1167 irresponsible chaos which will result from that lack of funds. I see no reason why defenceless people like disabled people should bear the brunt of the burden of the Government's miscalculation or refusal to finance properly.
I welcome the ministerial announcement about the funds being ring-fenced, but Ministers say that it will be a ring-fence for special transitional care. Why only transitional? I do not get the point of this. If it is necessary to ring-fence funds for the next two or three years, it must be necessary to ring-fence such funds permanently, because those recalcitrant local authorities who do not want to spend the money on disabled people or old people will not suddenly, at the end of the transitional period, give them a high priority. It is illogical to expect them to do that kind of thing, and certainly those local authorities with a bad record are not going to change at the end of the transitional period.
Those local authorities are only a small minority: I recognise that and acknowledge it freely. But it is important for the Government to ensure that no local authorities use the extra cash for popular local causes, designed to win votes. The money must be spent on disabled people or old people. We must prevent all local authorities from misusing it, and that is why I want all the money to be ring-fenced permanently and not simply for this transitional period. Of course some local authorities will be under pressure and some will be tempted, but the Government must make sure that they resist the temptation and the pressure so that local authorities spend the money only for disabled or old people.
I note that ring-fencing will apply only for the special grants, according to Ministers, and that the bulk of social service spending will not be ring-fenced. Why not? I think it is regrettable and I hope that the noble Baroness, when she comes to reply, will be able to explain—the noble Baroness looks a little doubtful, but I am making a reasonable proposition. I know that they have to fight those local authorities about this, but it is a very modest proposal. I think that perhaps the Minister is a little taken aback, but I believe that it is something that the Government should take on board. I know that it will not be taken on board overnight; it will not be done very easily, but I want to put forward that programme for what will happen eventually.
I should like to conclude by saying that the changes proposed are very complex and very difficult. We shall have many units which are now answering to many different authorities. They will need to work together, to link together and to co-ordinate their activities. This is a major challenge involving new relationships, new attitudes and new lines of communication. As to the solution, first, there must be adequate funds from the Government. Secondly, there must be a Minister for community care. Thirdly, there must be regular monitoring. Fourthly, there must be full and regular accountability and, finally, perhaps above all—except for cash—there must be the involvement of disabled and old people and their carers in all those decisions.
§ 6.25 p.m.
§ Lord Northbourne
My Lords, I am proud to recollect that the concept of care in the community was, in a substantial measure, pioneered in my own county of Kent by the Reverend Nicholas Stacey and Professor Bliddon Davis of the University of Kent. It is an exciting concept, and as the noble Baroness, Lady Seear, pointed out, nobody can really be against it. It has so many advantages. It is less costly, and if properly carried out it gives greater happiness and, I believe, longer life to the beneficiaries. The trouble is that it has to be properly carried out. It is not enough for the Treasury to say,"Hip hip, hooray!"to the aspects of community care which enable them to save money and then not to spend the necessary money on doing that community care properly. Without adequate support services, neither branch of community care will work.
A number of noble Lords have already spoken about the problems of old people living at home and of their carers. I would just want to draw your Lordships' attention to the other branch of community care, relating to the disabled and particularly to the mentally handicapped, who are being moved out of institutions. In some cases I am afraid that proper care is not being provided for them. This is particularly the case in London today. I have recent evidence that although many hospitals for the mentally ill have been closed, the private homes and hostels into which the people move—if they do not move on to the streets—are not able to cope with the acute phases of their problems.
The Salvation Army told me today that of their total hostel population,43 per cent. are now people with mental handicap; and of those at least a significant proportion need medical help. The difficulty is that the gateway to medical help is through the general practitioner, and the general practitioner does not always like having in his waiting room many people who fall into this category, particularly if they have been living on the streets, are dirty and ragged and do not look very attractive. The practice therefore is to send them to the casualty wards of hospitals. Those wards do not have any facilities to deal with that sort of patient: they are concerned only with acute cases. I have been told that referrals under Section 136 of the Mental Health Act who are sent to hospital are in practice very often back on the streets 24 hours later. Indeed, I was told that in one borough the police are now booking mentally ill people whom they find on the streets for minor offences which they would normally have overlooked, simply to get them into the courts and so that they get the care that they need.
I was particularly happy therefore to read in Hansard that community care funding is going to be ring fenced. I should like to ask the Minister one or two rather specific questions about the ring-fencing. The first is this. What plans do the Government have to ensure that local authorities deliver the quantity and quality of support services for community care for which the taxpayer will be paying? Have they laid down minimum standards for that care? What are the provisions for quality assessment, inspection and 1169 verification? As a farmer, I am very conscious of the nature of a ring fence. I should like to ask the Minister what groups fall within the ring fence. For example, is a group in which I have particular interest—18 year-olds coming out of children's homes and foster homes—included? That group has enormous pro-blems in making the transition from the over-protection of the children's home into independ-ence and the world of work—a transition for which they are very often ill-prepared and for which very often they have no support whatever.
I should like to read to your Lordships a quotation from a paper written by Shelter in the context of a seminar that it held this summer on the Foyer project. It states:What young people need is no different from what they have always needed: the social and economic skills to become responsible adults. Without a base from which to develop these skills we arc setting them up to fail. In the process we pay a high price, the symptoms of which are rising levels of incarceration and the symptoms of alienation visible in every town or city".My experience in one London borough is that when a young person in care comes up to the age of 18, the social services department heaves a sigh of relief. It sends the name down to the housing department which groans and tries to find a grotty flat on some estate in which to put the young person. I could show your Lordships, not more than three miles away from the House, young people in such flats where they are lonely and subject to the worst possible influences from other inmates of the block and the estate. Are those vulnerable young people within the ring fence? If not, do the Government have any plans to provide them with the support that they need?
§ 6.31 p.m.
§ Lord Desai
My Lords, I must first thank my noble friend Lord Carter for making the debate possible. It has given us the opportunity to hear the maiden speech of my noble friend Lady Jay who, with her singular authority, informed us about HIV and AIDS. We have also heard interesting speeches from speakers with specialist knowledge.
I rise as a newcomer to the subject of community care, and so I shall try to be brief. However, I shall begin with some familiar ground—numbers and expenditure. If care in the community is a better way to provide care, it is obviously desirable that that is what we should do. Of course, money spent on a service is not the best indicator of its quality. There is disquiet that that option has been chosen more because it will cost the Treasury less than because it is better. We should like to be assured that enough care will be taken by local authorities and other bodies to ensure that the services available are not just cheap but that they are better. Some services may be cheaper because there are hidden unpaid costs or costs passed on to the citizens. Many noble Lords have mentioned the position of the carers who are either unpaid or underpaid. If we cannot pay carers, we must ensure that we provide the supplementary services needed to assist the carers properly.
Estimates provided by the AMA indicate that there is likely to be a deficit. We should like to know from 1170 the Minister what the Government's view is about the shortfall estimated by the AMA. Is it as much as just under £300 million for 1993– 94, rising to nearly £550 million two years hence? Is it more, or less?
Secondly, I should like to know whether the grants that have been announced will be protected from the new round of public expenditure cuts which we are about to have. Can we be sure that these numbers are solid, as it were, and will not suffer the axe? While I agree that we should go for infrastructural investment, I do not agree that we should spend less or freeze public expenditure. If current expenditure is to be cut, I ask that money spent on community care is not cut, especially as we are starting the experiment and it is vital that it is successful.
There is a subsidiary problem which many people have experienced. Whenever people are due to receive payments from central government or a public body there are long delays. When we have the new institutional arrangement, will delays multiply because residential care centres may have to collect money from many local authorities and not just one? That may increase the delays. That causes cash flow problems for the hard-up, smaller establishments. We should like to know what care will be taken to ensure prompt payment.
I shall now deal with some general considerations about which I am less well informed. I shall try to risk some opinions. Many noble Lords have mentioned the fact that 75 per cent. of the money has to be spent on private sector arrangements. As my noble friend Lord Rea asked, will that restrict local authorities' right to spend money as they see fit? With residential care, there is a mismatch between where the people are and where the beds are. How will that mismatch be dealt with under the new arrangements? Previously, people who needed residential care carried their entitlement with them. They now have to be assessed by the local authorities. While care in the community is a good idea, people may not live in the community to which they are supposed to belong. We must be sure that the mismatch between the population and the beds is dealt with properly. It would be a great pity if we have the money but spend it so badly that we do not make the modest achievements that we can make if the money is spent efficiently.
I wish to talk about the problem of the elderly people in the ethnic minorities, which has not so far been mentioned. I mention it, not because I know much about it, but because I have been made aware that a serious problem arises in respect of the Asian elderly. It is one that the families themselves have not thought through. The cultural tradition was that the elderly would be looked after by their children. It is difficult in this country with the current economic climate to fulfil that cultural tradition. Many of the people thought that they would return to whichever part of southern Asia they belong. It may turn out that they cannot return. There will be a substantial problem about which some people—housing associations, for example—are thinking. Specialist skills may be required to look after the Asian elderly. I hope that someone is thinking about them.
1171 I shall finish by mentioning a subject in which I have just begun to take an interest. It is that of drugs and alcohol. Many noble Lords have spoken with greater authority than myself. I have just become involved with a drugs intervention agency called City Roads. There is a great deal of disquiet about the late change in the ring-fencing of the money available for dealing with drug and alcohol abuse. The agencies normally operate on a shoe-string. The problem is becoming worse. Cocaine use is increasing in inner city areas. That leads to different demands and different specialist needs. The demand will increase sharply. It would be a great pity if we were to lose the dedicated people who work in this area because of the late change—it may be technical—in the funding of work relating to drugs and alcohol.
§ 6.40 p.m.
§ Lady Kinloss
My Lords, the noble Lord, Lord Carter, is to be thanked for introducing this debate today and for his care in explaining his worries on this issue. He also outlined his constructive ideas for the success of the concept of care in the community. The county council social services department in North Yorkshire where I live has told me that it is grateful to the Secretary of State for Health for the announcement on resources available for community care from next April. Like all other bodies, my local county council had hoped for more money but it feels that the money offered constitutes a substantial amount. The announcement should enable local authorities to make clear and proper arrangements for the assessment of the needs of vulnerable people. That principle after all lies at the heart of the Caring for People White Paper.
The Government are also to be congratulated on changing their mind with regard to ring-fencing. I am glad to say that that means local authorities will be unable to solve other problems by diverting resources from their intended destination to other areas. I hope that the Government will therefore see their policies fully implemented. As the main funding agency for people with mental health problems and learning difficulties, local authority social services departments will be able to act with more flexibility, but resources will remain limited for those groups of people. The Government recognise that spending on community care for those with mental illness is limited. How therefore will they ensure that the needs of that client group will be met after the phasing out of the specific grant?
Care in the community is provided by a wide range of public, private and voluntary agencies. The elderly population is growing and the demands on social services departments are increasing. Therefore the need to harness all the sources of care is urgent. Many people think of community care as non-institutional care. Many people think of community care in terms of getting patients out of hospital. That is particularly true in the case of mentally handicapped and mentally ill patients. We need to make certain that local authority social services departments, district health authorities, family health service authorities and 1172 community health councils ensure that the necessary support services are in place before patients are discharged into the community.
The Government have recently announced that formerly ring-fenced resources for people with drug and alcohol related problems who need residential rehabilitation will, after April, be dealt with through the general community care grant. Does not the Minister agree that that goes against the principle of ring-fencing which has been established in the main programme? Can the Minister say whether the Government would reconsider their decision and allow ring-fencing of those resources again?
Alcohol abuse can cause death on the roads, as also can drug abuse. When the Government are trying to cut down the number of fatal accidents, would it not be a saving of overall government expenditure? They are not necessarily killed, but many are disabled as a result of these accidents.
I am sorry that the noble Baroness, Lady Seear, has had to leave, as she has already spoken of the need for adequate support for carers, as has the noble Lord, Lord Murray of Epping Forest, and the noble Baroness, Lady Turner of Camden. They are indeed a very important support and an essential prop if care in the community is to succeed. They will especially need access to support services where the carer may be looking after a disabled person or a very frail relative.
Many of these carers, so Age Concern (England) tells me, find there is no respite care available. I am thinking in particular of those carers who are caring 24 hours a day, seven days a week. Respite care is surely one of the needs that must be looked at to see how best to provide this service for carers who, like the rest of us, need a break or holiday, even more so if they are unable to get out much because of their need to be on call.
One other no less important point is what happens to the carer—perhaps a daughter who is no longer young herself—when the parent or a relative dies. Should there not be a review of all the benefits made available to carers? This would perhaps help towards making sure that they have an adequate amount to live on for the rest of their lives to compensate for what they have missed when they could have been working. North Yorkshire social services are well advanced with their planning, so they tell me, and I am sure that your Lordships would all like to join me in wishing them well.
§ 6.45 p.m.
§ Lord Ennals
My Lords, I, too, wish to congratulate my noble friend Lord Carter on the way in which he opened this important debate. April 1st next year will be an important date. I am sure the Minister already recognises the fact that throughout the country there is a great deal of concern as regards how local authorities will undertake their new responsibilities in 1993.
I am glad that in the current serious financial crisis—I believe that the Government brought it on themselves—the Government have not decided again to postpone the implementation of their community care plans. I give the Government credit for that. The 1173 issue of funding is very much at the nub of this debate. I must say that I do not agree with the view held by the noble Lady, Lady Kinloss, as regards the Government funding for community care. The Secretary of State has announced a figure of £539 million. I believe that most local authorities and most voluntary organisations consider that figure to be a tight one.
It was lovely to hear my noble friend Lord Ashley of Stoke take part in this debate. I realise how much we shall benefit from his presence in this House. My noble friend said that the Government funding is £300 million short of what is required. I believe the funding is £200 million short of what is required. Whatever figure one thinks is appropriate, the Government funding is inadequate in terms of enabling local authorities to fulfil their responsibilities in this area. The public expenditure round is upon us. Following that the Government will put pressure upon local authorities to keep within what the Government consider to be proper limits on expenditure. I fear that local authorities will be pressed not to spend the money they know should be spent on community care.
The other side of the cash coin is that there is now a rapidly growing number of desperately poor people. Over the years the gap between the rich and the poor in our society has widened greatly. I remind the House that one in four children is now living in real poverty and that 12 million people are living on an income that is below half the average income. That is the nearest definition that exists of an official poverty line. That figure is more than twice as high as the figure that existed when this Government came into power. The Government's figures show that 25 per cent. of all children are living below that poverty line compared with only 10 per cent. in 1979.
Those figures are relevant to this debate because most of the people for whom local authorities will have the responsibility of providing or contracting out community care are people living on low incomes. On average the income of the people who will be in receipt of community care will be well below half the average income. Those who suffer from financial pressures will have a much greater need of high quality community care to be provided by local authorities, the private sector or by voluntary organisations.
A report was published yesterday by the National Children's Home. That report stated that families receiving income support are now expected to live on about £100 a week. In addition, the Secretary of State for Social Security is planning to cut invalidity benefits by means of taxation. He also plans to attack other vulnerable groups in society. I must protest at that action. We are going through a difficult period and community care must be funded. The needs of poor people must be met. The poor should not be expected to suffer; rather the Government should put forward some bold tax proposals that would penalise high earners. The Government still have their priorities wrong.
Another aspect of funding that has been raised on all sides of the House is the effect of the ending of ring-fencing as far as alcohol and drug residential services are concerned. Like the noble Viscount, Lord Falkland, the noble Baroness, Lady Masham, and 1174 other noble Lords, this is an issue of concern to many in your Lordships' House who are involved in this field. I hope that we will have some rethinking from the Government.
During the course of my noble friend's speech I reminded him (though he did not need any reminding) that it was this House that decided that there should be a general ring-fencing and it was to satisfy the wishes of the House that special provision was made for services for those affected by alcohol and drugs. We have to recognise that traditionally these have not been local authority services. Many of those services fear that they will be facing the end of their lives. There are only about 2,000 beds in the voluntary sector for those with drug and alcohol problems. Over 20,000 people were referred to those bed spaces in 1989—the figure has gone up—5,000 of whom became resident. National demand severely outstrips supply.
This has never been a service that local authorities have been expected to provide. Now that resources are severely constrained with no previous history of involvement there is a danger that local authorities will not support this marginal sector. There are not many votes in it, but it is absolutely crucial for the welfare of these people and their families. One fears that they will be pushed to the wall. Under the new arrangements, services will need to trace virtually every "home" local authority of those referred to them to see if the funding will be released by those local authorities. An enormous burden will be placed on voluntary organisations all over the country in only a few months' time. Reference was made to the fact that the noble Baroness, Lady Masham, was until recently chairman of Phoenix House which is perhaps the pioneer in providing residential treatment for drug addicts. There is a real danger that several of the houses which are run will not be able to be maintained unless the Government come up with a new answer. I plead with them to look urgently at it again.
I refer to an issue in which I know the Minister has a great interest. I refer to the question of restrictive covenants preventing community care homes. The noble Baroness, Lady Cumberlege, will remember that we both took part in a debate on 20th May 1991. She followed me and we both followed the noble Baroness, Lady Gardner of Parkes, who was moving a Private Member's Bill. The noble Baroness, Lady Cumberlege, spoke of the current law which allowed a freeholder of property to create discriminatory covenants based upon the status rather than the actions of an owner/occupier. What we are talking about is a situation where lots of people say that they are going to leave their houses in their wills but they are not to be used for certain purposes—for example, for people moving from hospital, be they mental hospitals or not. On that very important issue the noble Baroness said:The key to community care is satisfactory housing arrangements, and residents must be protected from unjustifiable prejudice".— [Official Report,20/5/91; col.79.]As the noble Baroness will know—and this issue can be picked up all over the country—there is a case going on in Worthing at the present time in which the neighbours are arguing that the presence and 1175 behaviour of mentally disturbed and addicted proposed residents will be a potential nuisance and danger and that such a home will cause a considerable diminution in the value of the objectors' property.
This area of the law is one that the noble Baroness has said needs to be attended to. It is wrong for community care policy to be said to he coherent when private prejudice can ride roughshod over government policy. The Minister has shown her interest in this matter from the Back Benches. I very much hope that now she is rightfully and satisfactorily on the Front Benches, this will be an issue that she will take up. In the mental health field this is very important indeed. I very much hope that she will respond to the points that I have made.
§ 6.55 p.m.
§ Lord Thurlow
My Lords, perhaps I may pursue a point in the mental health field which was referred to by the noble Lady, Lady Kinloss; that is to say, the interface between the National Health Service and social security. The particular area about which I should like to make some brief remarks concerns the closure of the big mental hospitals. I do so with zest in view of the fact that the noble Baroness, Lady Cumberlege, has such extensive experience in the health field.
One recalls that Sir Roy Griffiths in relation to the health aspects of community care stated that the question of closure of the large mental hospitals was dominant. He said that each closure needed approval, monitoring and control at the highest level. Is this monitoring, control and approval being carried out at the highest level? In principle there must be suitable facilities elsewhere for those who are evicted. Early last year the Minister in another place said that the department did not hold information centrally about the number of beds and patients in those hospitals planned for closure by 1996. Mrs. Bottomley repeated a similar statement last July.
The Department of Health has made plenty of fine statements. It said in an official circular that community-based services are only an improvement when those who have been hospital in-patients get satisfactory health care. What are the facts? We know that 20,000 beds in the large mental hospitals have been shut since 1985. The number now is greater than that. We also know that there is very little margin in the remaining large hospitals to take the acute cases that have been accommodated in the closed hospitals because there is already 96 per cent. occupancy of acute beds.
A committee in another place dealing with health affairs said recently that many in the National Health Service and other agencies appeared to have interpreted the policy of care in the community as first and foremost a directive to abandon hospital treatment. We all know that in principle there is no such intention but that is the widespread interpretation of those who have to pick up the hits. Closures seem to proceed with a momentum of their own, local authorities and regional health authorities disregarding the Government's injunctions. Apart from a tiny 1176 minority of local authorities, we know there is not a sufficiently serious effort being made throughout the country to tackle these problems which are almost on top of us.
Official statements indicate or suggest that Ministers are abdicating their effective responsibility for the rundown of the remaining mental hospitals. A kind of ethnic cleansing is going on. Those who have been in mental hospitals for years and come to regard them as their homes are losing their homes without other suitable homes or facilities being provided. These can only be provided in acute cases either by the construction of new, smaller, modern hospitals (which is extremely expensive and we know the tightness of funds) or by designating areas for acute cases in general hospitals.
There the authorities have run into problems with nursing staff and others because of the difficulties of caring in hospital for the mentally ill. I speak from experience of these difficulties. My late wife and I have had to tackle such difficulties in our own home when our son was temporarily released from a large hospital. I know the difficulties and they are formidable. There is a challenge. The crux is the timing of closures in the years ahead. The timing should surely be determined now in strict parallel with the provision of alternative hospital facilities for acute cases and for that very high proportion of cases that can be accommodated in the community from time to time but for whom, since the acute symptoms are recurrent, there is no alternative to frequent returns to hospital.
I ask the Minister from her great experience, first, for a repeated assurance—we have had such assurances before—that no closures will in future be made without the provision of suitable alternative beds and facilities. Secondly, and as a necessary companion of the repetition of that assurance, will the Minister give a clear undertaking that the Department of Health itself will monitor, control and approve at the highest level (as Sir Roy Griffiths recommended) the future individual closures of the big mental hospitals?
§ 7.3 p.m.
§ The Earl of Longford
My Lords, when he was very old Mr. Gladstone wrote to Cardinal Manning, who was also very old:As the road declines so it narrows. I am glad that we too should draw near together as we both draw near our end".As this debate draws to its end, I am happy to think that I draw more closely to the last speaker, to the noble Lords, Lord Ennals and Lord Carter, and to other speakers. I should in particular like to express my strongest approval of the last words used by the noble Lord, Lord Thurlow. One can only hope that I shall he equally close to the speakers who follow me—I think I shall be so far as concerns the noble Baroness and the noble Lord, Lord Winstanley. I am more timid in expressing the hope that I shall be able to draw close to the noble Baroness who is to reply. She is so professional and at the same time so 1177 warmhearted, if those are not contradictory terms. I hope that if I cannot draw closer to her, she can draw closer to me.
Community care is certainly the most ambiguous term ever peddled. Up to now it has been somewhat damaging, on the whole. I still believe in that concept, which is a fine one. At some point or other it will prove to have been very valuable. However, up to now it has proved so ambiguous that it has produced a kind of smokescreen or alibi for inanition.
Noble Lords will forgive me for mentioning that wrote a book which came out in the spring which dealt with mentally disordered offenders. It is possible that it has got as far as the Minister opposite. I interviewed a great many people including leading forensic psychiatrists. That was not so difficult because there are not very many forensic psychiatrists—at least not as many as there should be. I subsequently wrote:of all the ambiguities, the concept of care in the community is the most blatant, because it can mean so many different things. Professor Wing of the Maudsley would like care in the community to be linked to existing mental hospitals. Others think of it as involving out-patient care in these hospitals; others see it as being provided primarily by local authorities. Others again think of it in terms of a mental patient returning to the community and being cared for by his family and neighbours".Be that as it may—I wrote the book in the spring—I cannot find a doctor or anyone else who is satisfied with the progress made.
I turn to the point made by the noble Lord, Lord Thurlow, and mention a hospital in my own area which is well known to the Minister. Hellingly hospital at one point had 1,400 mental patients (I think the right figure should have been about 1,000). Last year—I not know that the position has altered much—the number was down to 100 and the hospital was to be closed altogether. One may ask what happened to the other patients. Two hundred of them were in smaller units and the rest had to fend for themselves. That was the situation. That is the kind of situation described by the noble Lord, Lord Thurlow. Those were mental patients generally. Therefore in my conclusion to the book I said that up to now community care has been a farce. Many well qualified people have reviewed and criticised the book and no one has challenged that statement. That is where we are today. We have that concept which is both uplifting and confusing and the result so far is a farce.
When I mentioned Hellingly hospital I was referring to mental patients generally. When one considers patients who are mentally disordered matters become more complicated. Yet the sequence of events can be seen. Through the failure of community care to eventuate, a lot of people are kept in the few remaining ordinary mental hospitals who need not be there if they were in proper community care. As a result, the places are taken up and many people in special hospitals who do not need the security of those special hospitals are kept there when they could be in ordinary mental hospitals. As the places are taken up in special hospitals, people in prison who are mentally disordered are kept in prison. Therefore the evil sequence continues. It all begins with the failure of community care at ground level.
1178 I had wished to say more but I shall have the opportunity to speak further on the subject of patients in special hospitals since I intend to open a debate on an Unstarred Question on 18th November on Ashworth hospital. I am pleased that the noble Baroness will reply to that debate.
There is great disquiet about the future in the special hospitals. There was already disquiet because of the lack of resources, but the new legislation setting up community care officially places more responsibility on the local authority. At present those qualified to advise me with regard to special hospitals express their great disquiet. They believe that they are likely to obtain a raw deal when the funds available from local authorities are sorted out. That is their conviction. Perhaps we may have time to discuss that further when we debate Ashworth hospital.
Much of my information on special hospitals comes from my old friend Peter Thompson. I have referred to him in this House more than once as having done more for mental health than any other layman outside the caring professions—and more than most of those within the caring professions in recent years. At one point in his life he collapsed and went to Broadmoor. He is the only man I know—other noble Lords may put me right—who, having been in one of those awful places, has come out and done something big for the inmates. He has achieved a great deal through the Matthew Trust. He is closely in touch with the special hospitals. He would be the first to refer to the disquiet of the special hospitals that nothing is being done to protect their patients. Some of the funds appear to be earmarked for community care by local authorities. I gave the Minister short notice, which may not yet have reached her, of my intention to ask what can be done about special protection under the new arrangement for those who have been in special hospitals.
Professor Anthony Clare pointed out recently that of the large sums spent on mental health care—although the sums are not too large—the vast proportion goes to those in hospitals or attending hospitals. I believe that over 80 per cent. goes to the hospitals. There are 60,000 people in the hospitals. A much smaller proportion goes to the nearly 6 million people who suffer from some mental ailment or illness outside the hospitals. According to the figures given to me today, £72 a day is spent on an inmate in a mental hospital and 29p a day on someone who suffers from mental trouble in the community.
I agree strongly with the noble Lord, Lord Ennals—he was so moved by my speech that he decided he could not bear to hear more that we must not sacrifice the most vulnerable members of our community. If the Government in their wisdom are setting out on some new economic course—it could not be worse than the present course so we must welcome a change—whatever the success or failure on the economic front, it would be a disgrace if we try to save money at the expense of the mentally ill.
§ 7.13 p.m.
My Lords, I thank the noble Lord, Lord Carter, for giving us the long overdue opportunity—I agree with the noble Lord, Lord 1179 Mancroft—of debating this important and urgent matter. For months we have been nibbling almost daily at the subject at Question Time. It was time that we had a full debate. We are most grateful to the noble Lord for enabling us to do so.
I congratulate the noble Baroness, Lady Jay of Paddington, on her most eloquent maiden speech. I was particularly glad that she focused her words and our attention on AIDS, a subject on which your Lordships' House has great expertise. If the noble Baroness looks at the record, she will find that we have led the other place in ventilating some of the anxieties; and there are many who have expert knowledge of the subject in your Lordships' House. I am sure that all will be delighted that we now have the assistance of the noble Baroness. Needless to say, we shall be delighted to hear her speak on other subjects.
Most of what needed to be stated has already been said. The noble Lord, Lord Carter, is to be congratulated on attracting so many speakers with deep knowledge and wide personal experience of those matters. Some, including myself, are now in personal need of community care, which perhaps adds some weight to our words.
I would have found the Minister's speech immensely reassuring had I believed it. I know that the noble Baroness believes every word of it. I know that her heart and her head are in the right place on the issue. However, having spent almost a quarter of a century in one or other of the two Houses of Parliament, I have heard many reassuring speeches from Ministers for Health of both parties who have later found, for reasons entirely beyond their control, that they could not fulfil their commitments. The problem has always been resources.
The noble Baroness, in her battle for resources—she will have a battle—will have the full support of noble Lords on these Benches, and I suspect from noble Lords on all Benches in this House. I genuinely consider that your Lordships' House believes in community care and wishes to see it in action and working. Regrettably community care is now more of a concept— a very desirable one—than a reality. As my noble friend Lady Seear pointed out in a splendid speech, most of the burden is borne at present by carers. That does not belittle the splendid contribution of a host of voluntary bodies, the social services and other professionals. As has already been hinted in the debate, some resources could come from the report of Sir Bernard Tomlinson. As a true Liberal, I always welcome change although I tend to become suspicious when it arrives. When we had the report of the noble Lord, Lord Flowers, on London hospitals and medical schools, my first reaction was,"No flowers by request". However, on this occasion some of the proposals of Sir Bernard Tomlinson will have to be implemented. There will have to be changes in the hospital provisions in London. We on these Benches support those changes provided, and only provided, that the resources saved—which is the objective—will be poured into community and domiciliary care, as has been promised.
1180 On the size of the problem, I return to a question that I have often asked before. I suspect that I may have put it to this Minister, and to many others. It is one to which the noble Lord, Lord Thurlow, referred recently. Some mentally ill patients will always require long term hospital care. How many long stay hospital beds will be retained? Where will they be? That is important because many of the patients discharged will have to be readmitted. At present, the catchment areas of the big mental hospitals are enormous. People come from all over Britain. When the patients are discharged, into which community will they be discharged? It may be a local community with which they have had no contact. That problem has to be answered. There must be some long stay permanent beds for mentally ill people. How many will they be and where will they be?
Part of the burden of patients who may need to be readmitted and who are later discharged but have difficulties in becoming re-established in the community will fall on general practitioners. The noble Lord, Lord Holderness, raised that point, and he was absolutely right. Are general practitioners now able to shoulder that burden? During my time there have been changes in general practitioners' domiciliary care. In my practising days, home visits took the bulk of one's working time; but now they are becoming a thing of the past. Domiciliary now means the GP's domicile and not the patients' domicile, and everyone is expected to go to the surgery. Some patients, particularly the mentally ill, will be expected to attend the doctor's surgery. They will just not do so; they will get lost and finish up as do many either in a Salvation Army hostel or in prison. That was not the object of the exercise and somehow it must be avoided.
Many noble Lords have referred to the multiplicity of sources from which help in community care forms of one kind or another will come. I heard what the Minister said about the inspectorates which will carefully monitor what is happening. However, my experience has led me to believe that sometimes when many different people are responsible no one person accepts responsibility. Therefore, there will be a need in every district for a single named and well-known individual to act as a community care co-ordinator. That will not be a waste but a saving of resources. It will be necessary that in every district there is someone who can direct the traffic and ensure that all the people are pointed in the right direction. That will be necessary despite the assurances which the Minister has given about other forms of monitoring.
The debate has been interesting, and I too hope that community care becomes the kind of reality for which we have hoped. It could do so but we shall have some hard battles before the war is finally won. I tell the Minister yet again that in her many battles she will have the fullest support certainly of my noble friends and I believe of all noble Lords in this House.
§ 7.22 p.m.
§ Baroness Hollis of Heigham
My Lords, the debate has been full of wisdom, compassion and experience. We have heard moving speeches especially about people with learning disabilities, those involved in 1181 substance abuse and, as mentioned by my noble friend Lady Fisher, of the blind handicapped. I am sure your Lordships will join me in singling out the contribution of my noble friend Lady Jay. Hers was a truly memorable, elegant and informed speech on the problems of those facing AIDS.
The aims of community care are impeccable; that is, to empower clients and their carers to obtain the service they want and need at the time of their choice and in the style of their choice, and not to be pressed into institutional care simply because that is where resources lie. The Secretary of State has warned the Social Services Committee that community care is not a cheap option. Assessment, she said, will:expose areas of unmet need".As the BMA stated in Priorities for Community Care:The key to the success of community care reforms is adequate money … underfunding is the source of the greatest concern to all agencies concerned with the organisation and provision of care".So your Lordships will forgive me, I hope, if I talk about cash. As my noble friends Lord Ashley and Lord Desai have told us, without adequate funding care in the community will be well meaning, empty and ineffectual—and that is at best. At worst it will exploit yet further the carers, the middle-aged women, on whom it rests.
I wish to talk first about cash for clients. The disabled and the elderly rightly remind us that they do not always and necessarily need caring for. It is their lack of money as well as their disability that generates their dependency. They wish to be seen less as victims and more as citizens bearing rights and entitlements to benefits and to basic services which will allow them full and independent lives. In that respect I wish to make two points. First, as many noble Lords have said tonight, disability benefits are pitifully inadequate—two-thirds of the national average income—with which to meet the high outgoings of disability for heating, clothing, food and transport. Together they create a dependency on services which could often be met quite straightforwardly by more cash. In that context we need to reform the social fund. Secondly, as the noble Baroness, Lady Darcy (de Knayth), pointed out, many disabled and elderly people are capable of handling their own cash and care budgets. That has been shown by the Independent Living Fund. Such people tailor their own care packages and, like the adults they and we are, they take responsibility for their own decisions, including making mistakes. I join with other noble Lords in pressing the Minister to safeguard the future of the Independent Living Fund. Can we also save professional costs and empower clients by offering vouchers, perhaps, so that after assessment they become, to use the jargon, their own budget holders? In that way clients will regain control over their own lives.
Secondly, I wish to deal with cash for carers. As my noble friend Lord Murray has eloquently and fully reminded us, most caring takes place within the community. Many of your Lordships have noted that the need for carers is increasing at just the time when the availability and willingness of women to care is reducing. During the next 20 years the number of people over the age of 85 will increase by 50 per cent. 1182 and it will double in the next 40 years. One in four of them will have Alzheimer's disease. Yet carers receive little money and little support Their invalidity care allowance at £32.50 which is meant to be a full-time benefit for those offering over 35 hours a week of care, would buy only five hours of commercial care per week. Furthermore, that allowance is available to only 170,000 of the 1 million or so carers who are effectively full time, as the noble Baroness, Lady Seear, has reminded us. If the carers are over the age of 65 they do not receive it. If one carer offers 25 hours of care to each of two people she will not receive it. The allowance is mean, grudging, inadequate and inappropriate.
Most carers borrow, eat into their own earnings, bite into their own savings. Their own health suffers accordingly. As the Royal College of Nursing has stated:the quality of life for the carer can be more impaired than the person for whom they are caring".As a witness to the Social Services Committee (5th Report) added:caring, of itself, isolates you … it locks you into this relationship. It does not enable you, yourself, to build up the kind of relationship, which in turn will give rise to you being cared for".Carers face an old age of poverty, poor health and isolation. Therefore, as my noble friend Lady Turner, said, we need to move to a carers' benefit at least equal to state pension, in addition to providing decent day, domiciliary and respite services.
Thirdly, I turn to cash for local authorities. It is worth reminding ourselves that care in the community is coming after three years of the poll tax, of cuts and of capping. To my certain knowledge most social service departments throughout the country have closed homes, sacked care staff, reduced grants to voluntary organisations, trimmed training and have halved sheltered housing schemes. There has been serious underfunding of social services for many years. Now, to fund care in the community, local authorities are to receive a special transitional grant made up of two elements: first, the transfer of DSS money which would otherwise have paid for residential care (some £399 million) and, secondly, an additional £140 million for other local authority costs. That is a total of £539 million during the first year of funding.
As many people, including my noble friends Lord Ennals and Lord Desai have reminded us, that sum is far too low. The DSS money transferred assumes a new intake of 20,000 clients per year but everybody, except the DSS, believes that there will be some 35,000 to 40,000 new clients per year. That will mean a shortfall of nearly £100 million almost immediately.
As regards the money for the local authorities, a grant of £140 million, the topping up of benefits to meet private charges will cost £145 million alone, to say nothing of funding the 155,000 new assessments, to say nothing of training and managing staff and to say nothing of developing home and domiciliary care. Therefore, where the Government are providing nearly £539 million, local authorities almost certainly need £828 million, a shortfall borne not by the local 1183 authorities but by the most frail members of our society. Incidentally, that is a shortfall in transitional grant which will grow larger each year.
Therefore, local authorities are being seriously and substantially underfunded by perhaps 40 per cent. That problem is compounded, as my noble friend Lord Rea said, by the fact that they are having to spend 75 per cent. of their entire grant in the private sector.
That has several perverse effects, some of which have already been mentioned this evening. Quality residential care costs money. If local authorities seek to push down the price by block purchase, as the Government have suggested, to avoid topping up benefit shortfall—whatever that may do to choice—then the private home will inevitably make its savings from shared rooms, from using YTS trainees as night staff, from using unqualified aides to dispense drugs, cheaper food, lower standards of cleanliness and perhaps the ultimate risk of neglect or abuse. And yet, if local authorities do not push down those prices they will have to pay to top up benefits from grants which nowhere match them.
The requirement to spend 75 per cent. in the private sector is perverse in another way because by privileging the private sector in that way it reinforces the use of residential care, for the private sector does not offer day or domiciliary support. Therefore, on the one hand there are residents with low dependency going unnecessarily, reluctantly, into expensive private residential care, who could and would prefer to be maintained at home, while at the same time clients with high dependency—for example, dementia—are refused admission to private homes because they cannot afford to care for them. Those people are wandering the streets.
It is worse than that. The DSS money for residential care for most metropolitan and London authorities will be less than 75 per cent. of the total grant. That means that the £140 million earmarked for local authority services—home care, assessments and so on—will be eaten away by payments to the private sector for costly and inappropriate residential care in order to comply with that 75 per cent. rule. Money will be thrown at residential care not because it is appropriate but because it is private. Will the Minister please agree that the 75 per cent. rule should apply only to DSS transferred monies and not to the entire grant?
For local authorities there is an underfunded grant; there is an underfunded grant perversely hijacked into private residential care. And there is a third problem; namely, the distribution of the grant itself. Many elderly folk from the inner cities are in private homes outside the boroughs; for example,22 per cent. of those over 85 from Hammersmith and 20 per cent. from Manchester. The authority from which those elderly people come must pay the bills but the authority in which the private residential homes happen to be situated will enjoy the benefit of the grant. That is deeply unfair and perverse. Will the Minister please correct the formula? As the Permanent Secretary was alleged to have said to his 1184 staff, "If you are not now confused by community care funding, that is because you are not thinking clearly enough".
Finally, community care is meant to be a seamless service interleaving hospital and social care. As hospitals prepare for trust status they seek to increase their efficiency and profitability by speeding throughput; in other words, by exporting their patients—and 43 per cent. of acute beds are occupied by the elderly—to social service care.
East Anglia's regional health authorities simulated the workings of the internal market in health care in an exercise called "Rubber Windmill". After only a couple of years of simulation that health market crashed, triggered by a cut in social service budgets, cuts which are occurring every day of the year. Hospitals fear that they will not be able to discharge costly patients: social services fear that their budget will be pre-empted by costly hospital discharges. Unbelievably, at just this point in time when we need a seamless service, the Government have seen fit to remove elected local authority members from district health authorities, fragmenting the planning of care at just the time when co-operation, co-ordination and joint planning are surely essential.
If, as Mrs. Bottomley rightly anticipates, the policies of care in the community will expose areas of unmet need—those are her words—then those needs can only be met by cash for clients, for their carers, for voluntary organisations and for local government. Will adequate funding be forthcoming? It seems unlikely and yet none of us should tolerate for the elderly and disabled of our community what we would not tolerate for our own elderly parents or handicapped children.
Properly funded care in the community could transform the lives of hundreds and thousands of our fellow citizens, some of the most frail and vulnerable in our society. In that case, we would welcome it with all our hearts—I know the Minister would too. Without adequate funding, we shall see care in institutions replaced not by care in the community but by little or no care at all. We have a choice. What choice will we make? What will the Government do?
§ 7.37 p.m.
§ Baroness Cumberlege
My Lords, with the leave of the House, I should like to respond to this debate.
I would like to thank noble Lords who have taken part. There have been many interesting, informed and detailed debates on the proposals contained in our White Paper Caring for People. Tonight was no exception. I would like to thank the noble Lord, Lord Carter, for his initiative in stimulating this debate and in attracting so many knowledgeable speakers. I too would like to pay my tribute to the noble Baroness, Lady Jay of Paddington, whose thoughtful and perceptive contribution concerning HIV and AIDS was, we know, based on a great depth of expertise. It was of no surprise to those of us who have worked with her to hear her speak so eloquently. Of course, we welcomed her to this House just a week ago. I shall take up her point with my right honourable friend the Secretary of State to ensure that AIDS and HIV 1185 services are included in the review of specialist services in London. I hear too what the noble Baroness has to say on grants to voluntary organisations.
Community care is a modern cliché for a reality that has been going for all time. It is a philosophy which has been preached and practised for many decades but the preaching has often been better than the practice. It began with Victorian compassion but more recently a realisation that old workhouses were not suitable places to care for vulnerable people.
Community care is now generally understood to encompass care and support for all those people who need it due to frailty, disability or illness. It also means giving individuals more say and choice over their care and ensuring that services are tailored to meet their needs.
The great difference between institutional care and community care, and more particularly care in one's own home, is privacy. When authorities are invited in the door must be knocked, the occupier must be able to say "Welcome","Wait","Come back later" or "I just don't need you today". In institutions people requiring help arc on the staff's territory and the tables are turned; however kindly the staff may be, there is that great difference.
The concept of the state looking after people from the cradle to the grave with barely a thought for individuality is outmoded. It was always patronising and intrusive and flew in the face of human nature. In more recent years there grew up a notion that people fulfilled themselves by casting off any problems that might impede their progress. Old, handicapped, ill or dying relatives and friends could be jettisoned in the pursuit of personal ambition. But this was to forget human nature. People are warm, generous and kind. They instinctively want to look after relatives and friends who are in need, but the time may come when they cannot continue alone. It is then that there is a sense of personal failure, and the Government with their agencies must assist, adopting a light touch, careful not to intrude on these very special relationships.
As with all care, the tortuous path to be trodden is between providing for the needs and wishes of the person and prescribing for the desires of relatives, friends and carers. That immensely difficult task requires agencies to work closely together, but the ultimate responsibility is for local government social services departments.
We are all foolish enough from time to time to try to advise people how to conduct their lives—and we are nearly always wrong. Social workers are well trained, but to arrange people's lives is not an exact science and they may well make mistakes; but we will minimise mistakes by having the individual, their carers and other professionals who can enhance the quality of the decision being made.
A number of noble Lords raised the question of carers and some of the speeches I found extremely moving—the noble Baronesses, Lady Seear, Lady Turner of Camden and Lady Hollis, the noble Lords; Lord Carter, Lord Murray of Epping Forest and Lord Redesdale, and my noble friend Lord Holderness.
1186 The Government recognise the important role played by informal carers in the community. That is why they feature strongly in the new Act. We have demonstrated our commitment by the enhancements we have made in benefit provision and in our support for carers' organisations. Apart from social security benefits, which have risen from £4 million in 1978–79 to £213 million this year—a point made by the noble Baroness, Lady Hollis—we have spent over £2 million in supporting national carers' organisations and carers' initiatives since 1990.
I hear the plea of the noble Lord, Lord Murray, not to shoot ourselves in the foot and the specific points made by the noble Baroness, Lady Turner of Camden. I shall read Hansard with great interest on that subject.
Reluctantly I shall have to pass over the issues of the inflexible working of the present system and the whole question of choice. I am anxious to answer the points made by your Lordships. There are two other aspects I want to highlight this evening. The first is work for the voluntary sector. The Government have never believed that local authorities are by any means the only appropriate body to provide the services that people want. Many innovations and advances have come from the private and voluntary sector. The Government believe that the best should thrive where people are free to choose. I join with noble Lords in my appreciation for the voluntary sector, which works so effectively in so many fields.
At the moment a high proportion of home care services are run by local authorities and we particularly want to see the private and independent sector develop a new range of services in home care. I cannot share the despairing views of the noble Baroness, Lady Hollis. Some doom scenarios were actually flaunted 10 years ago when we had a negligible private sector. But we have seen that sector grow in number. We have seen the quality improve. We have seen the scope expand. We know that the sector provides choice for people in many parts of the country and are confident that with the incentive we shall be giving, domiciliary services will grow in a similar way.
I turn now to funding. I listened attentively to the many fears expressed by your Lordships on the question of funding. But I am absolutely sure that whatever provision is made by any government, there will always be claims that it is inadequate. For those of us with experience of the social services, voluntary organisations and the health service, we know that the work attracts people of great compassion and humanity and we are filled with admiration for the work that they do. The more they do, the more they find needs doing. It is difficult to legislate the limits where the need begins and ends. Each person sees the threshold in a different place.
Without a doubt we have seen the budget burgeoning. The noble Lord, Lord Ashley of Stoke, felt that the £539 million secured by my right honourable friend the Secretary of State was inadequate. But Peter Smallridge, the president of the 1187 Association of the Directors of Social Services, praised my right honourable friend for doing so well. He said,in the context of the present economic climate Mrs. Bottomley has done well to get this money and to give us specific funds for the second and third year of implementation".The noble Lord, Lord Ashley of Stoke, proffered me a proposition which sadly on this occasion I shall decline. Perhaps I should have the noble Earl, Lord Longford, as a chaperone.
I should like to pay tribute to the great opus the noble Earl published in the spring. It is a truly remarkable book and should be on the shelves of all those interested in this subject. I look forward to the future debate on special hospitals which he is initiating in November.
The noble Lord, Lord Carter, made a suggestion that ring-fenced money might disappear in the second and future years. Local authorities will buy care for people in the first year of the policy. They will need to continue to make payments for the same people in the second year of the policy, thus the first year's money will effectively remain earmarked for community care in future years.
The noble Baroness, Lady Hollis, and the noble Lord, Lord Desai, raised the question of the so-called dispute with local authorities and the alleged shortfall. We have no evidence that there will be a shortfall. The noble Lord, Lord Ennals, highlighted the difference in figures from local authorities even within this debate. The social security transfer represents a calculation of what the Department of Social Security would otherwise have spent supporting people in residential care and nursing homes if the current arrangements had remained. We do not know how many people will be needing care in the forthcoming year. The formula for making the calculation was discussed in some detail with the local authority associations and has been published. But we shall be publishing fuller details of the actual calculations when other details of the public expenditure survey have been announced.
I turn now to the question of long-term ring-fencing which was raised by the noble Lords, Lord Ashley of Stoke, Lord Desai and Lord Ennals, and the noble Lady, Lady Kinloss. We believe that local authorities should have discretion to use their resources to meet the needs of local people to whom they are accountable. We do not therefore favour long-term ring-fencing. We are proposing a special transitional grant specifically to recognise the special circumstances that apply in the initial years of an authority's new responsibility.
The noble Lord, Lord Northbourne, asked what groups fitted within the ring-fence. The ring-fence money must be spent on adult social services. That will cover all the groups mentioned by the noble Lord and the noble Lady, Lady Kinloss. I shall write to the noble Lord, if I may, on his other detailed questions.
The noble Lords, Lord Carter and Lord Ennals, my noble friend Lord Mancroft, the noble Viscount, Lord Falkland, the noble Baroness, Lady Masham of Ilton, and others were concerned about the ring-fencing of the alcohol and drug misuse services. As the noble 1188 Viscount pointed out, the proposal to ring-fence the alcohol and drug services element of the social security transfer was taken at a time when no transitional ring-fencing was proposed for the totality of community care.
I know that my noble friend Lord Mancroft has grave concerns for the private and voluntary sector, and that is why we are introducing the requirement that 75 per cent. of the transitional money should be spent in the private and voluntary sector. We believe that local authorities have the same responsibilities for this client group as for any other. It is my belief that they will not be dilatory in their duty. However, we are issuing guidance to local authorities as a belt and braces measure. I have taken the opportunity to draw on the expertise in your Lordships' House to advise Ministers in that task.
The noble Baroness, Lady Darcy (de Knayth), has long been a champion of direct payment. I have no wish to be blinkered or intransigent, which I believe were her words. I am therefore going to raise the matter with my right honourable friend. But there are of course issues of financial control here.
Since its inception in 1988, spending through the Independent Living Fund has risen from some £5 million to a figure of £97 million this year. That illustrates the level of growth. The Government have made clear their commitment to maintaining a fund which supports the most severely disabled. Ministers are currently considering how this commitment will be implemented and will make an announcement in due course. Current beneficiaries will continue to receive payments from a successor body after April 1993. Higher payments may be made to individuals whose care costs rise, but it would not be reasonable to expect that these payments should meet all the costs of care in every case. On the detail of DLA, I shall certainly talk to my noble friend Lord Henley as the noble Baroness suggested.
The noble Lord, Lord Rea, asked whether the 75 per cent. proposal will mean local authority homes having to close. Local authorities already fund residents in their own homes. These will be unaffected by the changes next April. The additional funding is to meet authorities' new and not existing responsibilities. The noble Lord also asked if we have set a limit on the amount of new money which can be spent for those under 65 or in any client group. The present proposal is that there is no limit. It is the freedom of local authorities to decide
§ Lord Rea
My Lords, I thank the noble Baroness for allowing me to intervene. Is it not the case that local authority homes gain from the housing benefit that the residents of those homes get from the Department of Social Security? Is not that part of the money which the department is passing over? I believe it was £399 million but now I understand it is £400 million plus which the Government, in their munificence, are passing over to the local authorities.
§ Baroness Cumberlege
No, my Lords. The present proposals are that from 1st April it is only new people coming into the service who require special care in 1189 private nursing homes and residential homes. So that does not actually affect existing people in local authority homes. They are secure.
§ Baroness Cumberlege
My Lords, the social security department will do as it does now. We are talking about a transitional period of three years. The responsibility for the inspection of residential care homes, which was another point raised by the noble Lord, is one that local authorities have had for many years. This Government though have extended that responsibility since April 1991 when the new arm's-length inspection units were set up. Local authority-run care homes have been subjected to inspection in the same way. Having visited some of these inspection teams, I am very impressed with the independence that they are exercising.
The recruitment and training of community nurses is a matter for individual health authorities. We have drawn the attention of authorities to the implications of the Act. It is very pleasing to see the number of nurses, which has grown from 17,000 to 19,000 between 1981 and 1990. The noble Baroness, Lady Seear, was concerned also about the inspection of residential care homes, but I hope that I have covered that point to her satisfaction. She also raised the question of the relationship between the Department of Health and the Department of Social Security. I am pleased to tell her that there is a very close collaboration between my department and the Department of Social Security at all levels. She may have been referring to the social services and already I have addressed that issue.
The noble Lord, Lord Rix, as he told us, has had to leave early tonight. I should like to say how good it was to see him here. I did not actually witness any deleterious effects from his recent operations. I shall write to the noble Lord on the very specific points that he raised. The noble Baroness, Lady Fisher of Rednal, whom I know as a doughty fighter for some of the most vulnerable people in society, raised several questions which I should like to take up personally with her. But with regard to the Housing Corporation, she may be unaware that it makes available substantial sums for special needs housing provided by housing associations. Revenue support has risen from £38.5 million in 1990– 91 to £95 million this year. It supports a total of 40,000 units.
My noble friend Lord Holderness so rightly focused our minds on the challenges of those leaving hospitals and particularly the whole issue of loneliness. Recent research though, which is described as the Taps Report, has shown that the social networks of those who have left hospitals—the study considered 498 long-stay patients—remain stable in size, but there was a great reduction in contacts with hospital staffs and patients. But there was an increase in the number of friends and the former hospital patients got to know ordinary members of the public often through pubs, social groups and meeting 1190 neighbours. Many of these people became friends. I believe that there is a lesson here for those local authorities to ensure, when they do suggest to long-stay patients that they should live in the community, that enough preparation is done. I am convinced that when that preparation is thorough then it is a very successful thing to be doing.
The noble Lords, Lord Northbourne and Lord Thurlow, shared their conviction that people leaving hospitals are abandoned. But all the evidence that we have is that homeless mentally ill people are not those who have been recently discharged from long-stay hospitals, but are people who have had little or no contact with psychiatric services. As regards general homelessness, this year we are committing £20 million to the homeless mentally ill initiative which is designed to offer accommodation and access to appropriate care to people with a mental illness who are sleeping rough in central London where the problem is most acute. We have, of course, also set up a task force which featured in yesterday's Starred Questions and which I hope will go a long way towards meeting the requirement suggested by the noble Lord, Lord Thurlow, for tackling the problems that he mentioned. I respect greatly his personal experience. If again he should feel that a meeting will be useful I shall be more than willing to offer one.
The noble Baroness, Lady McFarlane of Llandaff, spoke about nursing. I think it is so right not to forget our proud nursing history. This country has had a major impact on nursing services around the world, not least through the distinguished career of the noble Baroness. She and the noble Baroness, Lady Seear, are right to highlight the crucial role of district nursing and the need to ensure that this great resource is integral in community care planning. She may also be aware that we have a task force group now looking at many of the issues which she raised and also at the issues raised by the noble Baroness, Lady Masham of Ilton. That task force is due to report before Christmas.
The noble Baroness, Lady Masham of Ilton, quite rightly stressed the links between acute and community services. But for the purposes of today I plead the fifth amendment and I am going to reserve my views on London for another debate which I suspect is not too far away. I hope that I have covered most of the points raised by the noble Lady, Lady Kinloss, but perhaps I could endorse her point on preventing accidents which is a key area in the Health of the Nation White Paper.
The noble Lord, Lord Winstanley, asked how many long-stay beds will remain and where will they be. It is impossible for me to answer that. It will depend on local circumstances and local decisions. But one thing I can assure the noble Lord is that they will be smaller, appropriate and knitted into the local community. There are plenty of examples of that happening already in the country. I share the noble Lord's aspirations for community care and I very much welcome his support. I hope that I have replied to the noble Baroness, Lady Hollis.
To conclude, I must repeat the Government's firm commitment to community care. Their record and 1191 their proposals demonstrate that amply. I do not underestimate that care in the community presents very great challenges to very many people. It calls for flexible and imaginative thinking. It calls for a move away from familiar but perhaps unresponsive forms of service delivery. It calls for new ways of working together. The Government recognise that. By announcing now our proposals for funding over the next three years we are helping authorities to plan in the longer term. We are closely monitoring the progress of social services and health authorities in preparing for new arrangements. We have set up a multi-disciplinary support force of experts in the field to assist authorities to develop and share good practice.
The implementation of our policies will set the groundwork for the effective development of care in the community in a coherent responsive way. This will not happen overnight. It is a very long-term strategy, but not for nothing was our White Paper subtitled,"Community Care in the Next Decade and Beyond". Over time, the benefits to people who need support, and those who care for them will, I believe, become increasingly evident.
§ Lord Rea
My Lords, before the Minister sits down, can she give a word of comfort to the 2,000 mainly voluntarily-run units around the country which provide rehabilitation services for those who suffer from drug and alcohol misuse? I gather that they will have to apply to multiple local authorities for their money which I think that they will find impossible. The Minister has not yet given us any answer on that point, so has she any comments to make on it now?
§ Baroness Cumberlege
My Lords, I have tried to go as far as I could tonight. I have told your Lordships that we shall be sending out guidelines to local authorities to make them aware of some of the issues. I believe that they are aware, but I have involved some Members of your Lordships' House who have an interest in this subject and who have spoken tonight. I shall no doubt be addressing that particular subject in the months to come.
§ 8.1 p.m.
§ Lord Carter
My Lords, I am very grateful to all those who have taken part in this excellent debate. We have heard an excellent maiden speech from my noble friend Lady Jay of Paddington and there have been notable contributions, not least in the wind-up speech from my noble friend Lady Hollis of Heigham.
I venture to suggest that no institution anywhere can discuss community care with greater expertise and authority than your Lordships' House, and today's debate has certainly borne that out. I should like to take up many points, especially those arising from the Minister's two speeches. I believe that I have some 30 minutes in which to reply to the debate, but your Lordships may relax because I am well aware of the conventions at this time in the evening. Therefore, I simply repeat my thanks to all those who have participated and I beg leave to withdraw my Motion for Papers.
§ Motion for Papers, by leave, withdrawn.