HL Deb 30 June 1994 vol 556 cc969-82

8.23 p.m.

Lord Stallard rose to ask Her Majesty's Government, in the light of the report by the Alzheimer's Disease Society, what is their policy on the provision of National Health Service psychogeriatric continuing care beds.

The noble Lord said: My Lords, I regret very much the circumstances that have prevented my noble friend Lord Ennals from being able to ask this Question himself. We all wish him a speedy recovery and we hope that he will be back with us as soon as possible.

My own interest in this sad and tragic problem goes back many years to when I was privileged to serve as a constituency Member in another place. I have tried to maintain that interest since coming to your Lordships' House. Through all those years I have watched the Alzheimer's Disease Society grow. I have the greatest respect and admiration for how it has developed into a competent and caring unit providing us and many others with reports and information on all the aspects of this tragic disease as well as helping and dealing with carers and sufferers in all parts of the country. We owe the society our gratitude and support for the difficult tasks it has taken on.

This Question tonight gives me an opportunity to acquaint your Lordships with the findings and concerns outlined in the society's report National Health Service Psychogeriatric Continuing Care Beds, published at the end of last year. The report was also one of the subjects discussed by the House of Lords all-party group on ageing, when the executive director of the society, Harry Cayton, addressed our group a couple of months ago.

I shall start with the size of the problem. There are approximately 600,000 people with dementia in the United Kingdom. About 70 per cent. have Alzheimer's Disease. The term "dementia" is used to describe a group of illnesses which are the cause of progressive decline in the ability to remember, to learn, to think and to reason. Those people with severe dementia or who are in the later stages of Alzheimer's disease need continuing care where skilled nursing and regular medical supervision is available. This need will grow. We have discussed at length in a number of debates the demographic changes that will be responsible for that growth and for all kinds of problems. By the year 2021 there will be almost 900,000 people with dementia living alone in the community. That is a fairly sizeable problem that we should be tackling as soon as possible.

The Alzheimer's Disease Society believes that to meet this need there should be sufficient National Health Service continuing care available in every district. National Health Service continuing care beds are invaluable to carers in providing continuity, flexibility and reliability in terms of environment, staffing and high quality care for their relation or friend with dementia who can no longer be cared for in the community. In supplying continuing care which is free of charge, the health service has traditionally been important also in providing a real choice for those carers who cannot afford long-term care in a residential or nursing home run by the local authority or the independent sector. However, despite local authorities having a duty to provide continuing care for the chronically sick and terminally ill, the society's evidence is that the health service is withdrawing from this role at an alarming rate.

The report surveyed the level and type of continuing care provision supplied by 64 district health authorities. It had three main findings: first, 56 per cent. of those: DHAs were providing fewer beds than in 1990, 31 per cent. were providing more beds and 13 per cent. the same number of beds; secondly, there was a wide variation between different district health authorities as to the level and type of continuing care provision; thirdly, at least three authorities—5 per cent.—had no psychogeriatric continuing care beds available for the care of elderly people with dementia. Further evidence suggests that there has been a 40 per cent. fall in the number of continuing care beds over the past five years.

One significant development arose from the health ombudsman's report on the Leeds health authority. In February 1994 the health service commissioner published a special report on the failure by Leeds health authority to provide long-term National Health Service care for a brain-damaged patient. In perhaps the most revealing comment of the investigation, the. Leeds health authority said that in not providing any long-stay medical beds in hospital or having contractual arrangements for such beds in private nursing homes, they were no different in that respect from most other health authorities".

That is a damning indictment of the present situation.

While reductions in the numbers of National Health Service continuing care beds are in themselves worrying and important, the society feels that a number of other key issues are highlighted by the health service's abdication of its responsibilities in this area. There are serious territorial inequities as to whether people with dementia who have high needs and dependencies have access to suitable and sufficient psychogeriatric continuing care beds in their area.

There is a lack of accountability in this area of health service planning. More often than not, users, carers and voluntary organisations are not consulted adequately on health authority plans for closures or reductions in long-term care. Meanwhile the Government refuse to take effective action against those DHAs which are not shouldering their responsibilities in this area. If continuing care beds continue to disappear against the wishes of these people; if health authorities are accountable neither to the Department of Health nor to the community they serve, who is to ensure that they meet their responsibilities?

In those areas where people with dementia are denied access to National Health Service continuing care, carers are having to find and fund the care themselves. Most concern has been expressed by carers about the stringent means test for long-term care in a residential or nursing home. While the Alzheimer's Disease Society is not opposed to some people making a certain contribution to the costs of caring, a policy which places the financial burden increasingly on older people and which increases the likelihood of making carers casualties of caring, makes no sense on either social or economic grounds.

The report notes that it is the harshness and the impact of the means test for such care which has caused the greatest alarm among carers of people with dementia. One of the most bitterly contested aspects of the means test rules is that, where a resident of a residential or nursing home has savings of between £3,000 and £8,000, local authorities have the power to sequestrate the whole of a person's occupational pension to pay for the costs of care.

There is a great deal of concern about the obvious impact that this is having on elderly couples of modest means, but particularly on women carers who have been reliant on their husband's occupational pension for a significant proportion of their income. Although they are entitled to income support in such situations, it is clear from those cases which have come to light that the wife's income is substantially reduced and that they face serious financial difficulties as a result. As one carer puts it: As I have no occupational pension myself I have had to apply for income support which has been granted, but I am left in much poorer circumstances and I have to meet heating bills, electricity, telephone and any repairs to the house". Most of the women who have contacted the Alzheimer's Disease Society about the effect of the occupational pension rule have had to rely on their married woman's pension for income after their husband has entered long-term residential or nursing home care. These women have pointed out that they are therefore worse off than if they had been widowed or had divorced their husband. In both cases their pension entitlement would be greater. Therefore, these women would appear to be victims of both the system by which the state pension is administered and the rules by which their husbands have been means tested. Neither recognises this particular financial need. Of course, there are some men in similar circumstances, but by and large it is women who have had to bear the brunt of this kind of problem.

This feeling of injustice is compounded by one of humiliation that after many many years of working and caring and of priding themselves in their financial self-reliance and good housekeeping, they now have to claim benefits to make ends meet. That can be very hard on a large number of people in those circumstances. It is estimated that there may be as many as one in 10 women placed in that invidious position. It is well documented that among the over-65 age group women are even less likely than men to have built up significant pension entitlements of their own. The rules relating to the treatment of occupational pensions therefore discriminate indirectly against women over 65.

In response to the growing concern expressed by the carers and by the society about this particular aspect of the regulations, the Government have issued guidance to local authorities asking them to "bear in mind" that, where the income of the spouse at home is significantly reduced by the sequestration of the occupational pension, they can use their discretion to award an increased personal expenses allowance so that a proportion can be used to support the spouse. This personal expenses allowance is presently set at £13.10p per week.

Despite the guidance decisions, other decisions have been taken which worsen rather than ease the financial situation of the carer. Indeed, increasing the personal expenses allowance will have financial implications for the local authority. That means that it is not in the interests of the social services departments to operate any guidance rule for the benefit of carers—in other words, they will do nothing about it despite the Government's attempts to issue guidance.

In sum, the report feels that the present system of financial hardship arising from the treatment of a resident's occupational pension is flawed. Until carers have a preserved right to a proportion of the occupational pension, social services will continue to apply the rules in their own favour. While recognising that it will not ensure financial security for all carers in this position, nor the need for some to claim income support, the society favours reform of the regulations which would give women a preserved right to 50 per cent. of their husband's occupational pension when he enters long-term care in a residential or nursing home.

In response to the concerns expressed in the report about the availability of National Health Service continuing care, the Government have reaffirmed that district health authorities have a responsibility to provide such care. The noble Baroness who is replying to this Question this evening, herself said last February: Our policy is quite clear: if people need professional healthcare —and that is a judgment made by a clinician—they should get that care within the National Health Service."—[Official Report, 22/2/94; col. 513.]

Similarly in a letter of 25th May 1994, the Parliamentary Under-Secretary of State for Health, John Bowis, stated: As I have stressed in our correspondence on this issue the NHS has a responsibility to provide long-term health care for those who need it for reasons of ill-health".

That is clear enough. Despite those assurances, it is the duty of the district health authorities to provide long-term care. The experiences of carers of people with dementia suggest that such rhetoric does not match the reality of the difficulties occurring in this area of health care. They are just so many words which are not being implemented at grass roots.

The discrepancy between the evidence collected by the society and the reported results of the Government's monitoring, merely highlight the need for further investigation and for a more open public debate on the issue.

In view of the growing numbers of people with dementia this need will increase. In this context, National Health Service continuing care beds should be available in every district for those people who need them. The society is being constructive as well as critical. A useful model which it endorses was proposed by the Royal College of Psychiatrists in 1989, when the RCP recommended that DHAs should supply one continuing care bed for every 1,000 people over the age of 65 in their catchment area. It is a matter of concern that the society's report should reveal that 70 per cent. of DHAs are not aspiring to this sort of provision. I hope the noble Baroness will be able to enlighten us on that point.

The society is conscious of the need for the DHAs to decide such provision on the basis of local needs and resources. Of course we accept that. However, it is felt that the Government should not use this as an excuse for inaction where authorities are clearly not performing their duties. The report therefore urges the Government to issue stronger guidelines to district health authorities reminding them of their duty to provide continuing care; to clarify where accountability for continuing care for people with dementia lies; to issue further guidance to district health authorities on consultation procedures involving users, carers and local voluntary organisations in the future planning of health services; and to set out and consult with interested parties their future policy and objectives on psychogeriatric continuing care for people with dementia.

Before I conclude, perhaps I may give an example which encapsulates most of the issues. It is an illustration of the typical problems that are encountered by many carers. I am referring to the case of a lady who has; cared for seven years for her husband, who has Alzheimer's disease. He is 72 and she is 65. While caring for her husband at home, that lady has received limited help from the National Health Service in the form of day care and occasional respite care. She has had to continue caring for him at home because of the lack of NHS continuing care in the North Yorkshire area. In April her situation reached crisis point. Her husband was admitted to hospital in an emergency because of her mental and physical state and his own deterioration. Her GP agreed that she could no longer cope.

That month that lady wrote to the Alzheimer's Disease Society in desperation saying that she was waiting for an assessment to see whether her husband could be admitted into long-term care. She was anxious that that should be funded by the NHS since she could not afford the cost of a place in a residential or nursing home. She said: If I had to place my husband in private care I would be in the undignified position of receiving DSS support. I would be left with a demeaning £60 per week to live on after all these years of caring".

That lady wrote to the society again in May. Things had got so bad that she had tried to commit suicide. Her letter was written a few days after her discharge from hospital. She wrote: After being driven to breaking-point and still no firm promise of an NHS bed for my husband, whom they had taken into care because of my mental state I just couldn't take any more".

The society wrote to the area authority and to North East Yorkshire Healthcare, the trust, on her behalf asking them to intervene and to find her husband suitable care. In its reply the trust said: If you would like to assist [this lady] and many other carers like her … who at present do not have the hope of long-term care for their relative, I would ask you to make the points you raise in your letter to the North Yorkshire Health Authority. You may also like to ask them to tell you how the level of provision for elderly mentally ill people in the area compares with other nearby areas".

That lady and her husband are still waiting for an NHS bed. That case is not unusual. It is a sad problem and there are far too many such cases throughout the country.

Finally, I should like to remind the House of what the Secretary of State, the right honourable Mrs. Virginia Bottomley, said in response to media reports of age discrimination in the treatment of people by the health service. She said: The founding principle of the National Health Service shines like a beacon in our society. The NHS provides services for everybody, on the basis of their clinical need and regardless of their ability to pay. There are no exceptions to that rule, whatever the age of the patient… It is the duty of all health authorities to ensure that people of all ages have access to acute care, and that specialist care is available for those who suffer with chronic: conditions due to the ageing process".

I can readily agree with all those sentiments. What I and the Alzheimer's Disease Society would like would be for the Government to begin to implement those sentiments in their policies and to tell us what their plans are for the immediate future.

8.43 p.m.

Lord Addington

My Lords, when I started reading up on this subject in preparation for this debate, the main thing that struck me was how frightening Alzheimer's must be not only for the carer, but also for the person who starts to suffer from that disease. If my reading is correct, the person concerned goes through a process of losing layers of memory and of ability. In the first stages, the sufferer will be aware of that. He or she is often aware of starting to deteriorate mentally but they know that they cannot do anything to help their condition. After that incredibly worrying and disturbing process, the sufferer then starts to lose all functions, layer by layer. Sufferers cannot organise themselves and they lose their social skills. They do not know, for instance, whether they are correctly dressed for going outside their house.

While that process is going on, the carer, on whom the noble Lord, Lord Stallard, concentrated, will suffer on two levels. They will be caused distress and they will suffer the stress of watching the sufferer—usually their partner —deteriorate. That leads to incredible emotional problems. The partner can do very little to help other than deal with day-to-day tasks. Those tasks will progressively become more difficult over a long time frame. We are dealing with couples of generally similar age. As the sufferer becomes less capable of coping with the problem, the problems for the carer will increase in severity. I can envisage few more nightmarish scenarios than that. We are talking about a situation that will get worse as one gets more feeble.

There will always be variations, but surely the Government should make a point of providing sufficient cover and help for the simple reason that we cannot reasonably or realistically expect anybody 1o cope in the latter stages. We must remember the emotional stress that is involved when dealing with a loved one who is deteriorating in such a way, and the physical difficulties of so doing.

The idea of care in the community and of trying to keep people in their own homes is laudable in most situations, but surely we are talking about terminally ill people. People do not get better from Alzheimer's disease. When the Minister answers the debate, I hope that she will be able to give us some guidance about how the Government can help those people who, as the noble Lord, Lord Stallard, said, find their incomes being cut as their partner is placed in the type of care that they have to have. In most cases, the sufferer does not go into care because the carer wants to put them there but simply because they have to have it. Surely some arrangement can be made—it need not necessarily involve very much more money—so that the carer can get more support if he or she is dependent on the spouse's pension. Surely something can be done along those lines.

Can the Government give some form of guarantee about the provision of effective respite care during that period? Someone who is caring for a sufferer for, say, five days a week may be able to cope for very much longer than someone who is caring for a sufferer for seven days a week. That may well lead to a far better balanced, more rational and more efficient approach to caring than if the carer was cooped up for long periods. It is not unusual for the carers of those with Alzheimer's disease to have to cope in that way. Any carer who is constantly cooped up with a problem will react against it. That might lead to a lack of sufficient care or even to abuse of the sufferer. Such problems tend to be enhanced if the carer feels trapped. That is a perfectly natural reaction.

I do not think that I can add very much more to the debate. As always, the noble Lord, Lord Stallard, was very thorough in giving us the hard facts of the matter. I hope that the Government can give us some idea of their thoughts about providing support to carers in general, as well as, more particularly, to the carers of those with Alzheimer's disease.

8.48 p.m.

Baroness Jay of Paddington

My Lords, I thank my noble friend Lord Stallard for tabling this Unstarred Question and particularly for standing in for our noble friend Lord Ennals. I join my noble friend in hoping that we shall see our noble friend back with us soon. It is also important that I thank the Alzheimer's Disease Society for its important report which has stimulated today's debate.

As well as highlighting the acute anxieties of one patient group, the report has drawn attention to some serious general problems about the present provision of continuing care. The noble Lord, Lord Addington, referred to those general problems. I shall speak briefly about a few of those problems, and shall try to phrase my comments in the form of supplementary questions so that the Minister may be able to address some of them in her reply to my noble friend.

First, it is probably worth repeating the basic facts that were given by my noble friend in his extremely comprehensive introduction. Two points stand out. The first is that nearly 70 per cent. of health authorities now fail to provide the minimum number of psychogeriatric beds recommended by the Royal College of Physicians, and more than a half of health authorities provide in 1994 fewer beds than they did four years ago in 1990.

As my noble friend pointed out, we all know the demographic position in this country and how demand is clearly rising. So it is particularly surprising that at this time we are seeing less special provision of beds than we did four years ago. It seems clear that there must be a connection here with the introduction of the internal market and the reorganisation of community care. After all, as we all know, geriatrics, and psychogeriatrics in particular, have always been Cinderella services in the health service. Few people have wanted to work in them, and there have been relatively few specialist physicians. How much more so now, in 1994, when we see hospital trusts having to compete to achieve better star ratings for rapid patient throughput, and to try to balance their budgets by concentrating upon care which is economically efficient. I wonder to what extent the Minister thinks that the introduction of the health market has exacerbated the care problem in this area which we all know has always been financially difficult for local health authorities, but which now seems to be becoming almost scandalous.

The Alzheimer's Disease Society Report and my noble friend have drawn attention to the very patchy provision of continuing care, and the very different ways in which duties are interpreted at a local level. They have both called for more precise guidance from the Department of Health about minimum standards, and more direction from the centre. But of course that direction from the centre I see as one of the victims of the reorganisation. Even responsibility for care from the centre is, as my noble friend said, often denied, because chief executives and trust chairmen are given their heads. In many ways, that autonomy is welcome; but with issues like Alzheimer's Disease, which are unpopular and create special problems for local health authorities and local trusts, clear leadership is needed at a national level. After all, dementia, as we have heard, is a complex, degenerative condition which involves many expensive types of support. It is vital if we are to retain the concepts of the National Health Service that we must have national standards of care. The Government must ensure that they are adhered to.

I know that the health Minister, Mr. John Bowis, has recently written to the Alzheimer's Disease Society rejecting the need for further guidelines; but I hope that the noble Baroness, the Minister, will urge her colleague to think again and, perhaps in her reply will explain why the Government think that a departmental spur towards what could be uniformly good practice is unnecessary. One of the areas where national guidelines could be most helpful would be in demarcating the responsibilities of health and social services for the continuing care of dementia. We may need to go even further back than that, and try to secure a generally agreed definition of Alzheimer's disease as a progressive neurological disease, rather than, as it sometimes seems to be viewed, a social problem.

At the moment, as the society's report points out, the degenerative nature of the disease for which different types of care are appropriate at different stages, makes it difficult for local authorities to pigeonhole sufferers as the responsibility of either health or social services. That is true of other degenerative conditions such as HIV infection and AIDS, Parkinson's Disease and multiple sclerosis. The trend in all those cases is for social services to assume more of the burden of care and more of the responsibility. That has been particularly true since the introduction of the National Health Service and community care Act just over a year ago.

During a debate on where we stood on community care that we had in your Lordships' House in the middle of March, we discussed how the arrangements for the special transitional grant to local authorities and the Government's insistence that 85 per cent. of that grant is spent in the private sector have, at least in the view of speakers from these Benches, impeded the development of community care for many client groups. As my noble friend described vividly, it has been particularly hard for people with dementia and their carers.

Alzheimer's disease sufferers are assessed increasingly under the community care regulations. As my noble friend Lord Stallard recalled, that means stringent means testing. Carers themselves are not offered a separate assessment of their needs. That has led to the chilling threats to occupational pensions and family homes that my noble friend mentioned. If one were to be entirely cynical, it would be easy to deduce an almost Machiavellian process here. People with dementia are assessed for social services continuing care rather than being treated as NHS patients. Social services are compelled to spend 85 per cent. of their STG on private sector provision which usually means, because that is where the private sector concentrates, spending it on residential homes.

Alzheimer's disease patients are discharged from health service beds to private residential homes with obvious financial savings to the NHS but at the same time sometimes crippling financial costs to partners and carers. I do not think that the process is cynically planned, merely because I think what we are seeing in the present situation is probably a rather unfortunate muddle. That muddle would be greatly reduced if in her reply the Minister could give us a clear definition of the circumstances and conditions in which anyone, anywhere, is entitled to an NHS continuing care bed. A clear picture of the extent and limit of the duty of continuing care in today's health service market would provide a touchstone against which to judge an individual's needs and the type of service he or she should expect, and from what kind of agency.

At the moment it seems that genuine confusion about that crucial definition of where duties lie is causing a dislocation of local services and great distress to people suffering from Alzheimer's disease which, as the noble Lord, Lord Addington, described, is one of the most frightening conditions that anyone can face. These people are being passed from one agency to another and, frankly, when one looks at the examples given by the Alzheimer's Disease Society and other people involved in this area, many local authorities seem only to be competing with one another not to provide the right sort of care. That is a long way from ensuring a comprehensive service from different providers, which was recently described as the ideal by Mr. Bowis when he wrote to the Alzheimer's Disease Society.

The Alzheimer's Disease Society has asked members of the health Select Committee in another place urgently to review the system of continuing care. I hope that that inquiry will happen so that the questions noble Lords have raised briefly this evening can be investigated thoroughly and discussed. In the meantime, it would be valuable if the Minister could respond to some of our specific questions, because we have a collective duty to ensure that particularly vulnerable members of our society are not falling through what seems to be an alarming gap in the provision of care, and that their carers are not being oppressed by additional unfair financial burdens.

8.58 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege)

My Lords, I should like first to pay tribute to the noble Lord, Lord Ennals, who has done much to improve the quality of life for those who suffer from mental illness, particularly through his work at MIND. I am very sorry that he is not here tonight, and, like the noble Baroness, I wish him a speedy recovery. I should like also to congratulate the noble Lord, Lord Stallard, on picking up the baton at such short notice, but with his long commitment and knowledge of the issue he has appeared to do it with great ease. I should like also to acknowledge the work of the Alzheimer's Disease Society, whose tireless efforts in this very difficult and, some would say, somewhat unpopular area are so impressive. It has proved to be a strong and effective advocate for sufferers and their carers and has made a forceful impact, concentrating the nation's attention on Alzheimer's Disease. The department recognises the work that it does by giving it both a core and a project grant.

In 1991 there were not merely 9.5 million people of retirement age, but, of those, 750,000 were aged over 85. That figure will increase to over 1 million by 2000 —the largest number of octogenarians this country has ever had. Many of those people, although admittedly not in the prime of life, contribute much to society. They participate in voluntary organisations and are as a group not only receivers of care but also care givers. I remember hearing an 85 year-old woman who, after spending years supporting Age Concern, told the director that, sadly, she had had enough and that she would be giving up. "I want to spend my free time working for the peace movement", she said.

Despite the numbers of older people who are fit and well, the increasing population represents a significant challenge and will have a real impact on the kind of services which we develop in the years to come. One of the commonest diseases occurring in older people is dementia. It is estimated that 20 per cent. of people aged over 80 suffer from it and the main cause is Alzheimer's disease.

It is the Government's policy that people with a mental illness, including those with dementia, should be treated and cared for as close to their homes as possible.

In order to provide a seamless service, those involved —the statutory, voluntary, private and independent sectors—should work as closely as possible not only with each other but with informal carers, friends, families and neighbours.

As one becomes older the relationships within a family change. I have heard daughters say how difficult it is to look after a deteriorating parent when that parent has formerly been in a position of authority, a source of wise counsel, advice, love and affection. Dementia can tragically change all that, as was graphically described by the noble Lord, Lord Addington. It alters personalities and regardless of previous loving relationships a sufferer can become like a stranger. As one of the Alzheimer's Disease Society's striking posters states, "A wife can feel like a widow".

I agree with the noble Lord, Lord Addington, that the misery, the suffering and the tragic consequences for those with Alzheimer's disease cannot be underestimated. Nor do I wish to diminish the effect that a sufferer has on the rest of the family and indeed the community. But there is a balance, and some relations derive great satisfaction from caring for someone, however dependent, whom they love. Those people deserve not only praise but need a huge amount of support. Without it, their burdens become intolerable and they then feel diminished with a sense of failure. That is why it is essential that statutory services should respond promptly, flexibly and sensitively to meet their needs, giving them the necessary support.

In the past, older people with chronic mental health problems were often looked after in huge institutions. I visited many of those wards and I do have to say that, however ill or demented the patients, they were not appropriate places for people to live out the last years of their lives. Often they were frightening, impersonal and isolated places which posed great problems for friends and relations who wished to visit. Since then there has been a consistent effort to change the emphasis and to provide more places and more services in the community, using a wide range of facilities in the statutory, voluntary, independent and private sectors.

The noble Baroness, Lady Jay, was critical of the internal market and the requirement that a percentage of the new community care grant should be spent in the private sector. That move has brought a whole range of new facilities to the community that were not previously available. It is choice and range and a wide number of different facilities and services that people want.

The new community care arrangements which we introduced in April 1993 reaffirmed our commitment to this approach. Our aim has been to offer social services departments and health authorities greater flexibility in responding to the needs of people who require long-term support. Local authorities, working with the health service, are responsible for assessing people's needs and, after close discussion with carers, for arranging support and services to meet those needs. This includes people who may require residential or nursing home care and who previously sought help from social security. Under the new arrangements, there are opportunities through imaginative commissioning to enable very dependent people to remain in their own homes, if that is their wish, or to move into more homely residential or nursing homes. We have made significant new resources available to local authorities; £1.2 billion in the current financial year, rising to more than £1.8 billion next year.

Although it is still early days, there has been widespread support for this approach. The Audit Commission and the Association of Directors of Social Services have stated that the new arrangements have got off to a good start and that there is some evidence of more imaginative and flexible approaches being used to support vulnerable people in the community.

The noble Lord, Lord Stallard, was anxious that the NHS no longer has a role in providing continuing care. This is not the case. We have always been clear that the NHS's responsibilities remain unchanged. Health authorities and, where appropriate, GP fundholders should be contracting for a range of services to meet the needs of people, including those who suffer from Alzheimer's disease. But we cannot agree with the noble Lord that national norms or quotas are the way forward in terms of bed numbers. We believe that decisions about what services are purchased must be taken locally. Health authorities need to take into account local facilities both in the NHS and the independent sector. They need to consider how to use not only the skills and expertise which are available among professionals but also the range of initiatives, strengths and resources which are inherent in every community. Organisations such as the Alzheimer's Disease Society which know so well the anxieties, the tribulations, and often the very modest demands of their members have a crucial role in influencing the decisions about the planning and delivery of services. I would expect all local and health authorities to work with such groups and to take account of their views in developing their strategies and commissioning plans.

In looking at continuing care services we have emphasised the need for clear local agreements between local authorities and health authorities about their respective responsibilities. This was stressed strongly during the run-up to the implementation of the new arrangements. To reinforce local action, we required all local authorities to submit, as a precondition of receiving the Community Care Special Transitional Grant, evidence of agreements with health authorities about their respective responsibilities for continuing care.

We are monitoring the arrangements very carefully. When cases are brought to the notice of the department we act promptly, as we did in the Leeds case. The noble Lord, Lord Stallard, will know that the health authority has since revised its policy. It took action before the new reforms were in place. We will keep under review the need for further guidance. That point was raised by the noble Lord, Lord Stallard, and the noble Baroness, Lady Jay.

The noble Lord asked a number of questions relating to charges for residential care. The general principle of local authorities charging for residential accommodation has been established since 1948. That principle did not alter as a result of the recent community care changes. It is reasonable that people for whom social services, including residential accommodation, are provided should pay for the provision of those services in accordance with their means. Otherwise, people with assets are unnecessarily maintained at the expense of the taxpayer. The method by which local authorities assess the ability of residents to pay was largely brought into line with the income support assessment rules from April 1993. But, as the noble Lord mentioned, we have also issued guidance to local authorities which stresses to them their ability to vary the personal expenses allowance to allow a resident to support a spouse at home. We believe that that is a positive contribution to that issue, but again we shall keep the position under review.

The noble Baroness, Lady Jay, emphasised the point made by the noble Lord that most district health authorities have not implemented the Royal College of Psychiatrists' recommendations with regard to bed norms. I would be concerned if this debate were to revolve only around the number of beds. We need to look at the range of services which district health authorities, together with social services, commission to meet the needs of people with dementia. With a greater emphasis on community care, different models of provision are possible and we need to look at the totality of what is provided.

We have to recognise also that patterns of care are changing and that many providers—for example, in York, Lewisham and Bexley—are providing new and innovative services in the community, working with carers and, in one case, very closely with the society.

The noble Baroness asked whether I would define health and social care responsibilities. She will know that that is very difficult because people with dementia are often in need of both health and social care. It is not a question of pigeon-holing people but of the two agencies working together to best meet the assessed needs of the individual and his carer.

Baroness Jay of Paddington

My Lords, perhaps the noble Baroness will allow me to follow that up. It is not so much a question of creating a definite demarcation of administrative responsibility. But the concern is for people whose carers consider that they are ill and therefore qualify absolutely for free NHS care when they may, under systems which seem to be becoming more common, be assessed under social services and therefore be liable to the type of means-testing on which my noble friend expanded in some detail when he asked the Question.

Baroness Cumberlege

My Lords, for people with dementia, as is the case with other people who require NHS services, it is a question of clinical judgment. One of the issues that we have stressed to local authorities when they are making their assessments is that they need to involve the GP and in some cases the consultant who is involved with that person's care. It is a clinical judgment as to whether NHS care is needed but I appreciate that there are grey areas and that it is not possible to draw very strong demarcation lines. Often it must be left to the judgment of the individuals concerned.

I should like to pick up the point made by the noble Baroness with regard to the staffing of psychiatric services. I believe that the noble Baroness was suggesting that it is difficult to find people to work in psychiatric and pyschogeriatric services. But that is not always the case. Last Friday I was able to visit the psychiatric unit at the Manchester NHS Trust where I was shown one of the most, I thought, impressive facilities for people who are suffering from severe dementia. On that visit I was interested to find out from the sister in charge that she had a waiting list of staff wishing to work there.

Therefore, in conclusion, I am very grateful to the noble Lord for raising this subject this evening. As I said earlier, the growing needs for health and social care of an ageing population present an important challenge to us and to agencies on the ground. I am convinced that the new community care arrangements provide a more flexible framework within which health and local authorities can work. But their success will not be judged solely by the number of beds provided but rather by the quality of care given to users, the support experienced by carers and the views of organisations such as the Alzheimer's Disease Society.

House adjourned at twelve minutes past nine o'clock.