Community Care

HL Deb 16 March 1994 vol 553 cc244-86

3.28 p.m.

Baroness Jay of Paddington rose to call attention to the state of care in the community, and to the case for a national evaluation of organisation and services one year after the coming into force of the relevant provisions of the National Health Service and Community Care Act 1990; and to move for Papers.

The noble Baroness said

My Lords, in introducing the Motion standing in my name, I am grateful that in a previous discussion on procedure your Lordships appeared to agree that substantial subjects should not be excluded from short debates. The subject of community care is substantial and complex but my purpose in bringing forward this debate is simple. The community care provision of the National Health Service and Community Care Act 1990 were implemented in April 1993, and one year later it is appropriate to review what is happening. During this past year your Lordships have shown concern about the implementation of what was a very controversial piece of legislation by raising many specific and related issues through Questions and Unstarred Questions. But since my noble friend Lord Carter introduced. a debate in 1992, today is the first time that your Lordships have had the opportunity generally to discuss the broad and complex subject of care in the community.

I am pleased that we shall have contributions from noble Lords who speak with authority about different groups of people who need care and, most importantly, that their remarks will be based on experience in different parts of the country. I hope that we shall be able to persuade the Minister that a national evaluation will be useful in enabling local health and social service authorities to organise funding and services more effectively in the future.

I believe that we start from the agreed position that we all wish community care to succeed. My noble friends on these Benches supported the general thrust of the community care provisions in the National Health Service and Community Care Act. However, they consistently introduced amendments designed to improve it. Those amendments, had they been accepted, could have solved some of the difficulties seen in the first year of implementation.

There is no dispute about the broad principle of community care: looking after the elderly and physically and mentally disabled as far as possible in their own homes outside traditional institutions; and providing seamless care between hospital and home. In the last debate on this issue, my noble friend Lord Carter emphasised that the perspective of each user of the service must be paramount. He said that community care was something of a misnomer and that we should be thinking about individual care and examining individuals' needs and planning the services required to meet them.

That was the theory behind the 1990 Act. This afternoon we should focus on the extent to which, in practice, those individual needs are being well served by the new arrangements. As I said, it is such a vast subject that it is easy to be defeated by generalities and it is difficult to be sure that examples of personal experiences are anything more than specific anecdotes. But within the past month, the Ritchie Report on the tragic case of Christopher Clunis has highlighted some general anxieties about community care policy in an authoritative and disturbing way. It is worth examining and drawing lessons from that report.

Noble Lords will remember that Christopher Clunis, a man suffering from schizophrenia, killed. Jonathan Zito. At that time, Christopher Clunis was supposedly being cared for in the community after discharge from hospital. I am aware that that terrible event took place a few months before the new financial systems were introduced but we must remember that the mental health provision has been seen by the Government for many years as a model for extending community care. The Ritchie Report confirms what many people have long suspected; namely, that mental health is not a good example to follow.

The report described the community provision for Christopher Clunis as virtually non-existent and as a catalogue of failure and missed opportunity. The report said: It has been noticeable how little routine attention appears to have been paid, by anybody, to the quality or outcome measurement of community management of mentally ill people". It concluded: It is essential that the Department of Health sets up proper procedures for effective monitoring of psychiatric services in the community". The report concluded also that Clunis himself sought help but did not know how to ask for it. He remembered, lack of explanation as to what he was suffering from; frustration that he was not being involved in decisions that were being made for him; [and) an absence of planned help towards settling in a home of his own". Lack of information, lack of co-ordination, lack of consultation and lack of monitoring were all problems underlined by the inquiry into the Christopher Clunis case. They are all problems, I fear, which emerge from the first year reports of carers and users straggling with other aspects of community care.

Since the Motion that we are debating was tabled, I have been contacted by many statutory and voluntary organisations, informal carer groups and users of community services. There are, of course, success stories. I have been told about imaginative care packages which would have been impossible to arrange before the Act came into force. But the variation in local standards, between the good, the bad and the indifferent, is causing great alarm. The overall impression is of anxiety that vulnerable people will be inadequately or inappropriately looked after.

Perhaps I may select a few illustrations. Help the Aged has published a detailed first impression of how older people are faring under the new system. No Time to Lose includes many examples of confusing leaflets about care plans which are particularly unsuitable for minority ethnic elders; long waits for assessments for care; increased charges for day care and respite services which "harshly penalise" many people; and restrictive criteria for other domiciliary services.

The Local Government Drugs Forum, and Turning Point, the largest voluntary agency dealing with drug and alcohol abuse, have both expressed concern that local assessment procedures are still not fast or flexible enough to deal with their clients who are often in crisis situations. The addiction organisations' own monitoring also shows considerable confusions about practical care arrangements and funding opportunities. Significantly, a report by KPMG Peat Marwick, commissioned by the Department of Health, on implementing community care concluded: Our discussions with users and carers do not suggest that they are knowledgeable, well-informed and exercising greater choice in the community care process. Indeed we were struck by how little people knew about assessment, charging and care plans. Many did not know what to expect of access and assessment processes, service standards and specifications because often these did not exist. Generally people had too little information. No one told us they had too much". That conclusion in an official report to the Department of Health seems to make the cogent and simple case for government intervention to get the system working properly. Evaluation followed by action must be what is needed.

One of the major problems identified by many working in the field is the lack of any national standards for community care. With the best will in the world, how can local authorities, voluntary agencies and individual carers identify how well or badly they are doing if there are no objective targets to work to? The BMA, together with the major voluntary organisations, has proposed a series of national standards which it feels would help achieve a uniform level of high quality care across the country. The proposed national standards include undertaking assessments within one week of referral; information about constraints on services (such as their financial costs to users) to be clearly presented and openly available; and carers to be involved in the planning and assessment process and to be offered a separate assessment in their own right. That last proposal is very important. The needs and rights of carers are too often overlooked. I know that other noble Lords will speak specifically about the role that carers play in making community care possible. I look forward to those contributions.

I wish only to say that the Labour Party has this month published its own commitment to carers document to ensure that carers are treated as equal partners in service provisions and not as cheap alternatives to statutory care. Under our system all carers will have the right, for example, to flexible, affordable respite care to suit their needs.

I think respite care is crucial to success. I was appalled when I saw a recent survey by the National Federation of Women's Institutes which showed that more than half of carers were never able to take even an occasional one week break. In addition to the commitment to carers document, my honourable friend in another place, Mr. David Hinchliffe, is introducing an amendment to the National Health Service and Community Care Act to include a statutory provision for separate assessment of carers' needs for services.

When the Minister replies I should be grateful if she could expand on the reasons for the Government's opposition to national standards for community care which she has indicated in answer to questions in your Lordships' House and also if she could tell your Lordships whether or not the Government will be able to support Mr. Hinchliffe's amendment.

As so often in social policy, major anxieties about community care are rooted in anxieties about levels and distribution of funding. Throughout all the debates in your Lordships' House during the passage of the Bill in 1990, noble Lords from all parts of the House warned that the new systems must be properly funded with new money and that to expect financially pressed local authorities to absorb additional responsibilities for care without substantial financial support was to invite disastrously inadequate services.

The implementation of the Act, as your Lordships will recall, was delayed for two years, until last April, precisely to allow funding and management arrangements to be appropriately agreed. And yet, because the Government used an extraordinary formula to calculate the first year's special transitional grant the majority of local authorities —68 out of a total of 108—lost substantially last year. Sheffield lost over £2 million, Leeds lost £1.3 million and the London boroughs lost nearly £25 million.

The Government have now conceded that the original distribution formula was wrong and have changed it. But many local authorities are still suffering from the first-year arrangements which weighted allocations towards rural areas rather than inner cities and thus left many of those most in need of community care worse off. That bungled start-up affected everyone (both those who lost and those who gained) and made consistent year on year local planning a total impossibility.

However, while the mistake about distribution has been acknowledged, the Government are still insisting that 85 per cent. of the special transitional grant for the next financial year—that is 1994–95—is spent in the independent sector. That requirement is shackling the development of genuine community care by restricting choices for individual users. It is difficult to see that perverse incentive as anything other than ideological.

Local authority associations, social service directors and voluntary organisations have all urged the Government to review the 85 per cent. requirement because those with experience know full well that the independent sector does not pretend to offer domiciliary care in the community. Private care providers have always concentrated on residential care. Recent inquiries across the country conducted by the Labour Party show that unnecessary, expensive institutions are still being used inappropriately because local authorities are not allowed to use their STG to extend and improve care for people at home. If, as the local authority associations have suggested, there was a 50–50 split of the grant between public and private sectors, that would enable more flexible care choices to be offered by all local providers.

We also need to monitor and review the growing practice of charging for basic care services, previously freely provided. In some parts of the country, parents of young people with learning disabilities are now being charged for day care. Other care users report charges for home helps and meals on wheels.

The Alzheimer's Disease Society has published chilling evidence about the impact of stringent means testing on carers of people with dementia. The society is deeply concerned about the financial hardship faced by carers who have sometimes had to give up their occupational pensions to pay for a partner's private nursing home bed. It estimates that 70 per cent. of district health authorities are failing to provide appropriate continuing care beds in the National Health Service.

Once again, the picture is patchy and inconsistent. The overall impression is that whether or not someone receives appropriate community care depends more on where they live rather than on what they need. That cannot be the right approach. Care in the community should be organisation the basis of national standards and equitable funding. We cannot expect local health authorities and social service departments to organise a successful, seamless service unless they are given secure, sustained funding and clear guidance on good practice.

Mrs. Jayne Zito, whose husband was killed by the schizophrenic Christopher Clunis, has said that her husband's murderer had been reduced to a life of degradation and poverty. As your Lordships will know, since her husband's death, Mrs. Zito has campaigned very courageously for proper help and care for the mentally ill. None of us who want community care to succeed can afford more cases like that of Christopher Clunis. After one year, care in the community systems must he both evaluated and improved. I beg to move for Papers.

3.45 p.m.

Baroness Seear

My Lords, not for the first time—and, I expect, it will not be the last—I shall concentrate on one issue. It was raised by the noble Baroness, Lady Jay who rightly said that it would be taken up by other speakers. I refer to the position of carers. However, perhaps I may say, first, how grateful we are to the noble Baroness for raising the subject. It is of very wide concern to a large number of people in all parts of the country. The question of carers, upon which I wish to focus, is absolutely fundamental to the whole issue as to whether or not community care will be a success.

I am sure that the Minister will agree with me when I say that the success of community care will depend on the extent to which the informal carers will be able to cope. Whatever else is provided, the fact is that in the vast majority of cases it is the relations—that is, families and close friends—who will carry the burden of dealing with people who need care in the community. Therefore, the emphasis has to be on how those carers can be enabled to make a success of the job. Whatever else is done, if the burden is too heavy and they break down under the strain, community care will not work. The only alternative then will be to put the whole process into reverse. It is as central as that: without proper attention to the carers, we can say goodbye to any effective scheme of community care.

One year after the legislation came into force—indeed, it is not quite a year yet—is, I suppose, rather early to be trying to form any real judgment on what has happened. However, there are indicators from the information that we have received as to where the strengths and weaknesses can be found, where it looks as if the schemes are working satisfactorily and where it looks as if they, quite emphatically, are riot working satisfactorily.

So far as concerns carers, there are at least two areas of vital importance. First, in the home where they are looking after people and giving the care, carers should be able to have adequate, competent, reliable and affordable support and assistance. That is what they are not getting. Of course, there are very good examples of cases where such help is being received, but they are the exception and not the rule. Until this becomes the rule, we cannot be at all confident that the community care programme will work.

The reports that are received, especially by the Carers' National Association (of which I have the honour to be president), show that in many parts of the country the support coming into the borne reflects none of the virtues to which I referred. There are accounts where promised domiciliary care comes at the wrong time, does not come at all, or, indeed, comes at very erratic intervals. It does not take very much imagination to realise that, if you are looking after a very disabled person—for example, a person with Alzheimer's Disease—who is infirm and needs help with all his or her physical movements, it is not much good having someone to help with the nursing who arrives five hours late. Nor is it much good if you want the sort of help at domiciliary level that so many people really need, even if they are not dealing with acutely disabled people. I refer to help with the ordinary domestic chores. There used to be a home help service which provided people who were prepared to clean the floors and do the washing up. Of course, in theory, that help still exists. That is the kind of help that a great many carers want. They want relief from such responsibility so that they can concentrate on the needs of the person for whom they are caring.

One case came to the attention of the Carers' National Association of a man who was looking after his disabled wife. He wanted help with the housework—that is, the plain chores involved in keeping the house clean and tidy. He was told that he could not have that because it was not available, but he could have someone to get his wife out of bed in the morning and wash her. However, both he and his wife preferred that he should do that part of the work. They wanted to leave the house cleaning to someone else, but they were told that that service was not available. In other words, they could have help that they did not want but could not have the help that they needed. Such examples exasperate people beyond belief and are calculated to bring the whole scheme into disrepute.

We must look very carefully at the mundane tasks that need to be done. Here, I know that the noble Lord, Lord Ashley, is very much concerned with the development of a scheme for the registration of people in the private sector who will help with such domiciliary care. I believe that to be most important. We shall not get the type of care that we need if we rely entirely upon the public sector. There is no reason why there should not be good private care but it must be good care. There must be a temptation for people in the private sector—or sometimes in the public sector for that matter—to offer these services on a profit-making basis and to fail to give what is required. If we are to obtain the amount of care that is needed, it must be available in the private as well as the public sector but we need to be absolutely certain that the care is of a good standard and not of an exploitative kind. Carers and the people they are caring for are vulnerable and they are not in a position to carry on battles with the people who are helping them, because they need them too badly. Carers and their patients are weak negotiating partners and they need to be strengthened.

Secondly, the other kind of help which carers need above all else is respite care. Carers must be able to have a period of relaxation away from their heavy burden of caring. Proper respite care must be provided at a price that people can afford. It is no good telling the person who requires respite care—there have been cases of this—that he or she can have it the next week as by then it is too late for the carer to make sensible arrangements if he has to put the person for whom he is caring into care by the following week. By that stage alternative arrangements cannot be made satisfactorily.

In the moment that is left to me I must say that there are two major areas we need to look at. One is the carer's right to have an assessment properly and quickly carried out when he wants it, and for the carer's concerns to be taken on board in the making of that assessment. Secondly, the care provided should be needs based. It should be what is required on the basis of the assessment and not what is available because it suits the local authority to provide it. I am not suggesting that there should be unlimited resources but that the spending priorities should be based on what the carer and the patient need and not on what the local authority finds it convenient to provide.

3.52 p.m.

Baroness Eccles of Moulton

My Lords, I start by thanking the noble Baroness, Lady Jay, for giving us the opportunity to discuss the state of care in the community.

Working in a district health authority as I do which now concentrates entirely on all the ramifications of purchasing, or commissioning as we prefer to call it, I have been close to the changed approach to care in the community from the outset.

It was not a question of blowing a whistle on 1st April 1993, with all the new arrangements neatly in place and smoothly and effortlessly moving into different ways of providing care. A huge amount of work had to be done in the run-up to April last year. In fact, the implementation of the new arrangements had to be put back from an earlier date in order to allow the authorities, both local and health, more time to prepare. A glance at some of the literature that was produced for national consumption and guidance by the Department of Health, the Audit Commission, NAHAT and others, and material that will have been commissioned locally, gives an idea of the effort that was put into getting ready.

What has happened has been described as a community revolution, as local authority social services departments have had to undergo the transformation from being suppliers of a range of services to adopting a lead agency role. This has involved arranging services tailored to the individual which will meet his needs, and then commissioning these services. Therefore, community care, as has already been said, has become focused on the service user, not on the service itself.

The four main groups of users are: elderly people, people with physical and sensory disabilities, people with learning disabilities and people with mental health problems. Obviously providing these services involves a multi-agency approach. Health authorities, of course, play an important part, both district and family; but also housing agencies and voluntary bodies, which both provide services and represent users and carers, play a part in the preparation of social services departments' community care plans.

Individual care plans are of course of key importance and need to pass through the process of assessment, to provision of services needed by the individual and to monitoring that these services are being provided and remain relevant. It is particularly important that the NHS and local authorities work together closely in order to develop complementary community health and social care that makes good use of joint resources in the best interests of the user and avoids gaps, duplication in services or bureaucracy.

That is a brief outline of some of the background and aspirations with which we launched ourselves into community care a year ago. Although it is still early days, the most vociferous prophets of doom have been confounded and a growing number of practical improvements are visible locally. In my district I have noticed better planning of hospital care for elderly people so that they and their relatives are more involved in examining options for after care. I have also noticed that more people are able to live at home with support. The local authority and health authority have been stimulated to promote investment in new nursing homes so that people can be cared for locally and not sent to homes a long way away; the role of the voluntary sector has been strengthened—for instance, home bathing services, jointly funded by the local authority and the health authority, are being delivered by Age Concern. There is consumer choice in that people with long-term physical disability now have complex care packages organised and financed by the health and local authorities so that they can live in a supported home environment rather than be admitted to an institution.

The more general benefits of the care in the community reforms which can be identified so far are: a clearer joint approach to the care of individual patients; a closer working relationship to planning third party provision; and a stronger realisation of the potential benefit of strengthening the voluntary sector locally. It is true that these arrangements need time for the new opportunities to be more thoroughly developed. Different parts of the country inherited differently developed services as well as varying degrees of co-operation between their health and local authorities and the voluntary sector. In my district we welcome greater local autonomy within the NHS and the opportunity to work with local authorities and our voluntary sector colleagues more closely. What we do not look for are large amounts of central direction, unfocused wall-to-wall monitoring and elaborate time-consuming evaluations.

It is satisfactory to note that by and large this new approach to caring for people in the community has got off to a good start. It is apparent that there is a high degree of dedication and good will among the people across the sectors who are working in this field both as managers and as practitioners. I am hopeful that as time goes on and the new systems get established, the population will benefit increasingly. I would therefore like to commend to noble Lords the good progress that is being made. I am convinced that with continuing hard work and support these worthwhile reforms will move from strength to strength.

3.58 p.m.

Lord Molloy

My Lords, I congratulate the noble Baroness, Lady Jay of Paddington, on giving us the opportunity to discuss this subject. I also thank the noble Baroness for her informative speech. It may interest your Lordships to know that on 30th March care in the community will be discussed on the radio on the "Jimmy Young Show" and therefore the whole country will have the opportunity to discuss the matter. The major concern of people all over the country is the possible loss and closure of hospitals. That is causing particular anxiety in London, where it appears that hospitals are under a terrible threat.

I also wish to take this opportunity to thank the Minister for her endeavours to keep in touch with National Health Service staff associations. They appreciate that very much. There may well be further NHS reforms in the future. Reform is a frightening word, as whenever the Government talk about reforming the NHS we know that that will not do the NHS much good. Nevertheless I should be grateful if the Minister and her right honourable friend in another place will continue to keep NHS staff associations informed of developments.

I hope the Minister will examine the claims of the Audit Commission that NHS funds have been wasted by doctors who have apparently prescribed wrong drugs. It is claimed that many people are in hospital because general practitioners have given them the wrong drugs. I admit that these are serious charges, but they can be read in responsible newspapers and in the magazines of responsible associations, for example the BMA and others. Therefore, I believe that the Government should have a look at that issue. In Britain, through the NHS, fewer drugs are required for our population than for any other nation in Europe. That is because of the excellence of general practitioners and the drugs they prescribe.

Where there is a dispute between the British Medical Association and the other associations, which happens from time to time. I hope that the Minister will be prepared to see what can be done to help to heal the breaches.

Will the department examine the disturbing experience of nurses in Cornwall, for example? This matter has been mentioned in the national press and makes disturbing reading. It is claimed that assessment of patient needs is undertaken by untrained staff with no qualifications. That is another aspect which I am sure the Government will consider very seriously.

I should like to address briefly the issue of care in the community in relation to nursing home funding, which is a vital issue affecting thousands of families. I have to pay nearly £500 a week for my 98 year-old mother to stay in a nursing home in South Wales. I have received letters from many people. It seems that this is a very difficult situation. Before 1st April 1993 patients were accepted into private nursing homes with their fees paid by the DSS under the terms of protected rights until they died. After 1st April 1993 the funding was taken over by local councils. In each case funding is less than the full fees charged by the nursing homes. Will the DSS look at its funding policy? Its funding is far below council funding and is causing great anguish to many people?

Perhaps I may give the House an example. Hammersmith pays more than Ealing towards the cost of patients in its hospitals and homes. That seems to take advantage of what are called protected rights. Many people are totally unprotected against the imbalance in funding, and that can result in discrimination. They are the poor relations in nursing homes. Many nursing homes do their level best to keep very old and frail people with them, but sometimes they cannot, even with the best will in the world. They have to take cognizance of the fact that the relatives are so poor that they cannot afford to keep an ancient grandmother or a father or mother in a home.

Many of those people played a dignified role in the last two wars. I know that it will touch the hearts of noble Lords on all sides of the House that people whose sons fought in the First World War and whose grandsons fought in the Second World War know that they are now becoming a nuisance because relatives cannot afford to keep them where they are. People who have property sometimes sell their property in order to be able to pay the fees in these special hospitals. It appears that once capital is reduced to £3,000 the funding falls back on the DSS and the council.

The situation is not the same in every case. That causes irritation. Somebody living in one town does not have to pay a thing, whereas somebody else living somewhere else has to pay the full amount. I ask the Government sincerely to examine the issue. It causes great distress. I hope that the Government will acknowledge that we do not want that to happen to our people. But it has happened. It is no good trying to find out whose fault it is. I want the Government, together with the Opposition parties, to see what cart be done to put the matter right.

I want to talk briefly about the role of health visitors. I sincerely hope that the Government will help them. Health visitors play a vital role, particularly when dealing with young children, some of whom can hardly walk, and their parents cannot look after them. Health visitors are the sort of young men and—mainly—young women who bring the National Health Service into the homes of people who need it badly.

All parties in this House should co-operate to save our great National Health Service. We all know that it has worked miracles up and down the country, particularly for the not so well off. It has meant that members of our medical professions know that they have a job that is worth while. When the health service was introduced doctors were afraid that they would all be civil servants. That is no longer the case. The medical profession and the nursing profession value this great National Health Service. I believe that all parties agree.

In conclusion, I hope that all parties in this House will join together to save our great National Health Service, which is the envy of the world and an example to all mankind.

4.5 p.m.

Baroness Miller of Hendon

My Lords, like other noble Lords I want to thank the noble Baroness, Lady Jay, for raising this subject of community care. I cannot imagine that there is anyone in this House who does not believe that where it is possible and appropriate to look after people in their own homes, that has to be a much better alternative than their being in long-term institutions.

I shall not keep your Lordships very long today because the noble Baroness, Lady Eccles, expressed much of what I wished to say, and many of her experiences in her area are mirrored by much of what we are trying to do in my part of the world, which is Barnet.

I should like to mention two issues which I believe reflect very positively on what we are trying to do. The noble Baroness, Lady Jay, said that she would like national evaluation of both the organisation and services since the National Health Service and Community Care Act came into force. I believe that the change in organisation is one of our best successes.

It should not be forgotten that one of the main criticisms in the Griffiths Report was that no one had the sole and lead responsibility. All too often individuals dropped through the net because some people thought that they were the responsibility of the social services, others of the local health authority and others of the family health services authority. It has now been firmly put in place that it is the responsibility of the social services to take the lead and to act jointly with the other authorities. That is a very important point to remember. As a chairman of a family health services authority I try to do my best to support the GPs in my area. I am very well aware that people drop through the net and when something goes wrong it will be the GP who has to deal with the problem, perhaps as an emergency. Therefore, I am very glad that that organisational change has been made.

That organisational change has resulted in considerable successes, with district health authorities and FHSAs working together. In our case we now work together unofficially as a health agency. Of course everything will not be a success. Of course many issues that will be raised today will need to be examined very carefully, and I am sure that the Minister will respond to them.

The House may like to know that in Barnet between April 1993 and November 1993—the first eight months after the Act came into force—we carried out 4,699 assessments. That may not sound very much, but it represents one-and-a-half per cent. of the population of Barnet. Previously there had been no assessments at all. The mere fact that we have to put the patients first, think of their needs and discuss them with the patients and the carers, and do the best that we can in finding the most appropriate way of looking after those people, can only be an advantage. If one considers the short period of time in which we have made this enormous change, we should be grateful that the Government had the courage to look at what was wrong and to seek to put it right.

4.10 p.m.

Lord Ashley of Stoke

My Lords, I am delighted to follow the noble Baroness, although I cannot share her optimism. However, I am delighted to hear that she herself has had such pleasant and constructive experiences.

I congratulate my noble friend Lady Jay. She made an excellent speech and set the tone for a first-class debate on an issue of outstanding importance. I am glad that the debate has remained on that high level. I am glad too that the noble Baroness, Lady Seear, referred to the domiciliary care problem. The noble Baroness has made a major contribution to that aspect. I am only too pleased to support the noble Baroness's efforts and those in another place on that important issue.

Members of this House have been inundated with briefs from the voluntary organisations expressing deep concern about the state of community care. All those briefs have reflected the suffering of people who are or should be the recipients of community care. That suffering is in part the result of the Government's failure to organise the system and to provide adequate funding. Those briefs were not organised; they were a spontaneous outpouring by the organisations because of their deep anxiety about what is happening to community care in Britain.

Community care has been criticised by the individuals concerned as well as by the organisations. The provisions are young, just a year old; we cannot expect perfection or miracles. The Minister will have a strong point in saying that. However, even after having listened to the last speech, there are few indications that community care is progressing in the right direction. There are widespread expressions of anxiety.

The British Medical Association has been referred to. It said that its survey a few months ago portrayed a disturbing picture of failures on important aspects of community care. The BMA is no wild Left-wing organisation of irresponsible militants. The noble Baroness, Lady Miller of Hendon, may question that statement; but the BMA is a very responsible organisation. It does not throw words around irresponsibly, like confetti. When the BMA talks of a disturbing picture of failures on important issues the Minister should sit up and take notice. The BMA is not seeking to make party political capital, as one or two Members on this side of the Chamber might be tempted to do—although the noble Baroness, Lady Jay, and I have scrupulously avoided those temptations. However, the BMA cannot be accused of making party political capital. Its criticism is important because it reflects the views of an important section of the medical profession One of the BMA's most important findings was that the majority of doctors reported that, far from the promised improvements, there was either no change in the services or an actual deterioration in community care. That was stated by doctors working at the coalface, if I may use a cliché. Those important charges ought to be considered by the Government in the debate. Many of us have high regard for the Minister. Perhaps when she replies she will explain whether she agrees with the BMA. If she does not, will she tell us where it has gone wrong and from where it has obtained those facts? We would appreciate the Minister's views on that important subject.

The BMA urges national standards, as did the noble Baroness, Lady Jay, in her brilliant speech. I agree with that. But if the Government agree and do not provide the money to enable those standards to be met, talk of national standards by Ministers simply becomes a public relations exercise. I am sure that the Minister wishes to avoid that. Perhaps she could let us know when the funds will be made available, how much will be made available and how big the increase will be after the debate. I would welcome those facts from the Minister. The noble Baroness does not look too happy at present. Perhaps her figures do not match my expectations. However, I am sure that she will promise the House many millions of pounds of extra cash for those standards; and we look forward very much to her speech.

The consortium, Challenge, representing eight disability organisations states that community care has proved to be finance led rather than the needs led service so fondly proclaimed by the Minister of State. The noble Baroness, Lady Seear, spoke well of carers. I know people who for years have spent every hour of every day caring. If the service is finance led, it means that when those carers ask for just a little respite care, they receive the reply that there are no funds available. We do not say to people in physical agony, "There are no funds for an operation". So why should we be saying to those with emotional distress and in psychological agony that we cannot afford this or that? Such people should be placed high in the queue.

I have another 45 pages of notes to read. But I had better stop because the clock indicates that I have spoken for seven minutes. I think that someone has been maliciously whizzing the figures around behind the scenes. I conclude by saying that this important subject needs urgent attention from the Government. The Government have tried, but they have not succeeded to date. Apart from taking on board the legitimate criticisms of the noble Baroness, Lady Jay, and colleagues on both sides of the House, the best thing the Government can do is to give a significant injection of funds so that proper standards will be provided after the national evaluation.

4.19 p.m.

The Lord Bishop of Bristol

My Lords, I join with other Members of this House in thanking the noble Baroness, Lady Jay, for introducing the debate and for the manner in which she did so. I welcome the opportunity to take a cool look at community care one year on. As noble Lords have already heard, it is early days and any major reorganisation takes years to become rooted in the community. However, because it is impossible to pilot such major policy changes before legislation is in place, the lessons learned early on are vitally important. I note that monitoring has already begun to take place in the Department of Health Report, First Impressions, between April and September 1993. In that report there are already indications of areas where issues need to be addressed and changes made. However, the changes have been so basic that it is vital to assess the quality of the service being given to all our citizens.

The General Synod of the Church of England in a debate in February 1992 welcomed the Government's initiative to extend community care provision and believes that the principles which underlie the legislation were right. The General Synod always asks the Government for further initiatives and funding, but it had the grace to go on to say that it recognised the challenge to the Churches and voluntary groups alike to provide an effective partnership with statutory bodies.

The Churches—and I include all of them—have people, plant and networks to offer. Among the activities which will be found in most parishes and most areas are luncheon clubs for the disabled and the mentally ill; tea dances, which provide exercise and friendship (they take me back a long way); drop-in centres; people who regularly visit the shut in; the provision of transport for the many who find it difficult to move from their own homes; and perhaps more important than anything else we have already heard, the support of the carers, the provision of that evening off, that time away.

Because we believe that our contribution is important, during the autumn of last year the Board for Social Responsibility of the General Synod did a survey of the Church of England's involvement in community care. Twenty-six dioceses reported on a number of questions and two major issues emerged which I should like to share with the House.

The first concerns funding. There are still, many believe, major funding issues to be resolved. What can seem a good plan at a regional level can feel very different indeed at a local level, and, after all, that is what community care is about. Community care is not necessarily cheaper than institutional care. The risk is that—and it was underlined by many and has already been underlined in this debate—in the absence of adequate resources, social workers or care case managers will define the needs of the person they are assessing in the light of the resources available. That I believe is the wrong way round. There is still much to be done to achieve comprehensive services across the country.

The second issue concerns those groups with special needs. As the noble Baroness, Lady Jay, pointed out, we have already had the case of Christopher Clunis and there is a particular worry among many of us about care of the young mentally ill. The question is: who takes care of them? In my city, the Bristol Cyrenians published their annual report concerning homelessness among the people there. In last year's returns, 40 per cent. were suffering from significant mental illness. Over a third of those were under the age of 25. The special needs of the young, the homeless and the mentally ill still need to be addressed.

The Churches are among those groups which have an interest in what the slippery words "care" and "community" mean in practice. The experience of many seems to be that "community" has become, and easily becomes, family; and a privatised family at that, with carers locked into a role with minimal support and often little choice. If community care is to be what it claims to be, and to ensure that that happens, we need to remember that community is larger than family.

We will go on asking the fundamental questions about values and responsibility and go on insisting that all our citizens matter. The welfare state, of which I am a child, may have had some weaknesses but one of its strong areas was the theme of interdependence. That was a practical working out of the moral contract between the generations: the notion that each of us is responsible for people at vulnerable stages of their lives and can in turn expect to receive help when we ourselves become vulnerable.

We support good management. We know that resources are limited and we want value for money. But as a Church, in partnership with the statutory bodies, we wish to be evaluated as well as those who are involved in the main provision of services. We wish to be involved in any national evaluation. There is a crucial link between the individual and the wider community. We need to be vigilant that this new world, this new way of looking at things and this new language, do not lead to inadequate care, anxiety about the future and bleak isolation in the present.

4.25 p.m.

Lord Holderness

My Lords, I am proud to take part in the debate and grateful to the noble Baroness, Lady Jay, for making it possible. I believe it is time, after nearly a year, that we should ask certain questions of Her Majesty's Government. In the Minister's defence, I recognise that it will be extremely difficult to give as comprehensive an answer as we should like about a service which, not only in the first year, but, I hope, in the years to come, will gradually move and develop.

The concept of community care was one that I, like many other noble Lords, warmly welcomed, mainly for the reason advanced by my noble friend Lady Miller. It is that, with few exceptions, most people who have been ill or who are ill would like to remain at home or return home as soon as they possibly can. When they are at home, they look naturally for the opportunity to lead as full a life as possible.

I have reason to be grateful to hospitals but I have no wish whatever to spend one day more in them than is absolutely necessary. However, it is clear that the transfer and expansion of care outside must, by definition, make new demands on the receiving community. My own belief is that the combined cost of hospital and community care could and should be less than the cost of the more prolonged hospital care which was normal in past years.

If that is so, I should like to see the Government seize the opportunity which their own initiative has opened by going further and giving individuals the opportunity, with adequate finance where necessary, to manage their own care rather than having it arranged for them. In discharging those obligations to provide care, it would greatly please me to see authorities more willing to make use of volunteers. I believe that, properly and sympathetically organised, volunteers could add significantly, both quantitatively and qualitatively, to the service which authorities provide.

Like the noble Lord, Lord Ashley, I was concerned by reports from the BMA of doctors' anxiety about increased workloads unaccompanied, so they claim, by any comparable improvement in the service. I hope that when my noble friend replies she will be able convincingly to remove that anxiety. I hope that she can also remove an anxiety in my own mind which has been put there by a number of conversations with GPs. They complain that they are often not informed of their patients' discharge from hospital, nor are they informed of the details of the treatment that the patients received there.

The question of carers has naturally been covered. Among the thousands involved in the care of those who need it, the husbands, wives or relations who give hours of service with no discernible recompense are the most deserving of further reward. The invalid care allowance is small, and attention has rightly been drawn to that. I have heard homage paid on a number of occasions to the army of devoted carers. I wish we could do more to translate that homage into some form of reward, particularly in the shape of more regular relief from constant vigil. I rejoice that opportunities are growing. But I am afraid that for the absolute essential of respite care they are growing more slowly than most of us would like. That point was underlined by the noble Baronesses, Lady Jay and Lady Seear, and by others.

I am glad to see mobility, and the means to restore and increase it, claiming more attention from the community, which is wise enough to recognise that mobility is the source of much of the joy of living. I still long for the news which I believe my noble friend is just as anxious to give; namely that, before long, the Government will acknowledge the claim of a few thousand very severely disabled men and women whose lives would be utterly transformed by an improvement in their short-range mobility. That point was suggested by my noble friend Lord McColl not long ago.

Finally, I should like to emphasise the importance of the contribution which I believe communities can make through day centres. One such centre now forms part of an important foundation about which my noble friend Lord Hamilton may speak later with greater authority than I. But my own experience of it marks it out as an important builder of confidence, a restorer of natural social relationships and a gateway to the fuller life which I believe should be the ultimate objective of community care in all its many forms. I hope that when my noble friend replies she will be able to give us some conviction that we are gradually drawing nearer to that objective.

4.32 p.m.

Lord Taylor of Gryfe

My Lords, like others I thank the noble Baroness, Lady Jay, for introducing this subject. The House has responded to an excellent speech with an excellent debate. We are discussing not simply care in the community, but the nature of our society. Only a society that responds to the demands of caring for the less advantaged in our community can call itself a decent, Christian and civilised society. I therefore hope that, as a result of the debate, we shall sharpen the sensitivity of people in our community to their responsibilities.

I should like to give two quotations. The first is from Professor Anthony Clare, of St. Patrick's Hospital, Dublin, who speaks frequently on radio and television. The quotation is two years' old, but the circumstances have not changed substantially. He said: The health service spends no more than the price of a cup of tea a day on community care". A cup of tea a day, my Lords.

There have been various contributions this afternoon pointing to the fact that the services are under-funded. The suggestion that a cup of tea per day is the appropriate allocation of resources to caring in the community is hardly supportable. Those of us involved in this area, apart from receiving the excellent briefs of various organisations, also have experience of letters from carers and sufferers. We could spend a long time quoting them. I shall simply quote one which came to my notice quite recently. I should say that I am president of Scottish Action on Dementia, which is combined with the Alzheimer's society in Scotland. Therefore I see a good deal of the correspondence that comes into the office in this connection. The quotation is on the experience of living with dementia: Now I have got to wash him, I've got to dress him, undress him, help him sit in a chair. Going to the bus he gets mixed up—you've got to help him—you say to him to sit in and he lies down and people look at you and they think … he is drunk … but it doesn't matter what people think, you know. I know what's wrong with him and I have to cope with it". I could quote many letters that are similarly depressing about the problem of caring for people suffering from dementia.

The noble Baroness, Lady Seear, and others rightly drew attention to our responsibilities to the carers. My experience is largely confined to Scotland and Scottish affairs. It is estimated that if the state had to pay for the responsibilities that carers in Scotland discharge it would cost £1.2 billion a year. Those people, many of whom have given up careers to care for aged parents, save the state £1.2 billion a year in Scotland alone. I feel therefore that we should revalue the service which carers provide. I hope that in the reply today a word of encouragement is said about support for carers. Many are now suffering financial hardship as well as having no social life. The hidden costs of caring in a family are estimated to be an additional £46 per week. Items such as incontinence pads, extra fuel, washing, breakages and special equipment cost money. In addition to making a contribution to caring in the community, carers suffer very great disadvantages economically and certainly in their social life. I hope that we may once more acknowledge the state's responsibilities so far as carers are concerned.

I wish to follow up the point of the noble Lord, Lord Holderness, about the importance of the voluntary sector. We must not under-estimate the fact that while we look to the state for support—and it is a state responsibility—there are resources among our people, who, thank God, are prepared to give services in this case of need.

Although, as I said, I am president of Scottish Action on Dementia, which is associated with the Alzheimer's society, I have no great experience in this field of caring. Indeed, my main purpose is to raise money for those worthy organisations. My friends now move to the other side of the street when they see me coming. They know that I have my begging bowl out to assist those organisations.

I should like to mention one other organisation in Scotland. It is the research centre set up at Stirling University. The dementia services development centre was established there to improve and expand services for people with dementia and their carers. It is not a research centre looking at cures for Alzheimer's disease and dementia. It is a service that tries to measure and advise on the implications of community care. I suggest that those voluntarily funded organisations should receive greater support from the Government in dealing with the complex problems which they face.

4.40 p.m.

Baroness Faithfull

My Lords, I thank the noble Baroness, Lady Jay, for introducing the debate today. I fully support her request for a national evaluation organisation to evaluate the services one year after the coming into force of the relevant provisions of the National Health Service and Community Care Act.

Can my noble friend say whether any positive research is being done to measure the outcome of the Act during the past year? Is life better for the patients? What is being achieved? What are the views and experiences of families and carers? How many hospitals and homes are needed? Have we been too hasty in closing our mental hospitals? What is the relationship between health and social services? Above all, are the patients happier? Are they better served and are they leading a full life?

I wish to mention one other point that has riot so far been mentioned. It concerns the view of the communities in our country. I fear that there is often a feeling of "not in my back yard". That point has not been addressed. I know it is difficult but if community care is to be a positive aspect in our society then we must help the community to accept and realise the help that can be given and the responsibilities that go with it.

How can the services be better run? I speak particularly of those hospitals for the mentally ill, as well as for the disabled. Can my noble friend, when she replies, say whether or not there is a directive advising doctors, health visitors and social workers to draw up a specific plan laid out in consultation with the family, the carers and, if possible, also the patient? If such a plan is worked out, can it be stated how it should be carried out in the future? As we heard, so often mental patients leave hospital without any specific plan or report, and often with nowhere to live. A plan should be formulated for them and the doctor, the social worker, the health visitor, the carer and the family should sign it so that everything is fully understood.

As the noble Lord, Lord Rea, well knows, a great many of the problems with mental patients arise from the fact that after discharge they do not take their medication. If the patient continued taking the medication there would not be a problem. How can that situation be overcome? I agree with other noble Lords that there should be centres which patients are encouraged and helped to attend. At that time it would be possible to check their medication.

The training of social workers is a topic that also needs to be addressed. Nurses undergo a four-year training period—as my noble friend Lady Cox will verify—and doctors undergo a five-year training period; but social workers are trained for only two years. They work as a team with colleagues and I suggest that they should be given further training in co-operating with their partners in the work that they must carry out.

I believe also that the patients are not considered and consulted as to what they want. Some patients will say that they do not wish to leave the hospital. If that is so, must we make them leave? That point should be taken into consideration. If it is felt that a patient should leave the hospital but the patient does not want to leave, surely there should be time for consultation and help given to the patient to accept the change. It is my experience that some schizophrenics do not want to leave the hospitals for fear of what might happen. Should we not listen to them and respond to their wants rather than to what we think they should have?

When there is co-operation between all the services, the carers and the family; when they are all working together in a community which has understanding, kindliness and thoughtfulness and its members are not apprehensive of what they are facing; then, and only then, will the community care programme be the success that we wish it to be.

4.46 p.m.

Lord Dean of Beswick

My Lords, first, I join with other Members of your Lordships' House in expressing my appreciation to my noble friend Lady Jay for having tabled a debate on this extremely important subject. My contribution will probably be a little different to those of other noble Lords. Secondly, I offer my apologies, in that I shall have to leave shortly for an important meeting. However, I hope to be back in time for the winding-up speeches.

We should perhaps look back and see what took place some years ago. Community care is not new. It was in being and working successfully during the 1960s. Like many other Members of your Lordships' House, I was a member of a local authority when they provided separate social services. The welfare service looked after elderly people; the local health service looked after midwifery, chiropody and so forth. There was a separate department for children, with specialists dealing with their problems.

But somebody had the bright idea that all that had to be altered. It was based on a report by Lord Seebohm—who unfortunately is no longer with us. He had a tremendous ability and brought a great deal of talent to bear on issues such as this. But—and this is not the first time I have said this in this Chamber—we got it wrong. If we had not, I do not believe that we would see the clear examples of child abuse that we see today. I do not say that it would have been eradicated but I am sure that, with a section of people specially trained in looking after children, much of the neglect or mishandling of the situation by social workers would have been prevented. In the same way, older people would not be left alone as much as they are when they are discharged from hospital.

I believe I made the point three or four years ago in your Lordships' House when I said it was time to switch back to the situation that existed before. Of course, I am glad that the Government intend to do that. We can make all the pious statements we like in your Lordships' House in our demands for resources, but I hope that we are talking about a generalised system that will be as much to the benefit of people in Manchester, Leeds, Liverpool and Wigan as it is of those who live in Wandsworth and Westminster. I have discovered a strange thing. By accident, no doubt—I do not think the Government would do it deliberately—Wandsworth and Westminster received far more money per capita of their population than any of the big northern cities that have a much greater need. I found this morning that Wandsworth has just announced its council tax for the year. One noble Baroness—a Member of your Lordships' House—told me that her council tax in Wandsworth this year will be £6 a month. Looking at the equation, the people of Wandsworth are bound to get a good service. They are paying nothing now, and if they have to pay a little extra they will get a better service still. However, the only way the major cities of the north can redress their gross underfunding in the first 12 months is once again by charging a much higher council tax than Wandsworth and Westminster.

I have been involved in local government and national government and this is the first time I have seen a government so blatantly gerrymander public financial support to areas that just happen to vote for them. I never knew a Conservative government in the old days, under Mr. Heath and his predecessors, to go in for that kind of practice. They should not think that they will get away with it and that it is not noticed. I know that what I have said will be recognised by the noble Lord, Lord Rippon of Hexham. I used to have to go and see him about funding when he was Secretary of State. The government of which he was a member did not gerrymander finances for their so-called flagship councils. People in Leeds, Manchester, Liverpool, Birmingham and other areas are entitled to the same level of care as the people who live in Wandsworth and Westminster. Those areas should be receiving more funding from the Government than Wandsworth and Westminster.

I spent 17 years on Manchester City Council. Manchester has one of the most rapidly ageing populations in the country. Manchester decanted 250,000 people. They were the younger people who wanted to branch out from the city and now they live well outside the borders of Manchester. They are all over the place. Manchester's population is falling. The same is true of Liverpool. Manchester is top-heavy with elderly people who require care but the burden will fall more heavily on the authority unless the Government look at the problem and deal with it. Unless the Government help the authority to do the job it will have to set a ridiculously high council tax to do what is being done for peppercorn council taxes in Tory flagship areas. I think it is as well to bring that feature out.

The right reverend Prelate who spoke earlier talked about homelessness in Bristol. He said that a high percentage of the people involved are suffering from some form of handicap or mental instability. That point has been raised before in your Lordships' House by other noble Lords, including myself. We have always been told from the Dispatch Box that there is no evidence of that. I have to say before I sit down that there is concrete evidence from various societies, such as the Cyrenians, which are dealing with this problem at the sharp end. Even if homelessness is falling it does not mean to say that the number of handicapped people living rough is falling. In fact, in my opinion, those people are bound to become a bigger percentage of those needing special care. I do not expect the Minister to reply to that point today but I believe that the Government must understand that an increasing number of people are sleeping rough in what has been a rather long and adverse winter. They should have some form of special care.

My experience of community care is that if you have someone in the family who is taken ill you become the nurse yourself. You are the person who is the community care. Never mind that someone will knock on your door and look after that person. It does not work like that. I hope that the Minister will take this on board. Unless the Government give local authorities adequate funds, those local authorities will be left as whipping boys and the Government will say, "It is not the Government's fault, it is the local authorities' fault". I hope that they will not get away with passing the buck this time. On that basis I trust that the Minister will take on board my point about equalisation of resources.

4.55 p.m.

Lord Pearson of Rannoch

My Lords, I too am most grateful to the noble Baroness, Lady Jay, for initiating the debate today, which seems to follow on from the debate we had on 11th October 1993 in the name of the noble Lord, Lord Rix. I said much of what I have to say on this subject then (at cols. 71 to 75 of the Official Report) and will not weary your Lordships again with it now. But I am particularly grateful to the noble Baroness because this debate gives me the opportunity to repeat some questions and ideas which I put to my noble friend on 11th October and to which I regret to say I have not yet had an answer. In the meantime I have done a little research and can now put some interesting figures on the suggestions I put to my noble friend five months ago, which I trust will help to commend them to my noble friend and her department.

I should declare two interests, as I always do when your Lordships debate matters concerning community care and the mentally handicapped. I am the father of a mentally handicapped 13 year-old child, and I am a patron of Rescare, the national society for mentally handicapped people in residential care. These two interests have led me to the belief that our community care policy is too firmly committed—often through what I am sure is a flawed ideology—to moving people out of residential accommodation into a community which does not really exist and which too often does not care.

I hope your Lordships will not misunderstand me. I applaud those cases where community care is working as it was intended to work, where people who were kept inappropriately in residential mental hospitals are now living fuller and happier lives in the community, supported by appropriate social care packages. But for far too many of our most vulnerable people the good intentions of our community care policy have merely paved the way to a very private hell which they alone must tread. And, my Lords, I am convinced of another thing—that simply throwing masses more money at the problem will not do much to help, or certainly not enough to justify the huge sums involved in these days, when it is beginning to look as though our economy may not be able to continue to generate the level of benefit from our welfare state to which we have all become accustomed. So may I suggest again to my noble friend that the Government seriously consider promoting sheltered and village communities for the mentally handicapped, instead of treating them with disdain and in effect looking on them as though they were unwelcome?

I accuse the Government of this attitude because in 1992 they deliberately left sheltered communities off the list of provision which local authorities are encouraged to support and because they have continued their policy of closing residential institutions, some of which could easily and cheaply be transformed into village communities.

One of the questions I put to my noble friend last time was whether she agreed that the decision to leave the communities we favour off the list of local authority provision was taken on entirely inadequate advice and whether it was not taken instead on the back of a survey organised by her department which one can only describe, with the greatest respect, as bogus. So I wonder whether I could again ask my noble friend to reconsider her department's position on this matter. In doing so could I ask her not to reply by saying that local authorities are free to support placements in village communities if they want to, because she will know that that is not the same as active government support.

But why should the Government support these communities? For two very basic and very good reasons, I submit. The first is because many, if not most, people who have a mentally handicapped member of their family appear to want these communities as a genuine option for their relatives. The national survey being conducted by Rescare continues to confirm that some 65 per cent. of people like myself prefer them and know that their relations will be much happier in the sheltered and complete environment which these communities offer than they will under the cruel vagaries of our community care policies.

And the second reason, my Lords, is that our communities are very much cheaper than the official community care option. In fact, if the Rescue survey is accurate—and I have no reason to believe that it is not—we could be looking at savings of hundreds of millions of pounds if we followed the families' wishes and accommodated some 65 per cent. of our mentally handicapped people in the communities they prefer, instead of in specially purchased houses in the so-called community outside.

I say this because, although no one seems to be able to make exact cost comparisons, we at Rescare believe that the communities we support can offer full residential, educational and occupational facilities for the mentally handicapped at some 40 per cent. of the cost of similar facilities under the community care programme. I put this statistic to my noble friend in a Written Question and she did not deny it when she answered on 10th January of this year.

Looking at capital costs, we believe that it costs about £30,000 per person less to move someone from a bed in hospital to one of our communities' purpose-built units than it does to move the same person into an ordinary house under the community care policy and to give that person the care which they deserve and which we expect them to have.

The numbers of people upon whom these percentages and savings must sooner or later be calculated are large and growing. I understand that there are about 130,000 severely mentally handicapped adults in the United Kingdom today. Most still live with their families, but they are beginning to live longer than they did (a new phenomenon) and a much greater proportion than hitherto of the highly dependent are beginning to outlive their parents. There is the baby bulge problem there, too. I fear that our planners have not really started thinking about the greatly increased need which is on the way and, with the greatest respect, I suggest that they start to do so urgently. Rescare would be more than happy to co-operate.

In conclusion, I believe that there are sufficient worries about the way our community care policy is actually working out in practice to justify its national evaluation as suggested by the noble Baroness, Lady Jay. I hope any survey will not merely conclude that more money is the answer. I hope that it will look at some of the deeper issues which lie beneath the surface of the problems we are discussing, which I have not had time to go into today, such as the way in which social workers and others are trained to deal with the very difficult situations that they will have to face. But, above all, I hope it will take a fair and dispassionate look at the contribution which sheltered and village communities might make to the sad and difficult problems we are discussing today.

5.3 p.m.

Lord Howell

My Lords, this debate has been preceded by a very interesting discussion on the value of three-hour debates themselves. My noble friend Lady Jay has promoted a debate which underlines everything said about the value of such debates. I agree very much with the point made by the noble Lord, Lord Boyd-Carpenter, earlier today on the possibility of having proper debates in two-and-a-half or three hours. I feel strongly about that. This is a place of debate. It is of great regret to me not to be able to pick up points raised in the Chamber and to expand on them, deal with them or deny them. That is the purpose of debate. I hope that the business managers will take note of the deficiencies of the two-and-a-half or three hour debate, as well as the good reasons for promoting them.

In preparation for this debate I made inquiries at Dudley Road Hospital, Birmingham, with which I am well acquainted, and with the Birmingham Social Services Department. I shall state my conclusion at the beginning of my remarks since I may not have time to give it at the end. Those bodies confirm my own knowledge and observations; namely, the fear that once again we are engaged in a Treasury-led exercise which is dealing with a subject of great importance, not from the point of view of assessing what are the standards of care which we must insist upon and then addressing the question as to how we can, as economically as possible, provide for those standards, but the other way round. It looks to see how much money they can save and the amount of finance which is available and then try to adjust everything to that point of view.

A senior medical man at Dudley Road Hospital summed up for me the problem which he faces in this large inner city hospital, of which I had the privilege of being chairman for about 15 years. He said, "Please give this message to the Government: do not pull the rug from under the hospital care service until an adequate domiciliary service is in place and is properly funded".

As I have said, in a debate like this one can only speak in headlines, which I shall do, resting content in the knowledge that the noble Baroness, Lady Cumberlege, of all Ministers, will pay attention to what we say and give every consideration to the points, even if she is unable to reply to each of them today. In a limited debate that is all we can expect.

One of the issues which has come to my notice is the civil liberties of people in hospital whom the services are trying to get out of hospital. I endorse the 85 per cent. figure which my noble friend gave. It is a ludicrous proposal for a city like Birmingham, with a million people, to say that 85 per cent. of its budget in this area has to be spent in the private sector. It is nonsense. There is no private sector provision in Birmingham which can possibly deal with the needs of a million people. If that restriction is applied, the Government are automatically saying, "We shall restrict the amount of care available to people in need".

I have been told of hospital patients anxious to leave hospital who have been offered two or three alternatives of private accommodation which either they cannot afford or they do not like. But they have been forced out into residential accommodation, where they do not wish to go. That is a very important civil liberty point. It does not matter how old, frail or infirm patients are; they have the right to decide where they want to live if they are to be turned out of hospital. Incidentally, I am told time and time again that we are turning a great many people out of hospital far too soon with the inevitable result that they are returning to hospital, often in a more difficult situation than was originally the case. I hope that notice will be taken of that issue.

The quick turnover is being aggravated by the inability of many general practitioners to get their patients into hospital in the normal way, particularly because of the reduction in the number of beds. So time and again I have been given evidence to show that doctors are having to resort to emergency procedures to get their patients into hospital, and that is totally unsatisfactory.

It may help the House to understand the position in a city like Birmingham when I say that the number of whole-time nurses in the health service has remained static in Birmingham at about 450 from 1986 to 1993 as a result of all the changes. That represents a very serious reduction in the quality of service.

Perhaps I may make another quick point to the Minister, although it it does not refer to her department. There is no national housing strategy for providing for elderly people who have to be moved out of hospital and into institutions but who want to go into their own homes. Such a strategy needs to become an important and fundamental provision. The Department of the Environment should provide such a housing strategy both to local authorities and housing associations. I very much hope that that point will be taken on board.

I take the point about the increased burdens of home care. Again, I understand from what I am told by social service departments that many of their customers or patients, especially working-class people, are being denied proper home care arrangements because the home help service is being run down. Nothing gives people more pride than to see that their home is clean and tidy. However, that now goes by the board, much to the distress of many people.

The issue of mental health beds has been raised. The figures are appalling, but I do not have the time to give them all. It is clear, however, that when we have decanted large numbers of people out of the mental hospitals, we have not made adequate community provision for them or provided adequate funds for the local authorities. There is a large unmet need. One of the questions that I have been asked to put to the Minister is: will the Government consider measuring the unmet need in our society? Unless we can measure it and unless it can be monitored constantly, it is impossible to provide for that need and we are therefore talking from a position of ignorance.

I hope that some of the points that I have made—I could have made many more—will demonstrate how successful the debate has been in allowing us all to raise such matters. Perhaps I may suggest to my noble friend that I hope that it will not be another year before we return to them. We have to have a policy of constant vigilance on behalf of the millions of elderly and frail people in our population than for whom we bear no greater responsibility.

5.11 p.m.

Lord Hamilton of Dalzell

My Lords, perhaps I may add my thanks to the noble Baroness, Lady Jay of Paddington, for initiating this debate. I venture to speak as chairman of Queen Elizabeth's Foundation for Disabled People. I am conscious that I speak following, and in the presence of, my noble friend Lord Holderness, who is the foundation's president.

The foundation is for those with physical disabilities, not mental ones. I can understand the special difficulties of returning the latter to the community—my noble friend Lord Pearson referred to that group—but I do not accept that premise for physically disabled people. The purpose of the foundation is to equip those with physical disabilities with the skills that they require to lead as independent a life as is within their capability. In that object, the concept of care in the community was not new to us and we do not argue with its indisputable merit.

Disabled people want to be regarded as equal to their able-bodied peers. However, many are unlikely to achieve that ambition without assistance. The basic requirements are simple. They are the ability to look after themselves physically and to be able to cook and to shop. To do that, they must also have mobility, a case that was eloquently put by my noble friend Lord Holderness, who is somebody who knows. Finally, they must, wherever possible, find employment and, with it, financial independence as well.

The practical effect of putting into practice the commendable concept of breaking down the doors of the confining institutions, without having first equipped their inmates with those skills, threatens to drop a large number of people into an abyss. They will subside into their families under the patronage of state benefits and, because the majority have neither the inclination nor the self-confidence to complain, there they will remain, unnoticed. The foundation is providing a range of services, but its main ethos is to prevent that happening.

Perhaps I may give two examples. We had a teenage girl come to us at the foundation who had been born with no arms and reduced and deformed legs. Her family were unable to do anything for her. After two years with us, she went on to achieve a first-class honours degree in art at Sussex University. She is employed, owns her own house with a mortgage and not only drives but has passed the test of the Institute of Advanced Motorists. Again, a young man had viral encephalitis and could neither walk nor speak. After three years at the foundation, he could both walk and speak and is now in further education in Blackpool. I could mention many other instances of rehabilitation that we have achieved, some of which are more remarkable than others, but time does not allow it. But I believe that few, if any, would have acquired the skills and, above all, the confidence to attain independence without help.

There are four points which I believe emerge from this. First, it is not enough to will the desirable end of releasing people from the institutional imprisonment of disability, which I understand is the driving force behind care in the community, without thinking about the means to achieve that end satisfactorily. Secondly, I believe that much of what is required is already in place in the independent charitable sector. The foundation is only one provider among many. Thirdly, money provided by government to employ those facilities is money well spent. That is so because it both relieves families and carers from what are sometimes intolerable strains and because it is a good investment if it turns those who would otherwise spend their lives as clients of the welfare state into employed taxpayers.

Fourthly, I must tell the noble Baroness, Lady Jay, that I believe the independent charitable sector to be ahead of the game in certain aspects of national evaluation, at least in the field of physical disability in which I work. If we are to be effective, it is essential that people with disabilities should know where to find the services that are available to them. Queen Elizabeth's Foundation has, in my view, devised the best available system for making accessible the information that is required.

Last year, the noble Lord, Lord Ashley, kindly consented to launch a directory of opportunities for school-leavers with disabilities. It is a compilation of all the courses in the country that are available to them, codified by area.

The foundation has also produced a computerised program which is designed to be accessible from terminals placed in public libraries, hospitals and any other place that is readily accessible to the public. On that program are listed all the facilities that are available for disabled people nationally. Since it is designed to be used on a county basis, it also has an empty filing system for inserting those that are known locally. It is an extravagance to collect the same information more than once. If it would be any help to my noble friend the Minister, I am happy to offer her access to that program—for our usual fee.

In summary, I think the reason that we feel somewhat disconcerted by the concept of care in the community is that the cart seems to have got itself in front of the horse. The concept is there, but where are the practical means of executing it? I feel sure that, at least in my own field, the means to make it work are there. But the policy should be clear. Before people are returned to the community, they should first be assessed and, where possible, be prepared to look after themselves.

5.19 p.m.

Baroness Cox

My Lords, I, too, thank the noble Baroness, Lady Jay, for giving us this timely opportunity to discuss care in the community. I must declare three interests which will influence my contribution. I am a non-executive director of the West Lambeth Community Care (NHS) Trust, a vice-president of the Royal College of Nursing and a patron of the charity RESCARE, which is committed to the provision of good residential care for the mentally handicapped.

As a member of West Lambeth Community Care NHS Trust, I wish to commend many excellent initiatives that have been achieved within community care not just in Lambeth but in many other places. I, like many of your Lordships, have been moved and deeply encouraged to see how some developments in care in the community have brought a new quality of life, new dignity and new independence to many people who were previously in residential institutions, including many frail elderly people, many mentally handicapped people and many of those suffering from mental illness. It is good to have the opportunity this afternoon to pay tribute to those in the health services and social services who have contributed to those achievements. But there are also many problems. It is because of those that I support the Motion for a national evaluation.

Time permits me to give only a few examples of the problems. First, as a patron of RESCARE, like my noble friend Lord Pearson of Rannoch, I share the deep anxieties of many families with mentally handicapped relatives. I use the term "mentally handicapped" because they prefer that term to the current politically correct terminology, and I respect their wishes. There is widespread, acute concern over the lack of adequate residential accommodation in the community for mentally handicapped people discharged from long-stay institutions. Of course many have settled happily into local authority-provided care, and we welcome and appreciate that, but many others are very unhappy, lonely and neglected. Life for a mentally handicapped and/or multiply handicapped person in a small house on a busy high street can be much more institutionalised and confining than in a larger community with a sheltered environment, diverse recreational and occupational facilities and company among people with similar life opportunities. Moreover, many parents of mentally handicapped children who are caring for their relative at home are themselves growing older and are deeply worried about what will happen to their child when they die. Those families are shouldering a colossal burden now—a point made by many other contributors to the debate —but too many of them are receiving no adequate reassurance from their local social services about what will happen to their loved ones when they can no longer care for them themselves.

RESCARE believes, on the basis of experience in this country and elsewhere, that the village community concept is one which should be supported by the Government as one option of care. As my noble friend has said, a majority of those families want that form of care for their relative. But the Government have dropped village communities from their list of recommended options. I, too, should like to ask my noble friend the Minister whether the Government will reconsider their position in order to meet their own commitments to the principles of diversity, choice and accountability, as well as cost-effectiveness and, more important in my book, care effectiveness.

Widespread problems are caused also by a shortage of appropriate care in the community for many patients discharged from mental hospitals. That is a point already touched upon by other noble Lords. In particular, the paucity of secure, sheltered and supportive environments for people with conditions such as schizophrenia may render them a danger to themselves and/or others.

There appears to be a difficulty in practice arising from the wording of the Mental Health Act for patients appealing against sections requiring compulsory detention in a mental hospital. As the wording stands, patients can be refused an appeal only if all of three specified criteria are met: that they are perceived to be a danger to themselves or others; and that the hospital is providing effective treatment; and there is no alternative accommodation outside the hospital. That formulation means that in some cases there may be a patient who is regarded as a danger to self and/or others but who can win an appeal for immediate discharge if the hospital cannot prove that it is providing any effective therapy. That may be difficult sometimes with some psychiatric conditions.

The result of that wording is that some patients may be in a position to win an immediate appeal against continuing detention under a section order, even when the medical staff responsible believe that they may be a danger to themselves or to others. That makes it even more imperative to have an adequate range of care provisions in the community, including those which provide a relatively secure and supportive environment for such people. Without that provision, there is a risk that the kind of tragedy which occurred with Christopher Clunis may recur. Perhaps I may therefore ask my noble friend the Minister whether the Government could give especially urgent consideration to the recommendations in the Report of the Inquiry into the Care and Treatment of Christopher Clunis, in particular those contained in paragraph 51.0.9 which concern adequate provision of medium secure units, for supportive environments, and for haven-type accommodation in the community for such people.

Finally, perhaps I may highlight one of the concerns expressed by the RCN over shortfalls in qualified nurses working in the community, providing support for vulnerable groups such as the frail elderly and the mentally ill. When the numbers of people coming into the community needing care are increasing because of demographic change and current policies, it is worrying that cuts are proposed in the number of nurses to be trained: an RCN report on nursing students shows a decline from 87,500 in 1983 to 56,870 now, but the Government have recommended a further 20 per cent. cut in 1994–95 which will result in a predicted student nurse population of only 40,000. That will mean a 54 per cent. reduction by 1997 compared with 1993. If that trend continues, the disparity between the need for qualified nursing care and the availability of qualified staff will become acute.

I therefore support strongly the Motion for a national evaluation. Where policies are working well and good practice is established, it is important to recognise and promote them, but where there are problems, it is urgent that they are identified and addressed as soon as possible because in health and social care problems mean suffering; and in the case of community care, that suffering is often experienced by some of the most vulnerable members of our society: the elderly, the mentally handicapped and the mentally ill, those least able to articulate their needs or to assert themselves. I believe that an evaluation should commend itself to a government who are committed to the concepts of quality care, freedom of choice and principles of accountability; and I hope that my noble friend the Minister will be able to give a reassuring response to concerns over current problems and a sympathetic response to the suggestion for a national evaluation.

5.28 p.m.

Baroness Robson of Kiddington

My Lords, I too thank the noble Baroness, Lady Jay, for having introduced the debate. An evaluation of community services after one year is highly desirable. I know that my noble friend Lady Seear said that it was perhaps a short time since the National Health Service and Community Care Act was first introduced, but I believe that it is desperately important that that evaluation takes place now, because we are, after all, setting out the new plans for the forthcoming year. One cannot make meaningful plans unless one has the evaluation of what has happened previously.

I remember clearly the Second Reading of the National Health Service and Community Care Act, when we all welcomed the principle that, if possible, people should be able to remain in the community and stay in their own homes, because we felt that that would make for a better life for such people. It is right, therefore, that after a year we should ask 'whether that Act has worked. We should also ask whether we have achieved a balance between the closure of hospital beds and the provision of care in the community, and whether the provisions of the Act have been implemented across the country.

It was inevitable from the beginning that most of the caring in the community would have to be undertaken by family members, most of whom would be happy to undertake that care on the understanding that the services and support they need would be available within the community.

The aim of the Act was that the support should be provided and that the existing services should be generally improved. In examining what has happened we must keep in mind the fact that the Institute of Actuaries has estimated that the family carers save the country £30 billion per year. In our view about whether we have sufficient resources to help the carers we must never forget the enormous sums of money which they save the community, often by making heavy sacrifices.

The most important point is that carers should be involved in the planning and assessment process of the patient. Furthermore, they should be offered a separate assessment of their own. It is also important that they should have the right to choose not to be carers, and therefore alternative care provision must be in place. We are not all naturally good carers; I do not know that I would be a good carer. That right should exist and it should not be taken for granted that, just because one is a member of the family, one must be a carer.

Has that happened? The Royal College of Nursing, whose representative has just spoken to your Lordships, estimates that one in four older people most at risk are not receiving any statutory services. A recent survey carried out by the National Federation of Women's Institutes revealed that 52 per cent. of full-time carers are never able to take an occasional week off. Support for the carers which is separate from that available for the patient must be provided. Most importantly, a carer should be able to have at least two weeks off in a year so that he or she can be his or her own person. Carers should also have the statutory right to have one day off a week. That should be built into the assessment process in order that these breaks should always exist.

Reference was made in particular by the noble Lord, Lord Taylor of Gryfe, to carers who are looking after patients with Alzheimer's disease. A relative looking after such a patient cannot take any time off during the 24 hours of the day. Frequently the patient cannot be trusted even when he or she is supposed to be asleep in bed, and the pressure on carers is therefore enormous.

Rural carers have also been seriously neglected. As a result of isolation, they are of particular concern. Frequently they have less easy access to the support services which we expect our community carers to have available to them. Often it is not even possible for them to go out shopping for half a day. Rural carers more than any others are thrown back upon the companionship of their patient. It is not possible for them to have much communication with other people living in the community and therefore we must concentrate on ensuring that support services exist for them.

The lack of services give rise to certain problems because it helps to create a bed blockage in accident and emergency departments. Elderly patients waiting for assessment are blocking the beds. Nurses carry out assessment on the admission of a patient. When a hospital considers that the patient is ready to leave, a further assessment is undertaken by the social services. In making those assessments there is insufficient communication between the hospital and the social services and a great deal of effort and time is wasted.

Much has also been said about the reduction in the number of psychiatric beds. Has the number been reduced to such an extent that we are endangering the patients and society? Examples such as the Clunis murder of Mr. Zito have been given. The problem is particularly acute in London. I understand that the average bed occupancy in four London hospitals ranges from 100 per cent. to 130 per cent.

Do we have enough community psychiatric nurses? The number may sound large but it is estimated that there are as many as 4,000 seriously mentally ill patients in the community. Those patients are seriously mentally ill. However, there are only 5,000 community psychiatric nurses in the whole country. They must concentrate on the most seriously mentally ill patients and will not be able to give support and preventive support to the many others in need of community nursing. At present only one in five of those who suffer from schizophrenia has access to a community psychiatric nurse.

We cannot close our eyes to those shortages. Our consciences should tell us that we must solve the problem as regards referral beds for psychiatrically ill patients. A young man set fire to his room in the hostel where he was living. He went to the hospital requesting admission. Although it was agreed that he was a sectionable case, there was no available bed in that hospital and none in the nearest medium-secure centre. A further 11 hospitals were contacted to no avail. In the end he had to spend a fortnight in Wormwood Scrubs before a bed was found for him. That is certainly not acceptable.

The noble Baroness, Lady Eccles, and the noble Lords, Lord Taylor of Gryfe and Lord Holderness, referred to the input which volunteers can make in helping community services. I agree that as volunteers we can do an enormous amount. I am chairman of the National Association of Leagues of Hospital Friends. It has recently changed its constitution in order to call itself Hospital and Community Friends. Most of the patients whom it used to look after in hospitals are out in the community. I wish to voice a worry because our members believe that volunteers are not as happily welcomed by the social services as they were by the hospital authorities. I wish that the Department of Health would give guidance to the social services departments stating that volunteers are enormously useful and helpful. Also, I should like guidance to be given on the legal position of volunteers who visit patients alone in their homes. There could be problems as regards insurance. I should like the department to resolve those problems. All volunteers want to help and want to try to do their best to make the community care legislation work.

5.40 p.m.

Lord Rea

My Lords, my noble friend's Motion and her introductory speech have stimulated a very well informed and—I hope the noble Baroness agrees—useful debate.

In considering the state of community care, I thought that it would be useful to look at one of the foundation stones of the community care part of the 1990 legislation; namely, the report by Sir Roy Griffiths entitled Community Care: Agenda for Action. That is an excellent report. The case is so well argued that the Government had to follow its basic recommendations which gave local authorities and their social services departments in particular the lead role in the provision of community care, despite the Government's systematic attempt during the past few years to diminish the power of local authorities.

However, the Government have attempted to continue the process of diminishing the local authorities' role by requiring 85 per cent. of the (eventually) ring-fenced additional grant transferred from the Department of Social Security to be spent in the private sector. That is a far higher percentage than was recommended by Sir Roy. He said: Proposals should encourage a proportionate increase in private and voluntary services". I emphasise that he included voluntary services. He did not prescribe any percentage, but in my view the 85 per cent. is vastly greater than what he had in mind. In fact, voluntary services, particularly those in the field of drug and alcohol rehabilitation, have had to be funded largely from the remaining 15 per cent. to be spent in the public sector. That has meant that those services have had to contract in many areas, although local ingenuity is finding ways round that in some cases.

There is little doubt that everyone, at all levels of society and on all sides of your Lordships' House, wants community care to work. The basic structure of the Act is a good basis from which to work, although, as my noble friend argued, the 85 per cent. provision added by the Government on mainly doctrinaire grounds restricts severely what local authorities can do. However, as my noble friend pointed out, we are very short of reliable, countrywide information on how the legislation is working.

One survey which has been mentioned by noble Lords is that carried out by the British Medical Association last October. The association received replies from 553 doctors working in community care. That was six months after the Act came into force. That survey revealed that not all was well because 39.5 per cent. of the total said that services for patients had deteriorated, while only 15 per cent. said that they had improved. At least some said that they had improved. Rather significantly, of the 128 psychiatrists surveyed, 52 per cent. said that services were worse and only 11.2 per cent. said that they were better; 55.7 per cent. of the geriatricians surveyed said that the new system was delaying rather than improving the provision of care in the community and 71 per cent. said that bed blocking had increased. They said that an extra 24 days of hospital stay per patient had resulted because of delays in getting assessments and then, following the assessments, there were delays in implementing the recommendations made in those assessments.

Sir Roy Griffiths said that social services departments should develop and sustain informal and voluntary community care resources by supporting informal carers. The noble Baroness, Lady Robson of Kiddington, referred eloquently to that. Of course, informal carers still care for by far the largest group of disabled people. Sir Roy recommended also that volunteers and voluntary organisations were deserving of support.

An important part of the support which carers need, as many noble Lords have pointed out, is respite care to allow a break from the long periods of continuous responsibility which they have. The evidence that there is not enough respite: care has been given by a number of noble Lords. It is the British Medical Association's policy that more respite care should be provided. It is not only the Labour Party that thinks that. I do not believe that that necessarily means that the British Medical Association is very far to the Left, as was perhaps suggested by the noble Lord, Lord Ashley. The Women's Institute survey has been referred to by a number of noble Lords.

Lord Ashley of Stoke

My Lords, I hope that the noble Lord did not get me wrong. I was joking in my suggestion. The BMA is a responsible organisation.

Lord Rea

My Lords, I rather hoped that the noble Lord would realise that I was joking too. I am not saying that the new system is all bad; quite the contrary. Apart from the diversion of funds to the private sector, there is a real attempt in the country to make community care work. In some parts of the country matters are improving. One of those appears to be the district of Bassetlaw in Nottingham, which was the subject of a British Medical Journal article this week. Some rural or semi-rural local authorities may find the transition easier than inner city areas. That is not only because of the favourable share of the transitional financial cake, which my noble friend mentioned, that they are receiving compared with the cities. It is also because inner city areas are much more difficult to deal with.

In many cities, despite the greater concentration of people, there is a lack of sense of community because of a shifting population, poor housing conditions and high unemployment. Although the standard spending assessments, which will more and more take over the funding of community care, are weighted towards deprivation, they are not sufficiently weighted in that direction. As other noble Lords, and in particular my noble friend Lord Howell, have pointed out, inner cities are doing badly. It is in those areas that social services departments have the most difficulty in maintaining good community care.

It is in those areas that one of the worst effects of the private sector requirement is evident. Nearly all the money has to go on residential care because that is where the private provision is. That leaves social services short of money to provide imaginative schemes for keeping people in their own homes. Even before last April, local authorities were having to decant elderly, infirm people into homes which were well outside the districts where their younger relatives or former neighbours lived. That made it difficult for those people to visit. That is largely because the private sector homes cannot afford to operate in the inner cities where housing costs are higher and staff are more expensive and difficult to retain. I believe that that process will only become worse under the present requirements. The Government could help to retain a stronger sense of community in the inner cities if they were to relax the 85 per cent. rule for those local authorities which have very few residential homes in the centre of their area.

Many noble Lords mentioned the Report of the Inquiry into the Care and Treatment of Christopher Clunis. It is a very important report and gives a chilling account of what is wrong with the operation of the present system of community care for the mentally ill. The fact that the events described took place before April 1993, when the community care Act came into force, does not diminish the importance of its conclusions and recommendations. Indeed, they are just as applicable today. However, it is a sad reflection that it takes the murder by one patient and the mauling by a lion of another to sting a government into action.

As I said, the report is chilling; it details many missed opportunities when the course of events could have been changed. Nevertheless, it is also very humane and fair to everyone involved. In particular, it praises Mrs. Jayne Zito, the widow of the victim, Jonathan Zito. Its recommendations are clear. Moreover, in her response to the report, as well as promising the well-publicised £10 million for London's mental health services, Mrs. Virginia Bottomley also agreed to one of its principal recommendations, which states: A new power of supervised discharge will underpin the care programme for the most vulnerable people … patients who do not comply with their programme of care may be recalled compulsorily to the hospital". The Ritchie Report gives some useful advice on the detailed operation of such a power. I would welcome a brief description from the Minister on how that power will operate without discouraging those patients who are seeking to become independent and whose health is actually improving. At page 123 the Clunis report says: It has been difficult to understand the objectives of services other than to achieve ever more rapid turnover of inpatients. Judging from the example of Christopher Clunis … responsibility, once a patient has left hospital, has usually been vague or misunderstood, leading staff to work in the dark. Communication has often been duplicated or not done at all". I return now to the theme of the debate. The report recommends that the Department of Health should set up proper procedures for effective monitoring of psychiatric services in the community. It is our contention on these Benches that the monitoring of community care as a whole needs to be strengthened. For example, there should be reports on a regular basis which should not be restricted to mundane statistics; they should honestly describe shortcomings and the reasons for them, including underfunding where applicable, and should be published in an easily accessible form. They may answer some of the questions posed by the noble Baroness, Lady Faithfull.

We should not forget the enormous amount of good work—informal, voluntary and professional—which is taking place. That also should be reported; good practice in one place can be adapted and taken up elsewhere. (I see that I have exceeded my allotted time, but there is still at least half an hour to go before the debate is due to finish.)

It is the job of government to make the task of those working in the community more satisfying and effective, rather than, as Sir Roy Griffiths put it, having to grapple with problems at local level which make them feel that the Israelites faced with the requirement to make bricks without straw had a comparatively routine and possible task.

5.55 p.m.

Baroness Cumberlege

My Lords, I should like, first, to add my thanks to those expressed by all speakers in today's debate to the noble Baroness, Lady Jay, for giving the House the opportunity to debate community care almost a year after the full implementation of the new arrangements. Her insight and perception were, as always, evident, as were those of other noble Lords who took part in today's wide-ranging and interesting discussions.

We know only too well from our own experience that most of our great social institutions—the police, the National Health Service and education—look to and thrive upon the active involvement of the public. We support the views expressed by the noble Baroness, Lady Seear, and the right reverend Prelate the Bishop of Bristol. But, by and large, we are not a society that is content to shuffle off our responsibilities onto agencies of the state: we recognise the imperative of caring for our neighbour and we know that many people seek to put that principle into practice.

That is why so many people in this country are prepared to devote long hours each day to care for a dependent friend or relative. That is why many, willingly, bring comfort and support to friends and neighbours who are not linked by family bonds. Of course, a great many people prefer it that way, as was so clearly elucidated by my noble friend Lord Holderness. I suspect that there are very few people in your Lordships' House—and we know that there are only a minority in the country—who would not rather live out their lives to a ripe old age in their own homes and die in their own beds.

However, we also recognise that many elderly and disabled people live alone and often with a sense of trepidation. They are fearful to have an unlocked door or an open window. They worry that neighbours may turn violent through drink or drugs or because they are common criminals. They dread isolation and a future in which they are both unloved and unneeded. In such cases, we seek to ensure that those who are in a position to help, mainly the local authorities, are able to respond quickly and with compassion. Where the problems are most acute, such as in relation to people who suffer from a severe mental illness, that response must be thorough, sensitive and effective.

There is no argument that the principle of the community care Act is right. As the noble Baroness, Lady Jay, said, we all want it to succeed. Moreover, as my noble friend Lady Miller and the noble Lord, Lord Ashley, said, such a tremendous shift in policy cannot be achieved at lightning speed, without any problems and to the same high standard everywhere. The reforms give the lead role to social services departments and in doing so make the assessment of an individual person's needs the pivot, the fount from which all else flows.

That is a marked change and requires social services staff, community nurses, GPs and many others to work differently. Organisations providing care in the community, whether residential or home-based, independent, private or voluntary, have also had to adapt to new ways of working, particularly working in close partnership. Money has been transferred from social security to enable that to happen. New procedures have had to be designed, assessment arrangements put into place and financial and information systems installed.

It is a massive agenda and one which will take years before all the benefits are realised. At its outset, we said that community care was a programme for a decade not a quick overnight fix. I shall try to satisfy the noble Lord, Lord Ashley—not an easy challenge—on the question of resources. Many speakers today expressed their concern on that front, especially the noble Lords, Lord Taylor of Give and Lord Howell. However, we have put huge resources into that area. For this year and the next three, the special transitional grant is ring-fenced: £565 million this year. We will make available a total of £1.2 billion next year and £1.8 billion in 1995–6, amounting to over £2.2 billion in 1996–7.

The noble Baroness, Lady Seear, is always eloquent in putting the case for supporting carers. The noble Baroness and other noble Lords will be pleased to learn that we have been able to allocate £20 million next year and £30 million the year after to give a boost to day and respite services. And of course the mainstream personal social services element of the standard spending assessment for local government totals over £3.3 billion, with a near doubling of SSA, plus STG from £3.6 billion in 1990–91 to £6.4 billion in 1994–95.

It is simply not true to say that authorities lost from this year's distribution of the special transitional grant. A thorough examination of the formula would reveal that all those authorities received far more than would have been spent by the social security system on their residents had the old system continued. Standard spending assessments for personal social services are based on a complex and carefully considered formula. One of the most important factors is the local population of elderly people who may be in need of services.

Furthermore, the changes we have made to the special transitional grant benefit many of the authorities to which the noble Lord, Lord Dean, referred. Manchester will receive an increase of 41 per cent. next year, while Wigan will receive an increase of 54 per cent. and Leeds 51 per cent. We can fairly claim that as regards community care we have put our money where our policy is. But, of course, there will never be unlimited resources. However, the strength of our reforms is that, above all, decisions on how to allocate resources are now made on the basis of people's assessed needs.

Both health and local authorities have made a sound and promising start. My noble friend Lady Eccles, drawing on her experience as the chairman of a commissioning agency, pointed out to us the enormous initial effort that has been invested in getting this system working. The framework is now in place and the system is beginning to work. The Audit Commission, whose initiative in the mid-1980s was vital in focusing attention on this policy, commented recently in its report Taking Care that, So far, implementation has proceeded smoothly—a major achievement for all concerned, given the many forecasts of disaster". The noble Baroness, Lady Jay, and the noble Baroness, Lady Robson, will, I am sure, be pleased to learn that we entirely agree with the main thrust of the Motion before us today. It incorporates a central feature of the Government's approach. We do need a proper programme of monitoring and evaluation. In the run-up to last April's start, a vast effort was put into ensuring that all authorities were in a position to handle these new responsibilities. The department published an array of guidance, supported authorities through conferences and visits and, of course, established the community care support force. During this first year of implementation, the focus has been on ensuring that all authorities have basic systems in place. Every social services and health authority has been visited at least twice.

The right reverend Prelate the Bishop of Bristol drew your Lordships' attention to the evaluation of the Social Services Inspectorate and to the NHS Management Executive's 14 special studies into specific areas of the reforms. The report of the first six of those studies, entitled First Impressions, has recently been published. This should help authorities to move further forward. Much of this monitoring has already produced tangible results. Some local authorities have recognised that their procedures are too complex and are revising and simplifying them.

We have not yet finalised our programme for next year but this will need to reflect both authorities' growing competence and how best to help them in the future. For example, there is already quite a lot of evidence that where local care managers have devolved budgets, they can purchase a range of imaginative services to suit individuals that would not have been possible under the old system. In one case a man aged 81 was discharged from hospital because his 70 year-old wife was adamant that she wanted him living at home. His house was adapted, district nurses called to wash and dress him and put him to bed and respite was made available. I think it could be argued that this could have happened before the 1st of April last year but the attitudes then were very different and probably he would have been discharged into a residential home.

In another case, an 89 year-old man with lung cancer lives with his son who works long hours. The man cannot prepare himself a midday meal and his son was unable to get home until early evening. But rather than have a meal delivered, the father expressed a preference for someone to come in and prepare a meal for him. This has now been arranged through a private home care agency at a cost which is actually less than the local authority's meals on wheels service. That is an important point.

The noble Baroness, Lady Jay, and the noble Lords, Lord Howell and Lord Rea, questioned whether we should continue with our policy of requiring 85 per cent. of the grant to be spent in the private and voluntary sectors. The purpose of this condition is to make sure that people get a choice. If the old system using the social security money had continued, all of the social security transfer money would have been spent in the independent sector on residential care. It is hardly unreasonable to expect authorities to spend 85 per cent. of that money in the independent sector now, and we hope that they will increasingly spend more on domiciliary services. That is in fact only 60 per cent. of this year's total grant.

We know that the progress we have made cannot happen without considerable effort and energy and we need to ensure that the reforms remain on track. That is why, as well as our monitoring programme—I am sure my noble friend Lady Faithfull will welcome what I am about to say—we have also commissioned independent research from, among others, the Universities of Kent and Leeds and from the National Institute for Social Work. I was interested to learn of the research being undertaken by Stirling University, as was mentioned by the noble Lord, Lord Taylor.

The noble Baroness, Lady Jay, called for national standards, as did other Members of your Lordships' House. We are not talking here about national monitoring but national standard setting. The Government have issued a wide variety of policy and practice guidance and we have a programme of national inspection, but what we do not want to do is to take over the role and the responsibilities of local government. Community care is a service for local people delivered by local agencies. They know far better than us at the centre what is required locally and what the strengths and weaknesses are in the local community. We do not wish to impose on them rigid national standards which may or may not fit into their local circumstances.

We are concerned about the particular needs of special groups. The noble Baroness, Lady Jay, the noble Baroness, Lady Robson, and my noble friend Lady Cox have drawn attention to the case of Christopher Clunis which has quite rightly received a lot of national attention. My noble friend Lady Faithfull, with her usual knack of getting straight to the heart of the matter, drew out some of the weaknesses which were highlighted in this tragic case.

As we know, Christopher Clunis killed Mr. Jonathan Zito and that case has been thoroughly examined by the independent inquiry chaired by Miss Jean Ritchie QC. Miss Ritchie's report emphatically endorsed the Government's policy of care in the community but chronicled a series of failures where agencies were not adequately working together. Vital facts about Mr. Clunis were not made known to relevant people. Though all involved were trying to help, time and again no one took responsibility for ensuring that a very vulnerable patient received the treatment he needed. I am sure my noble friend Lady Faithfull will recognise the same elements which used to be so apparent in child protection services. What happened in the Clunis case is the antithesis of what the care programme approach is all about and we are committed to helping local agencies overcome the problems which lay at the heart of these failures. My noble friend Lady Cox will be pleased to learn that my right honourable friend the Secretary of State has accepted all the recommendations of the Ritchie Report.

In addition, last August my right honourable friend announced a 10-point plan to reinforce community care for severely mentally ill people. This includes seeking new powers for supervised discharge—as has already been mentioned in the debate—and the introduction of supervision registers and also some revised guidance and training for key workers on the whole question of discharge. We have consulted widely about draft guidance on the discharge of mentally disordered people and their continuing care in the community. We shall also be publishing further guidance, focusing on inter-agency working, which will take account of Miss Ritchie's recommendations.

The noble Baroness, Lady Robson, raised the issue of bed blocking. We agree with her that we need effective hospital discharge. That is vital. Before last April we were regularly told that the so-called bed blocking would increase dramatically and that hospitals would grind to a halt. But our monitoring shows that that has not happened. Indeed, it seems that the new focus on assessment is improving collaboration between hospitals and social services, strengthened by the joint discharge agreements that we have required.

I hope that I can reassure the noble Lord, Lord Molloy, who raised this subject, that those in nursing homes before 1st April 1993 have preserved rights to income support. Those income support rates will rise from April 1994 by considerably more than income support rates in general.

The noble Lord also raised the question of untrained staff doing assessments. We have made it very clear to local authorities that the full range of professional skills must be drawn upon in carrying out these assessments, although of course social services have the lead responsibility.

The noble Lords, Lord Molloy, Lord Ashley of Stoke and Lord Rea, and my noble friend Lord Holderness mentioned the BMA survey of community care. We fully recognise that GPs have an important role in community care, although not the central one. They are very often the first point of contact for people who may be in need of help and support. Our own monitoring has confirmed to an extent some of the BMA's findings. There is a need for social services to work more closely with GPs and, indeed, for GPs to reciprocate. We are currently carrying out a special study which will identify good practice that can be used to make improvements in that relationship.

At the same time, I would say that the BMA's own survey contains reasons for optimism. For example, 60 per cent. of those who responded felt that the quality of services for their patients had either stayed the same or improved since 1st April. That, after all, is not a bad result only six months into a major set of well-publicised reforms, particularly from a study in which only one in four of the doctors surveyed chose to respond.

My noble friend Lord Holderness mentioned the question of disabled people and their training and responsibility for their care arrangements. We are sympathetic to the objectives of those who argue that local authorities should be able to make cash payments in lieu of services. However, such a system would inevitably add considerably to local authorities' responsibilities. We do not think it right to consider a shift to direct payments until we have had a good chance to examine how well authorities are coping with their new responsibilities for community care. Unless we look at the wider picture we risk prejudicing the general services which authorities must deliver. I can, however, assure your Lordships' House that we will be keeping this under close and constant review as we gather more evidence about local authorities' performance.

My indefatigable noble friends Lord Pearson and Lady Cox raised again the issue of village communities. I know that my noble friends will be dissatisfied with the answer that I am about to give. They asked me not to reply by saying that village communities are one of the range of services that authorities may purchase. However, that is the simple answer. We do not propose to tell authorities how they should meet individual needs, but we want them to explore the widest possible range of residential and other care.

My noble friend Lord Holderness and the noble Baroness, Lady Robson, raised the question of the use of volunteers, and my noble friend Lord Hamilton of Dalzell the independent charitable sector, highlighting the remarkable work of the Queen Elizabeth Foundation for Disabled People. It is an organisation I am well aware of and one which I admire. The Government are committed to the involvement of volunteers in both health and social services. As my noble friends said, they can often perform very valuable tasks. I agree with him that independent organisations are often ahead of the game.

The Department of Health has recently increased its funding of its key Opportunities for Volunteering scheme to nearly £8 million a year. That will support over 500 local projects. With regard to the legal status of volunteers visiting people in their homes, which the noble Baroness, Lady Robson, mentioned, I shall have to come back to her on that.

In conclusion, community care is exactly what it says: every person in the community contributing their talents to the benefit of their families, friends and neighbours. It is inherently good. So do not let us join in the national spurt of denigrating what is best. We shall need a great effort, particularly in inner cities, to strengthen communities. The need is to encourage: to encourage social workers working in the toughest and at times the most depressing conditions; to support nurses and doctors; pray, and fund the Church initiative; co-operate with the police; cherish employers, support clubs, voluntary organisations and activities that help to build a community; and, above all, sustain the users of our services and care for, and listen to, their views and wishes. The more people who are involved the better will be the monitoring, the greater the success. The state provides professional support but the community also has a part to play, for essentially it is a people's project.

Lord Pearson of Rannoch

My Lords, before my noble friend sits down perhaps I may say that I was very grateful for her saying, as I am sure we all agree, that local authorities should consider the widest possible range of facilities available. If that is so, why can she not agree with the request from my noble friend Lady Cox, from me and from others that village communities should simply be given a level playing field with those other facilities? Why should they be discriminated against? That is the question we are asking. We are not asking for preference; we are just asking for the equal treatment which many people want.

Baroness Cumberlege

My Lords, I do not believe that it is a case of our discriminating against them. We say that it is one of the options that is available, but it is up to local authorities to evaluate the contribution that they feel that village communities can make and then to purchase those services.

6.16 p.m.

Baroness Jay of Paddington

My Lords, I am very grateful to the Minister for her helpful and detailed reply to our debate this afternoon. I was particularly pleased to hear her say that her right honourable friend the Secretary of State has accepted all the recommendations of the Ritchie Report on the Christopher Clunis case. I am sure that that will be of great interest to many people working in this field.

I was less happy with her reply in respect of the adoption of national standards for community care, but grateful for those noble Lords who supported that idea.

In general I should like to express my great thanks to all noble Lords who have taken part in this debate. They have contributed to a very authoritative and well-informed discussion, as is always the case in your Lordships' House on these issues. I was particularly pleased by the support all round the House for the idea of a proper national evaluation of community care. If it was not against the conventions of your Lordships' House I almost feel that I could test the opinion of the House on that subject, but as it is I beg leave to withdraw the Motion for Papers.

Motion for Papers, by leave, withdrawn.