Long-Term Care: Financing

HL Deb 30 November 1994 vol 559 cc602-43

3.9 p.m.

Lord Ashley of Stoke rose to call attention to the uncertainties within the health and social services concerning the financing of long-term care; and to move for Papers.

The noble Lord said: My Lords, I very much regret that I shall be unable to stay for the whole of the debate because I am in some discomfort which requires attention. Of course, no discourtesy is intended and I apologise to noble Lords. I shall return if I am able, but in any case I shall read avidly the speeches in Hansard on this important subject.

The central theme of the debate is the failure of the Government to deal with the health and community care problems of some of Britain's most vulnerable people: those who need long-term health care. At a time when such people need reassurance and dignity, they are faced with anxiety and distress. Today we are concerned with people whom doctors simply cannot help yet whose health is such that they need continuing care which is often nursing care.

Our aim in the debate is to seek constructive solutions. I have no doubt that the aim of the noble Baroness, Lady Cumberlege, is the same, because she always tries to be helpful. Nevertheless, it is urgently necessary to explain the ways in which the Government have created uncertainty, confusion and even despair.

The basic principle of health care is that it is funded largely by taxation and is free at the point of delivery, whereas personal care services are provided by local authorities, are means-tested and are charged at the point of delivery. The significance of that distinction is absolutely crucial, especially in view of the reduced number of NHS continuing care beds and the movement of funds from social security to community care.

The facts are staggering. In the past three years the number of NHS beds for continuing care has dropped dramatically from 73,000 to 59,000. The reassuring open-ended social security funding for people in homes has been replaced by rigid, cash-limited community care budgets. So it is no surprise that, trapped in this web of inadequacy, both district health authorities and local authority social service departments have become involved in squabbles—undignified squabbles, but squabbles nevertheless—about who is responsible. That is damaging to everyone concerned. I believe those squabbles damage the relationships between the district health authorities and the social service departments. But they damage the interests of the patients even more. There are frequent reports of patients actually being forced out of National Health Service beds. The sad case of the brain-damaged man who was ejected from a Leeds hospital led to an inquiry by the ombudsman. The question is how far that very sad and distressing case was an isolated one or how typical it was of others.

The recent draft guidance from the National Health Executive, presumably supported by the Minister and her colleagues, failed either to clarify issues or to ease the growing tension. Instead, what it actually did—although it sought to disguise it—was to introduce significant changes of emphasis and of policy. It has been widely criticised. The criticism has provoked Ministers in this House and elsewhere into claiming, with an air of injured innocence, "No, nothing has changed".

Well, let us have a look at the assertion. The House is entitled to examine rather dogmatic insistences that nothing has changed. For a start, the guidance- is ambivalent. I trust that the Minister has it on her knee. She will notice that on page 1 is trumpeted the reassuring message: The National Health Service remains responsible for meeting … the needs of people who require long term physical or mental health care". That is fine; there is no ambiguity. It is a clear statement of fact. However, if the Minister turns to page 2, she will see that, the expectation will be that the significant majority of people who require continuing care in a nursing home setting are likely to have their needs met through social services". Not the National Health Service, but social services! We have already seen the distinction between the two: one where you pay and one where you do not, with a great variety between them. So it seems that, according to the official document backed by the Government, you choose your page and then you make your choice.

The guidance has even more tricks tucked away in the text. After reassuring us that the NHS remains responsible, it slips in the phrase "within available resources". That is a significant point for the Government to make about the National Health Service which we have always assumed to be free at the point of delivery.

The Association of Directors of Social Services has observed that the comment is in marked contrast to the guidance issued to local authorities before the implementation of community care. That indicated that once eligibility for a service had been established budgetary constraints could not be a consideration in the provision of a service. That is a very important statement. In other words, the local authority service was a right, but continuing care on the National Health Service is now conditional on money which may or may not be available. It is a very different health service that we see unfolding, judged by the guidance of various authorities.

If the Government really want to clarify their policies, they should define their concepts. As the Minister will see in the guidelines, one of the most important sentences is: For some people, and certainly those with complex or multiple health care needs who will require, on a long or short term basis, continuing and specialist medical or nursing supervision, the NHS should be responsible". Yes, of course it should. Apart from the clumsy phraseology, may I ask what is meant by the phrase, complex or multiple health care needs", or the phrase, specialist medical or nursing provision"? I know that the Minister will try to be helpful. I invite her to give a clear and specific explanation when she replies to the debate.

The caring organisations are very concerned that no precise meaning has been attached to the words. Many are very anxious indeed; in fact, all those to whom I have spoken are anxious because on those words, definitions and precise meanings hangs the positioning of the future care of thousands of individuals together with major financial implications.

So it is no small issue. It affects the whole of the financing of vital services for thousands of people. That is why I press the Government for clear, categorical and specific answers. Without national definitions, national criteria, we shall have increasing conflict and growing variation as local bodies make definitions to suit themselves. The present mish-mash of decision-making is causing undignified bickering, angry conflict and deep misunderstanding. It is eroding, even destroying, the equitable provision which is the real strength of our proud National Health Service. If that equitable provision goes, it is no longer the National Health Service all of us have cherished.

There is an overwhelming need for national criteria for National Health Service provision of continuing care. The Government should take steps to provide such criteria. If they do not—and millions of people will listen to the reply to this debate—the reasoned and reasonable presumption, the moderate presumption, is that the Government are working towards relinquishing National Health Service responsibility for continuing care. That, to put it very mildly, would be deplorable.

The issue of hospital discharges is a sensitive and distressing one. Here again, the Government are ambivalent. Most people, I assume, in this House, and certainly millions of people outside, have long assumed that no National Health Service patient should be placed in a private nursing home against his or her wishes if he, she or a relative is unwilling to be responsible for the home charges. After all, that is what the current guidance on hospital discharges says. It is in black and white. It is official; it comes from the Government. That is why millions of people believe it. That is fair enough.

But the new guidance, which the Minister has on her knee, disingenuously omits that stipulation. It speaks merely about "taking account" of the person's and the family's wishes. I could take account of the philosophy of Genghis Khan, but it does not mean that I take it very seriously. The Government can take account of these issues; it does not mean that they have to take them seriously. The previous guidance made the commitment mandatory; the present guidance wriggles out of that. It avoids and evades it. This is a matter to which Members of this House and of another place should give very careful scrutiny and in relation to which they should insist on clear government answers.

The guidance goes on to say that although, Every effort should be made … to meet the … wishes of the patient", if a person has been assessed as not requiring NHS long-term care the question of how long the person can stay in an NHS bed depends on, the needs of other patients". It does not depend on that patient; it depends on the needs of other patients. I suggest—it is only a suggestion—that bed needs are winning when they conflict with the patient's wishes to retain a National Health Service bed.

The Association of Directors of Social Services, a very responsible body, says that there is increasing evidence—not hearsay—that in a substantial number of local authorities there has been a significant increase in elderly people who die shortly after having to leave hospital to go into a nursing home.

What a situation to have to consider! The Minister can always contradict me if I am wrong. This is only my interpretation, not that of the association. But apparently the harsh message is: if you are dying but the shortage of beds means that your bed is needed, you must leave hospital to die; if you are a man, while you are dying your wife may have to use all the proceeds of your occupational pension scheme to pay the fees for a private nursing home; and if you linger too long before you die, nearly all of your joint savings may have to go too.

I believe that to be the correct interpretation of the present situation. To put it mildly, it is shocking and disgraceful. Without national definitions and criteria, we shall have increasing conflict and growing variations as local bodies make definitions to suit themselves. We have to be very, very careful indeed about this matter.

I shall draw my remarks to a conclusion as I am afraid I have spoken for far too long. I emphasise that in no way do I criticise the hospitals or their dedicated staffs of doctors and nurses for any of these enormously complex and difficult problems. The staff are in no way to blame. They do a marvellous and dedicated job. They are struggling to meet new obligations and to provide for people from money that has not been made available to the required extent. The fault—I wish to emphasise this—lies not with the hospitals or the doctors. It lies with the Government.

Ministers have a clear responsibility to ensure that vulnerable people who are in difficulty and distress suffer no additional burden. The Government should reconsider their policies. They should make sure that those policies are clear and constructive and that they rest on the criteria I have mentioned. They should act speedily, sensitively and generously.

My Lords, I beg to move for Papers.

3.27 p.m.

Baroness Seccombe

My Lords, first, I ask the indulgence of the House. I am afraid that I am unable to observe the convention of the House in remaining in the Chamber for the entire debate. I have a long-standing commitment so I shall have to leave early. I have apologised to the closing speakers, and especially to my noble friend the Minister.

The debate on continuing care is part of a wider debate on community care in general, which affects many stages of our lives. This afternoon, however, I shall concentrate on care for the elderly. I start by addressing two common misconceptions.

First, community care is not a new concept. For many years and in many circumstances care has been provided for people in their own homes, or in homely surroundings in the community. But it has increasingly been recognised that long-term institutional provision, particularly in geriatric wards in hospital, may often be degrading and dehumanising. Providing appropriate care for elderly people in the community, properly financed and properly organised, is, I am sure, an ideal towards which all of us would wish to aim. We live in a compassionate country where we value choice for our elderly relatives. Living in their own home or in homely surroundings is, for many, vitally important.

Secondly, when care is provided in the community that does not exclude the possibility of it being provided by the health service free of charge where there is a need for health care. The 42,000 NHS community nurses working across the country would, I am sure, confirm this; as would the 1½ million elderly people who are treated by those community nurses every year and the many who receive health care in a residential setting.

As noble Lords will be aware, earlier this year the Government published draft guidance on continuing care. This made it clear that the NHS has, within available resources, an ongoing responsibility to meet long-term health care needs—including the needs of people who require continuing care from the NHS in a residential setting or in the community rather than in a hospital.

Clearly, people's individual needs for care differ, but their general requirements remain the same. In each case, they require a full assessment of their needs. They need a clear decision on whether they require continuing NHS care —a decision based on a clinical judgment—or whether they require social care. Also, they require information and advice on discharge procedures and on options for long term care. These requirements were set out in the recent guidance. It stressed the need for health authorities and local authorities to work closely together. Contrary to general belief, it did not change the responsibilities of the NHS to provide continuing care, but sought to reinforce and clarify existing responsibilities. Indeed, I understand that working relationships between health authorities and local authorities have already improved recently, as a result of the agreements which have been negotiated between them as part of the community care reforms.

Nevertheless, the distinction between health care, which is provided free of charge by the NHS, and social care, provided according to means, has been in existence since the foundation of the welfare state. The House may be aware—certainly noble Lords opposite must be aware—that it was a distinction recently endorsed in principle by Labour's Social Justice Commission.

But there is also a third sector which provides care for elderly people: the voluntary sector. Many of us throughout our lives are conscious of the great kindness and support given to those who live near and are in need of a helping hand one way or another. I should like to pay tribute to those who give so generously of their time and love.

I have been deeply impressed by the very valuable work done by young people, who are often still at school; and more and more retired people care for a parent in their 80s or 90s. But many elderly people reach a stage where more formalised care is necessary and this is where residential care plays its part. Clearly, it is essential that their needs are assessed without the ethos of care becoming lost in bureaucracy.

Local authority social service departments have willingly grasped the nettle of organising such assessments and arranging for services to be provided. In most cases good progress has been made. But, as in the case of any new initiative, some local authorities may have faced a few teething problems.

I have recent experience of looking after an elderly relative. I found the rigidity of the system a little difficult; for example, those requiring help with getting ready for bed may be forced to accept it at any time between 6.30 p.m. and 10.30 p.m. In such circumstances nothing can be arranged for the evening, which consequently can be lonely and miserable. Clearly, greater flexibility may be required.

There has been much publicity over funding for community care. Some local authorities claim that they have exhausted their funds at this stage of the financial year. I read that with some amazement. The amount available for social services spending in this financial year, including community care, is £6.4 billion, which is nearly double the amount available four years ago and an increase of 48 per cent. in real terms. No other area of local government spending has increased nearly so rapidly. It is up to local authorities themselves to discharge effectively their new responsibilities—responsibilities for which they have long campaigned.

However, I am confident that in working with the health service and the independent sector they will be able to move us towards the "seamless service" of health and social care, provided according to individual need, which we all seek.

3.35 p.m.

Baroness Hamwee

My Lords, I thank the noble Lord, Lord Ashley of Stoke, for introducing this very timely debate. I am glad to have the opportunity to look at what care in the community should mean and how it can be paid for. I believe that it should mean encouraging independent living, where that is practical, and particularly facilitating an informed choice for users. I include carers among the users. It should mean enhancing the development of communities, so that the designation "care in the community" can be given real substance. It is a concept that we on these Benches support.

It is ironic that so much effort was put into debating whether or not community care budgets should be ring-fenced. Would that the cash were there and that it were now a material issue. The noble Baroness, Lady Seccombe, spoke of social services departments "claiming" to have exhausted budgets. The claim is a very real one.

I too see the matter somewhat from the viewpoint of social services. Like the noble Baroness, I believe that the provision should be a seamless provision—both health and social services—and that the right perspective is the perspective of the user. We know of ministerial statements that there are no changes in policy but we must all also have encountered the wide perception that in fact health care boundaries are shifting, leading to greatly increased demands on local authorities. The reduction in waiting lists, day surgery, the management of performance related to throughput and contracts concerning the volume of patients must all have their effect.

If there is to be less structural cohesion between health and social services—by that I mean the use of the local authority structure to bring health services into local democratic control and locally accountable—then various issues must be addressed: issues about defining the boundaries of responsibility; issues of quality, such as where very ill people want to be; and there must be the maximum of openness and clarity with patients and carers on the services that they can expect and the financial contributions that will be required of them. It seems to me that one of the tragedies of the current situation is that the relationship between the NHS and social services departments must tend to be less collaborative without enormous efforts to be more so.

The debate is about financing. That includes financing by individuals. There is an increasing tendency of the NHS to define its boundaries as relating to those who are acutely ill. As the noble Lord explained, costs going to local authorities means the covert—I do not use that word with any sense of malice but it defines one of the hidden effects —withdrawal of free health services and in their place a charged means-tested service. I accept that care at home or care in a nursing home—many nursing homes are homes—is often more acceptable than care in hospital; but that care should be accessible.

It seems to me from a local authority perspective that increasingly services provided by local authorities are not necessarily provided most cost-effectively or appropriately. Let me mention domiciliary care. Too often those who provide domiciliary care—those at the sharp end—were originally home helps. They have had a little training but the strain on them in undertaking what is increasingly a nursing function must be enormous. Of itself, that will lead to a vicious spiral in recruitment. On the other hand, nurses are trained not just to give direct health care but to diffuse emotion and counsel when there is a bereavement. We need to review the use of our resources overall.

Over the past few days I have asked colleagues what might come positively from the current crisis. Sadly, I have not found any real, positive, constructive ideas—and this is a crisis. Indeed, the only sentiment that I can identify is that, among the public, who think that local authorities should put all their efforts into picking up litter and dealing with other important but perhaps more minor matters, there may be a greater understanding of the emphasis that local authorities will have to put on social services care.

I conclude with a thought that was put to me at a meeting last week by a representative of a carers' organisation. Among those for whom we need to care—not all, but a part of the client group—are elderly people. They come from a generation who thought that their national insurance contributions would fund their care; who fought the last world war or are the widows of people who fought the last world war. This year we commemorated the Normandy landings; next year we shall commemorate VE Day. The Royal British Legion act of remembrance ends, We will not break faith with you". Let us not do so.

3.40 p.m.

The Countess of Mar

My Lords, if ever there was an occasion when noble Lords could justifiably turn to the Government and say, "We told you so", this is it. They will recall their struggle to persuade the Government that funds allocated to local authorities for community care should be ring-fenced. Sadly, that battle was lost and we are now finding that many local authorities, especially those shire counties in the south-west of England, are having to make very painful decisions on behalf of their vulnerable and elderly clients.

I believe that local authorities approached the introduction of care in the community constructively and responsibly. The fact that central government allocation of funds is strictly cash limited has ensured that the rapidly escalating expenditure under the social security system has been successfully capped. Of course, that is exactly what the Government meant to achieve.

If the provision of community care really is to meet the needs of those for whom it is intended, it must be properly funded. I live in Worcestershire. On 17th November this year the chairman of Hereford and Worcester County Council social services committee announced that the council could be facing a £2.4 million deficit unless stringent measures are taken. She said: In this county it is putting staff in an impossible position and some very difficult decisions may have to be made as to who will receive care and who may be left wanting". The chair of Shropshire County Council policy and resources committee, on 15th November 1994 predicted a shortfall in their community care budget of between £1 million and £1.5 million this year. She said: Our figures arise from significantly increased use, particularly of nursing home places, as well as packages of care. The extent of spending was not anticipated in early community care plans which were drawn up for the first time 18 months ago". Similarly, Gloucestershire County Council is facing a £2.5 million shortfall. A Conservative and Independent member of the council's social services committee is quoted as saying, Community care is one of the most important innovations to come from the Conservative Administration. It was working well in this county but it is asking the impossible when £2.5 million of grant is suddenly removed from us and similar or larger sums from the other shire counties. It puts our staff in an impossible position". Why is it that social services departments in those local authorities are suddenly finding themselves in an untenable position? There are two main reasons. First, after a slow start, demand for home care and residential and nursing home care has greatly exceeded early estimates. In Hereford and Worcester community care workers are having to deal with 1,000 extra referrals a month; requests for home care are up by 20 per cent. on last year's figures, and the number of children in local authority homes has also escalated. In Gloucestershire there has been an increase of 40 per cent. in clients being assessed. Perhaps the Government's publicity machine worked too well!

The other reason for the shortfalls is the sudden and arbitrary decision of the Government in December 1993 to redistribute their allocation of the special transitional grants between local authorities. The shire counties lost nearly £80 million, while the metropolitan districts and inner and outer London authorities gained that amount. Will the Minister please explain why so much money was taken away from the shire counties so suddenly? They had drawn up their budgets on the basis of funds promised by central Government only to find that, without any prior discussion, those promises have been broken.

What is the result of that combination? The director of Gloucestershire Social Services wisely says, this is not a budget crisis, as managers within the Department have a responsibility to maintain expenditure within their budgets. They can only do this however, by applying much tighter criteria for the delivery of services. This will have severe implications for users and carers in the county". The reports I received from Hereford and Worcester and from Shropshire are similar. They are not profligate local authorities. Their staff are prepared to cut their coats according to the cloth, but they must make painful decisions. In some cases services will have to be refused and in others they will be withdrawn if clients do not fall within the priority categories. Services will inevitably be reduced and rationed to people who are at risk and there will be extended waiting times for services.

Time does not allow me to expand upon the impact that those strictures will have upon clients and their carers. I simply say that we should not be surprised to hear a catalogue of horror stories similar to those which prompted Her Majesty's Government to develop a community care strategy in the first place. I am extremely grateful to the noble Lord, Lord Ashley of Stoke, for enabling us to debate this subject this afternoon.

3.45 p.m.

Baroness Macleod of Borve

My Lords, the noble Lord, Lord Ashley, introduced the debate with his usual eloquence, which we have come to expect. Unfortunately he is suffering from a badly trapped nerve which must cause him a lot of pain. However, I congratulate him in his absence on the way in which he introduced the debate.

I want to concentrate on widows and the elderly—and I must declare an interest in both. When I was young our sell-by date was three score years and ten. Following advances in medicine, science and the experience of doctors, it has now become three score years and twenty. In declaring my interest your Lordships may like to know that I am very near three score years and twenty and feel therefore that I can speak for a few minutes this afternoon.

During the time of the present Government—the past 15 years—enormous help has been provided for the elderly. All sorts of things have been introduced to enable them to live better, to work if they are not too old, to be happy, to be surrounded by as much comfort as we are able to give them and, with any luck, to allow them not to have to worry too much about the future financially. We have come a long way, perhaps further than with any other part of our society.

If we look around we can see what various boroughs are doing to help the elderly. This morning I rang my own borough of Enfield, which is where my late husband and I lived and worked for many years. It is doing an enormous amount to help people stay in their own homes, with in many cases the help of carers and government finance. I can say to the Minister that we should be proud of what we are doing for our old people.

It is estimated that over 800,000 UK citizens are over 85 years of age, of which 60 per cent. are infirm. If one is infirm one needs specialist care. It is not enough for someone to come in occasionally and make a cup of coffee. Carers cannot look after infirm patients and it is a large number of people to cater for in their own homes. However, there are now many more purpose-built homes which cater for local authority people, private residents and those who have a limited amount of money—under £3,000—to go towards their keep. That is a help, but it is a drop in the ocean of the enormous costs involved.

We are a very ageing population. However, not all the widows whom I meet are elderly. One can be a widow from the age of 19 to 99. Many widows need help and consideration from carers in the community. I should like to pay tribute to the carers and to the inspiration behind the carers. They are very specialised people, or perhaps I should say very special people. They go into other people's homes to help them. They are not necessarily there all day. Sometimes each carer will have three different patients per day and she goes round from house to house. I pay tribute to the inspiration behind the carers.

As always with the elderly, lack of money is the dread. Very few of us, even in your Lordships' Chamber, are not worried about getting old and all the costs involved, which leads me to one very difficult subject. I refer to funerals. I do not know whether noble Lords are aware of how much a funeral will cost anyone who is left behind, but it is way over £1,000. Fairly recently—about eight years ago—the Government provided a grant of £1,000, which is of enormous help. That can be paid by the social services at once. But if the funeral itself costs way over £1,000, then money is very tight in many families.

I have a very great interest in the children as well. However, so many noble Lords will be talking about the children that I thought I would leave that subject to those who have perhaps more up-to-date knowledge than my three score years and twenty allow.

3.52 p.m.

Lord Brimelow

My Lords, the noble Lord, Lord Ashley, has thrust a very powerful light into the shadowy uncertainties surrounding the financing of long-term care. The previous speakers in the debate—so far I have agreed with everything that has been said— have adopted a rather broadbrush approach and have tended to describe what is instead of concentrating on the uncertainties. I wish to focus a very modest hand-torch on a limited subject; what is actually going on at the moment in the health area of Islington and Camden, where I live.

I am very worried about the future of district nurses in Camden but I am also very uncertain about how discussions at present in progress will turn out. Perhaps I should explain the background. Not all long-term care ends with death in an institution or in hospital. As the noble Baroness, Lady Macleod of Borve, has stressed, there is a great deal of care at home which has been very well rendered hitherto. The uncertainty is in regard to the future.

In the health area of Camden and Islington the provision of community services, including district nursing, is in the hands of the Camden and Islington Community Services NHS Trust. The trust is under pressure to effect economies. The current two-year contract between the trust and the Camden and Islington health purchasing authority calls for a reduction in costs over the next two years of 7 per cent. As part of its search for economies, the trust is proposing to reorganise district nursing. It proposes to establish within the Camden and Islington area 29 nursing teams, each headed by a nursing sister—technically a G-grade nurse. Acceptance of this proposal would mean the disestablishment of 32 G-grade district nurses—more than half of the present complement. My understanding is that the posts of head of team and deputy head of team will be open to competition.

The trust says that there will be no compulsory redundancies, but among the district nurses there is anxiety that those who fail to secure appointment as head of team may be offered posts of lower grading, with presumably a reduction of pay. They are worried and uncertain about their future. They also fear that, if they turn down a post offered, they may be held to have made themselves redundant. The district nurses are now working to see whether they can find an alternative system whereby the economies imposed on the trust can be achieved. They are uncertain whether they will succeed in finding such an alternative system. The prevailing uncertainty is worrying quite a number of general practitioners.

I have read the job description of the G-grade sister who will be the head of a team. In my opinion, it is not a job description suitable for a district nurse engaged in nursing. It is a job description of an administrator. In it the word "nursing" is not even mentioned. It is all about co-ordination. I fear that we may be moving towards a bureaucratic system in which actual nursing is done by smaller numbers of lower qualified nurses; in other words, a service which is likely to be inferior to what we at present have. My fear may prove to be unfounded, but I am uncertain about the future.

The present system is flexible and not bureaucratic. For terminal care, and terminal care in the community for people who have been cared for over a long period in hospitals or other institutions but who for one reason or another wish to leave or have to leave, the sisters attached to the health centre nearest to where I live are quite splendid. They are well qualified, but, much more important, they have the tactful understanding which comes from long years of dealing with people who are about to die. I speak from personal knowledge.

I fear that we may be about to lose something excellent for something less good, but I am not certain. With the devolution of authority to trusts and to local health authorities, I am not certain who is really in control of developments as a whole. The Departments of Health and of Social Security may not even know in detail what is happening. They may be glad not to know. The Government have told us that the NHS is safe in their hands, but how much of the local administration within the departments—

The Countess of Mar

My Lords, order. The noble Lord has now had eight minutes.

Lord Brimelow

My Lords, I beg your Lordships' pardon.

4 p.m.

Baroness Masham of Ilton

My Lords, I thank the noble Lord, Lord Ashley of Stoke, for initiating this debate which I hope will bring to the Government's attention some of our concerns over the grey areas of health and social services. There are two great differences between health and social services. Health provision is free at the point of delivery while the provision of social services is being means-tested.

To illustrate what a dangerous situation long-term disabled people can find themselves in I shall tell your Lordships of a case history which ended in tragedy this summer. In North Yorkshire a paraplegic woman, who was one of the most uncomplaining and splendid of people who gave much of her time to helping others, became ill. She had two separate attacks of pneumonia and diarrhoea. She lived at home with her brother who had an alcohol problem and a terminal condition. He was not adequate to help her in any way. She was the organiser at home. Two of her friends and neighbours felt that she should be in hospital. A trainee doctor visited, but did not send her to hospital. Her friends, neither of whom could give her a bath because of back problems, kept requesting help. A district nurse called, saying that she could have help with a bath only once every two weeks. With diarrhoea and being weak as a paraplegic, is that adequate?

The case was passed to the social services. This is the grey area: what is "health" in such a case and what is "social services"? Her friends became more and more concerned, bringing her food and trying their best. Her doctor came back from three weeks' holiday and admitted her to hospital. She was by this time very ill and dehydrated. In the early hours, she fell out of bed. The next day she died of an undiagnosed perforated ulcer. Care in the community had let her down. The community had lost a good member. Her friends, who were her carers, were devastated.

As president of the Spinal Injuries Association, I can assure your Lordships that when severely disabled people become ill they are very much more at risk. They do not need less help. They need constant monitoring and attention. When feeling is non-existent or partial, very careful diagnosis is needed. When the Minister replies, I hope that she can give some assurances and say that there should be safeguards, not vacant spaces, in the care system.

People who have lived carefully, who have worked and saved, always seem to be the ones who get little, help when they need it. Buying in care, be it privately or paying the social services, can leave them without enough to live on. Is there not some way in which they could buy their care and have some tax relief?

Much is going on in the strategic development of primary health care, but much has to be done to improve the system. Family health services authorities and health authorities are working closely together. Many have joint executive officers in preparation for merging. The continual change within NHS structures costs a great deal in terms of time, work and uncertainty, but there is still a great deal of good will. Local communities and voluntary bodies are keen to be involved. Everybody wants to see improvements in the equity and effectiveness of the services.

One area of concern is the shortage of doctors now going into general practice. I should like to ask the Minister what is the reason for that. With so much more health care taking place in the community, doctors need to be trained and resourced for the job to a high standard.

Everyone, I am sure, wants to see patients receive the care that they need safely and in the place that best suits their needs and wishes. Patients and GPs need quick and helpful access, when needed, to a consultant, and health workers and patients need to have confidence that hospitals will be there when needed. It must not be forgotten that in rural areas there are extra expenses in terms of time and travel when providing care in the community.

Alcohol and drug detoxification centres and treatments are examples of the need for health and social services to work jointly. Incontinence is another aspect which can fall between two stools, with the Department of Health providing some care and social services the rest. There need to be national explicit criteria clarifying National Health Service responsibilities. When social services carry out an assessment, there needs to be the provision of care if necessary.

The big "in" word at the moment is "assessment". I end by asking the Minister: Is there a time limit on how long people have to wait? Are there enough occupational therapists to do the job?

4.6 p.m.

Lord Jenkin of Roding

My Lords, I welcome the opportunity that has been provided by the noble Lord, Lord Ashley of Stoke, to say a few words on this subject. It is in the nature of a debate on such a subject that one hears more about the failures and shortcomings of the system than about its successes. No noble Lord has questioned the rightness of the policy of community care. Indeed, as my noble friend Lady Seccombe said, there is nothing new about community care.

In the field of mental health, it was Enoch Powell who nearly 40 years ago sounded the death knell of the old, remote mental hospitals. The process is steadily proceeding whereby the great majority of such patients can be cared for in the community. I remember that it fell to me to open many of the new community facilities that were provided under the Worcester Project, as it was called, when the Powick Hospital closed and a whole range of community facilities were provided. Since then, great strides have been made. The milestone was what is sometimes called "Griffiths II", which placed a very firm and continuing responsibility on local authorities for patients being cared for in the community.

I should have liked to follow many of the points that were made by the noble Lord, Lord Ashley, but time is inevitably limited, so I shall address just one aspect. I refer to a point that was picked up by my noble friend Lady Masham; that is, the importance of collaboration between all the various agencies involved. I see it from the point of view of an NHS trust, which is not only a hospital trust but an integrated trust having responsibility for community health services in the area. The Forest Health Care Trust covers an area surrounding Whipp's Cross Hospital in the north-east of London. We are heavily involved in various aspects of community care. I should like to give the House some examples of what is being done to make good community care a reality. It will not surprise noble Lords that much of that depends on partnership, on working with others and on ensuring that we are all working towards the same end.

The noble Lord, Lord Brimelow, mentioned the district nursing service. We attach enormous importance to expanding and developing the district nursing service to ensure that as much care as possible can be delivered to people in their own homes, in residential care or wherever they may be. Having abolished the hospital door, as it were, because we manage on the basis of client care groups, we find as an integrated trust that providing such care comes completely naturally as one moves services out into the community and works alongside the other agencies and voluntary bodies that are involved in the same area.

We are building up the local GPs—and here again I agree with my noble friend Lady Masham—by the establishment of primary health care teams, involving a wide range of disciplines including the community psychiatric nursing service, which is something of enormous value. We are increasing the outreach of physiotherapists and occupational therapists to make sure that services can be delivered in people's homes and that they do not need to go into hospital.

I should like to draw your Lordships' attention to three specific projects. We have a joint project, jointly funded by the trust and by Waltham Forest social services. It is managed by Age Concern and it enables quicker and more appropriate discharge of elderly patients from hospital care. The project aims to supply an after-care service to elderly people who are discharged from hospital but perceived by hospital staff as not requiring statutory services as part of the discharge plan. It also helps other patients prior to admission when they have been in receipt of social services care and who are also visited as part of the aftercare project to ensure that all is well on discharge and that the social services have started efficiently.

It is actually filling a gap in the service provision on discharge from hospital and testing the criteria for the need for social care, as perceived by ward-based professionals and with the help of their social service colleagues. It is in its early stages and we shall have an evaluation coming to my board in February. I hope that we are going to be able to show that this is a very specific model of collaborative care that is making a reality of community care.

To take another example, we have what is called the Larkshall Young Disabled Unit. It offers specialist health provision to highly dependent, younger and physically disabled patients. It has a highly skilled specialist nursing workforce and they offer a valuable contribution towards multi-agency assessment of need for highly dependent younger disabled people, following trauma or medical conditions such as severe strokes, who wish to remain in the community and do not want to be in an institution. A lot of the work involves confidence building among users and carers who are in touch with the service, empowering patients to live independent lives in the community.

There are obviously facilities for respite care and so on. Here again, this involves a great deal of collaboration between all the various agencies which are involved and which can make a reality of community care. We have a proposal coming before us for a primary intervention service —sometimes called a hospital at home—which is being developed jointly with the primary health district nursing service, with the services for the elderly with social services, with the general practitioners and with the residential home owners. This is to enable the health trust to be able to deliver health packages to those living in the community and who can be helped to maintain an alternative to hospital admission. In some cases, we would expect this help actually to avoid the need for hospital admissions for selected acutely ill episodes.

Here again, we are working very closely with Waltham Forest social services, interested local home-owners, and with one general practitioner practice to research the possible extension of the hospital at home scheme into the residential care home environment. Again, a pilot scheme will be set up; it will be monitored, evaluated and eventually reported. I suppose the point that I should like to make on this, and then I must sit down, is that this is possible in an integrated trust. I think we are going to be able to demonstrate that that is actually a very good model for the delivery of care.

4.14 p.m.

Baroness Nicol

My Lords, I am sorry that my noble friend Lord Ashley was unable to stay until the end of what is proving to be a most interesting debate. I want to concentrate my few minutes emphasising the value of, and the pressures on, carers—all carers, but in particular those who care for a relative, a friend, or in many cases a child, from love or a sense of duty, and who are in that position for 24 hours a day.

It is estimated that some 6 million women and men in the United Kingdom act as full-time or part-time carers for those in need of support. Many of them struggle in difficult situations without help and even without recognition. About 1 million of our fellow citizens are caring full-time for a disabled elderly or mentally ill person. The National Federation of Women's Institutes estimates that one in three carers do not receive any support. Some may be helped by local services, but whether they receive support or not many have to carry the burden of responsibility of caring for someone who cannot manage alone for 24 hours a day, seven days a week, with all the ongoing strain involved.

All too often the carer has had to abandon any attempt to follow his or her career and is unable to maintain any separate personal life. Even when some outside work can be undertaken it is part-time and therefore mostly low paid. So financial problems are added to an already stressful situation. It is not unusual to find that when a carer is finally released from his or her responsibility, re-entry into the job market is difficult, and the loss of job and pension prospects can never be recovered. Yet carers save the taxpayer billions of pounds. It has been estimated that if they all had to be paid the going rate of £5.80 per hour the average annual cost would be of the order of £30 billion. It therefore makes good economic sense as well as good social sense to make sure that the support services are good enough to keep the carers going.

Perhaps the most desired and the most immediate relief is that mentioned by the noble Lord, Lord Jenkin of Roding: respite care. I think he has been alone in mentioning it. To be given a break from the daily pressure can be a life-saver. Some voluntary organisations and local support organisations do a splendid job in providing respite care for carers, but there is not nearly enough and, geographically, it is patchy. It is not unusual for a carer to find that there is no one within the kind of reach that makes it easy to come and go.

My party has produced a consultation paper called Making Carers Count. It gives valuable information on the background to the problems of carers and makes many useful suggestions for improvement. There is not time to read all of them, particularly as I have a question to put to the Minister. I wish, however, to mention one or two. We suggest that local charters for carers should set out clearly the services available in the area. It is surprising how little some carers know about what is available to them. We need a charter in which carers can find all the information they need. I understand that a scheme in Leeds has been very successful.

All carers should have an opportunity for separate assessment of their needs. That will obviously require visits from the professionals but it is important that carers should know exactly what they are up against and what is available to them.

Carers should have access to flexible and affordable respite care. That is always available if you can pay for it, but it is not an option which is open to many people, particularly if the problem has gone on for any length of time. As the noble Lord, Lord Jenkin, who has now abandoned us, said, it should be done by way of partnerships involving local authorities, the private sector and voluntary organisations. This is something the Labour Party supports.

The noble Baronesses, Lady Seccombe and Lady Macleod, mentioned young carers. They should have particular attention paid to their needs. In some cases they should be identified as "children in need" under the Children Act, and be supported as such. There are obvious difficulties for young carers who have not the mental experience to cope with many situations they find themselves in. But many of them battle on regardless.

I would be grateful to hear that the Government have identified the area of concern of carers generally and that they will encourage actively some solutions. We all want care in the community to work. Carers are the essential ingredient in any plan and should have all the help we can give them.

I wish to put to the Minister one question. The matter has been worrying me since I heard about it. An elderly couple, one of whom has had to go into a private nursing home, have had to pay part of the fees. Is it the case, when their savings run out, that the family home has to be sold to meet the costs of the private nursing home and that only when that sum has been reduced to about £8,000 is other help forthcoming? That creates an enormous anxiety for elderly couples. I hope that the Minister can lay it to rest.

4.20 p.m.

Lord Thurlow

My Lords, the subject of the debate finds us all in the same boat. It is not a partisan matter. If at some future date we have a change of government they will have the same problems, including that of financial constraints, on their plate. The debate has illustrated the enormous breadth of problems. None in your Lordships' House would question the broad policy objectives of community care that the Government introduced when they decided to implement the Griffiths Report. That was a revolution, and all revolutions cause problems, especially over timing. I am one of those who regrets that the implementation was not done over a longer timespan. The Government delayed introduction for over a year, when it was manifestly impossible for local authorities to take on their responsibilities. I am sorry that the delay was not longer, but that is history.

I shall confine my remarks to two aspects of the subject. The first relates to monitoring and the other to the revolving door syndrome issue to which the noble Baroness, Lady Robson, referred during the debate on the Address. The noble Lord, Lord Brimelow, questioned whether the Department of Health knows what is going on. I should not be surprised were the answer to be that it cannot know everything that is going on because it is part and parcel of the system of delegated responsibility that statistics, and so on, are fragmented. Nevertheless, the NHS, as it acknowledges, is responsible. It has the final and continuing responsibility for medical treatment and medical care. It cannot delegate that beyond a certain point. It is a fundamental responsibility.

I should like to refer, as evidence of the problem, to what happened some time ago now when a commercial residential nursing home in, I think, Oxford, had a case of homicide which has received a great deal of publicity. Before the implementation of Griffiths the home had catered mainly for homeless people and not sick people. At that time the home was staffed by a young volunteer who was making a social contribution before going up to Oxford. He was on duty by himself for 24 hours with 10 or 11 residents. A schizophrenic patient had been introduced to the home after those responsible for that commercial project became aware that there was a slice of cake to be had from operating in the mentally ill field. During the night that unfortunate schizophrenic patient stabbed the young volunteer who, incidentally, had received no specialised training in looking after the mentally ill.

I have no doubt that in that case corrective action was taken. The point is that that was a residential home responsible for providing difficult care for the mentally ill. It ignored the Department of Health's guidelines on staffing and training. When confronted with the fact that it was ignoring the guidelines, it said calmly that the guidelines were not legally mandatory. I should like the Minister to ensure that in future the guidelines are given greater legal mandatory force. I hope that that will be one of the objects of the legislation to which we look forward.

On the revolving door syndrome, the public perception is—rightly or wrongly—that with the run down of the big mental hospitals and the reduction in the number of acute beds, there is no longer an assurance that those requiring treatment after discharge can always obtain it. I am a parent who has benefited from the past arrangements with big hospitals under which our schizophrenic son could always go back through the revolving door, and I am greatly concerned that there is no longer an absolute assurance that a bed will be available wherever and whenever it is wanted. We should be pleased to have the maximum transparency in this area.

4.28 p.m.

Baroness Gardner of Parkes

My Lords, this has been a most interesting debate, but the only distinction too many speakers have drawn between the NHS and community care is that one pays for one and not for the other. That is a false distinction as the NHS has not been entirely free since 1950 when the Labour Government introduced the first charges for the NHS. People tend to think of the NHS as a hospital service, and that is free, but there are many other aspects of the health service for which patients are means tested and for which charges are made. Priority cases, of course, are still treated free. That point needs to be put to make it clear that that is not the only distinction. There are much greater distinctions to be drawn between the NHS and community care.

Baroness Jay of Paddington

My Lords, I apologise for interrupting the noble Baroness, but surely what we are discussing this afternoon is continuing care, and the distinction there is between the free continuing care in the health service and means-tested social services.

Baroness Gardner of Parkes

My Lords, I am sorry that the noble Baroness interrupted, because that is not the usual custom when a debate is time limited. Even so, I could argue about that point because the new dental contract provides for continuing care for two years whereas that did not apply before. There are many points of discussion, but I cannot spare any more time to respond to that point.

The underlying principles of community care are that the care should be patient-focused, not in the self interest of the people providing the care but in the interests of those receiving it. I take into account the points that have been made about carers, who are relevant too. However, as regards community care, the prime consideration is the patient who is receiving that care. The individuals who do not require hospital care should be cared for in their own community. The social services are correctly the fulcrum for the co-ordination of an individual's full range of longer-term needs.

The National Health Service and Community Care Act provides a framework for translating these principles into specific benefits for individuals. At the strategy level, community care plans provide the mechanism for bringing the plans and policies of health services, social services, other local authority services and voluntary and community groups into a coherent strategy. At the level of the individual, case management and assessment procedures, referred to by the noble Baroness, Lady Masham, ensure that the needs of the individual, and not the separate interests of the service providers, drive the delivery of care.

That has led to the development of innovative collaborative arrangements to secure flexible care packages; that is, meeting the needs of the individual, including the carer. Respite care is a most essential and valuable way of ensuring that more patients and carers obtain relief. The philosophy of community care has been embraced by health service providers which have sought to develop new approaches to delivering health care in the community; for example, home dialysis, palliative care teams for the terminally ill and discharge teams. They are examples of collaboration between the health service and community care.

The National Health Service and Community Care Act created a single unified budget to cover the costs of social care. By transferring to social services departments the social security payments for people in residential or nursing homes the perverse incentives for moving people out of their homes and into residential care were removed. The financial flexibility that the Government have provided has promoted the innovative flexibility in the delivery of care.

However, with the level of need in the community and an increasingly older population, there will always be pressure on resources. The community care framework enables individual needs to be identified and provides the flexibility for resources to be deployed in a manner that is responsive to those needs. There has been a great deal of talk about people being asked to contribute to their social care. I believe that that is correct and that it should be done on a means-tested basis. Those well able to afford their own care should do their best to do so. Those most in need of financial help should receive it.

I was interested to hear the noble Lord, Lord Brimelow, refer to community care in Camden because my NHS trust is in that area. Today I read the current edition of HealthCare Today which states that the Camden and Islington Community Health Services NHS Trust has a staff of 2,500, a budget of nearly £90 million and serves the communities of Camden and Islington from nearly 100 sites. That was interesting to read because most of us regard community care as a small operation. In fact, it is large and largely successful.

The noble Baroness, Lady Seccombe, said that she was amazed that local authorities had spent their budgets. That does not amaze me because the community care Act has revealed the need that exists. Local authorities in central London had no idea of the vast demands. They were unknown and unmet. No government can afford to meet the financial demands that lie ahead. There must be a need to look at how best to use the resources. I believe that there is an opportunity to use volunteers. The noble Baroness, Lady Lockwood, the noble Lord, Lord Murray, and I are members of the Advisory Council of the Retired Senior Volunteer Programme (RSVP). Recently retired people are keen to carry on working and to fulfil their lives helping others. They can meet a need that cannot be fully met because no government can provide the amount of money that is required to meet every demand that is put on them. I wish to see the gradual use of more volunteers in community care because that would benefit both the patients and the carers.

4.35 p.m.

Lord Hollick

My Lords, I wish to apologise to the House because a prior engagement prevents me from staying to the end of the debate. Today's debate is timely because there is a rising anxiety about the provision of continuing care. There is a financial crises among various local authorities and that will prevent them from meeting their requirements in the current year. There is also a rising anxiety about the diminution in the number of continuing care beds within the health service.

My experience of the problem has been gained from working with sufferers of Alzheimer's disease. As your Lordships know, that is an extremely sad disease. It is a slow journey into an abyss of unknowing and darkness. There is, however, a journey through a "Kafkaesque" world of administration and bureaucracy. The noble Lord, Lord Ashley, vividly mentioned some of the words used in the guidelines and government publications. At a time when carers and Alzheimer sufferers are seeking to deal with a terrible disease—it is usually at the end of their lives —they are also having to find their way through a maze of bureaucracy and administrative chaos.

The journey that I have described begins with the diagnosis of the disease, after which the patient must spend time at home. The carer—the unsung hero of our story—looks after that person. Rapidly the time comes when, because no hospital bed is available, the carer is put into a nasty and serious financial position. As a result, the carer's health suffers and his or her future is at the mercy of the social services, which are inadequately funded. As regards the individual, we see the beginning of a war of financial attrition.

That comes as a surprise and a shock to sufferers and carers because, naturally, they expect that having paid their national insurance contributions they are entitled to free health care, particularly at the end of their lives. The Patient's Charter confirms that they are to receive health care on the basis of clinical need, regardless of ability to pay. However, many sufferers find those words to be hollow.

On 15th April the Secretary of State said: The NHS provides services for everybody on the basis of their clinical need and regardless of their ability to pay", thus confirming the Patient's Charter. She continued: There are no exceptions to that rule whatever the age of the patient". The words "clinical need" must be weighed carefully. It is the view of the Royal College of Nursing that continuing care is nursing intensive; in other words, there is a clinical need.

The August guidelines, published by the NHS Executive, confirm that the NHS remains responsible for meeting the needs of people within available resources. However, the words "where appropriate" are then inserted. That condition is causing so many problems and difficulties. The particular problem is that there is no nationally accepted definition that ensures that everyone throughout the country receives the same care and attention. There are examples of some local authorities and health trusts ejecting people from hospital into the care of social services while in neighbouring authorities patients are cared for within the NHS. I suggest that that is unacceptable.

I believe that that muddle is avoidable if there are proper definitions. What we need to do—the August guidelines call for it; and I welcome that fact—is to devise national eligibility criteria to ensure that there is a consistent approach and that it ceases to be a regional lottery. There is also a need for the Government to monitor health authorities to ensure that they are living up to the promise made on their behalf by the Secretary of State.

My concern is that there is no central monitoring of the need for continuing care. I have asked several questions of Ministers about the number of continuing care beds. I have to say that I have been given a number of unsatisfactory answers; indeed, if I were being unkind I would say that I have been fobbed off. I am always told that such information is not collected centrally. The noble Lord, Lord Thurlow, mentioned the difficulty of collecting it. But it is possible to do so. In fact, this very day, I saw an extremely good National Health Service-designed software system which gathers together information centrally about such matters. Therefore, it is possible for the NHS to have that information centrally and then to know whether or not the needs and requirements of the community and patients will be met. Without that sort of database, I am afraid that we shall continue in the present muddle.

I have a suspicion that the Government—and, certainly, some local authorities and health trusts—are in fact turning a blind eye to the problem. They are perfectly happy to see people and patients (sufferers) leave hospital and go into community care. By doing that, they know that they avoid the financial responsibility which I believe is rightly theirs.

In my view, it is fair to characterise some of the developments within the National Health Service on continuing care as effectively privatisation by the back door of this part of the health service which affects people at the most vulnerable time of their lives, and at a time when many of them simply do not have the financial resources to pay for it out of their own pockets.

4.42 p.m.

Lord Mottistone

My Lords, I, too, should like to congratulate the noble Lord, Lord Ashley of Stoke, on his introduction of the debate. I am so sorry that he is unwell; I trust that he will get better soon. The timing of today's debate is especially apt for me as Governor of the Isle of Wight. Some noble Lords may have heard from the media recently that we have a real crisis in my island over the financing of our community care. Sadly, that sort of thing, though especially urgent, is not new to the Isle of Wight. It stems from a continuing lack of understanding by officials in all English government departments of the special peculiarities of islands in particular and also, it seems, of authorities with small communities.

I, and successive Members of Parliament for the Isle of Wight, have been grappling with that ignorance for over 20 years. The late Lord Ross of Newport nearly got an important understanding of the problem accepted by Mr. Peter Shore when he was Secretary of State for the Environment in 1979, but the Government fell before the understanding could be reached. I have had two or three similar near misses since with Conservative ministerial friends.

The particular problem is simple to describe. In October 1992 the Secretary of State for Health promulgated a plan for transferring the distribution of moneys for community care from social security to the local authority-run social services, with transitional grants over a four-year period and specified increases year by year over that period. All counties, including the Isle of Wight, made plans accordingly. In October 1993, the then Minister for Health, Dr. Mawhinney, made a statement which indicated that there would be no change in the plan.

However, on 2nd December 1993, almost exactly a year ago, for the Isle of Wight—and, as we now know, for other counties—a bomb was dropped. The Department of Health announced a revised method of calculating for the grant for 1994–95 (the current year) which slashed the Isle of Wight's expected grant by over half. The Isle of Wight County Council and its social services director reacted sharply. They wrote within a week to officials of the Department of Health saying that such a large, damaging, downward change could not be handled and repeated those letters in January. My honourable friend, Mr. Barry Field, the Isle of Wight MP, arranged a meeting with my honourable friend Mr. John Bowis, the responsible Minister, just before Christmas last year.

There was no response to the letters and no helpful outcome of the meeting until February when an official of the Department of Health wrote to say that, inevitably, a change in distribution mechanism involved both winners and losers. Some authorities, like the Isle of Wight, would be losers. Effectively, that letter said, "Bad luck old boy, better luck next time". Just how callous can you get? There was no thought for the effect on the old people of the Isle of Wight who were those principally affected.

The grumbles continued throughout the year; I shall not bore your Lordships with the details. But at no stage did the Government do anything to show that they recognised the acute problem of the Isle of Wight and propose some way of alleviating it. So, in mid-November, in exasperation, the Isle of Wight County Council announced to the press that it had only three weeks of community care money remaining as it had warned the Government a year before and throughout the year thereafter. I was gravely distressed by that publicity and told my county council friends so. Inevitably, the effect was to frighten seriously some of the old people of the island. I received letters from the clergy telling me that their parishioners were seriously worried about what might happen.

So what then to do? The Isle of Wight County Council has had a clean bill of health from the district auditor on the spending of its community care money to date. For the future up to March, it has arranged to transfer as much money from other resources as it dares—fewer road repairs for example. Let us hope that there is no snow this winter. It has asked the district auditor to report on all its expenditure during the past year so as to show the Government that it has acted as wisely as it knows how.

The problem is that small communities do not have so much money to reallocate when they get surprises. I expect several of the new unitary authorities—like, as I have discovered, the smaller London boroughs, which have populations not terribly dissimilar to the Isle of Wight—will discover that. Moreover, islands have their own special problems. For example, our fire brigade cannot expect support from adjacent authorities in dealing with major fires. My noble friend Lord Ferrers, when at the Home Office and responsible for fire brigades, had a long and enduring battle with the Department of the Environment to persuade those concerned that our arguments made sense. He was terribly frustrated and never finished the argument; for look where he is now.

What is needed is a quick, fresh look at the Isle of Wight's special problems by the Department of Health and action before Christmas to adjust the transitional grant for this financial year upwards by as much as is necessary. There is need also to ensure that next year's grant is enough. I suggest that anything less would be a grave dereliction of duty on the part of my noble friends responsible for that part of the world. I tried to get a warning through to my noble friend the Minister who is to reply to the debate that I intended to say such things. I hope that she will be able to give me some reassurance that something will happen between now and Christmas.

4.50 p.m.

Lady Kinloss

My Lords, I should like to thank the noble Lord, Lord Ashley of Stoke, for introducing this debate today. In 1988, a report to the then Secretary of State for social services by the late Sir Roy Griffiths was first published entitled, Community Care, Agenda for Action. Since then questions have been asked and the subject has been debated, and six years later we are still discussing the best means of ensuring that care in the community is working.

Age Concern fears that some local authorities appear to be defining the need to enter institutional care on the basis of the cost of the care package which would be required at home. They say they are unclear how this apparent move towards resource-led assessments fits in with the underlying theme of Caring for People: Community Care in the Next Decade and Beyond, published in 1989, which suggests that assessments should be needs-led and not resource-led.

The Association of Directors of Social Services welcomes the opportunity to comment on the draft guidance issued by the NHS Executive in August 1994 and welcomes the recognition that there is a need for guidance in clarifying responsibilities for long-term health care. Surely it is vital to decide which authority is responsible for which need, as this is necessarily a cause of financial concern and possibly a cause for confusion and worry for not only those trying to provide services but those on the receiving end. It would surely help those supplying different needs if it could be defined more precisely what constitutes continuing and specialist medical or nursing supervision and in what circumstances these definitions apply.

In the draft guidelines, Health Service Guidelines, the paragraphs dealing with hospital discharges of people with long-term health and social care needs worry families who are unsure of what they are entitled to in the way of help. Patients and their families need to be fully informed about how the procedure will work, and whom to ask about their needs. Can the Minister say whether any local authority or health authority has produced a small pamphlet explaining what is available for long-term care, whether in a nursing home or residential care home, which should also include information of the financial implications of each option? Perhaps the social services and health authorities should produce a small, easily understood pamphlet with guidance on what one can have and where to ask for the information.

The Alzheimer's Disease Society has found that there are about 17,000 younger people with Alzheimer's disease in Britain today. It is extremely rare for it to occur in young people under the age of 30. It is increasing, though, in people under pensionable age. The greatest worry seems to me to be those developing it in their 40s and 50s, who have young families, and who see their parent with this disease. It must frighten children when the parent gets progressively worse. A survey reckons there are 17,000 younger people under 60 out of 635,000 people who have the disease. There is only one consultant who has a special responsibility for younger people, and he resides in Liverpool.

The Alzheimer's Disease Society says there is a likelihood of between 50 and 100 younger people in every health district who have Alzheimer's disease. I ask the Minister to look into this apparent lack of focus on this most important aspect of care in the community, because of its knock-on effect on young families. Even those in their late teens will be affected by it. Will the Minister also ask health authorities to assess the needs in their districts of these younger sufferers from Alzheimer's disease? Does the Minister agree that there seems to be a need for more consultant specialists in this field, and not just one?

The noble Lord, Lord Ashley of Stoke, spoke of people being discharged from hospital and only living for a few weeks. Often they would wish to stay in hospital which represents a safe and caring place for them to stay, where they are looked after and may die in dignity. If a patient's wishes are to be considered, surely this is a small but very important consideration for the happiness of those who may not have long to live. I hope that one day community care will work as the late Sir Roy Griffiths hoped.

4.54 p.m.

Baroness Eccles of Moulton

My Lords, society's responsibility for organising appropriate care for the growing number of elderly people is a major policy issue confronting all countries of western Europe. It can rightly be seen as one of the yardsticks by which a civilised society can be judged. I am grateful to the noble Lord, Lord Ashley of Stoke, for giving us an opportunity to debate this important subject today. I am sorry that he is in pain and is unable to be with us.

Since the 1980s there has been a dramatic increase in the level of funding provided by the Government for long-term care generally and for elderly people in particular. This is reflected in the substantial growth of the nursing home sector, and as a result the number of beds run directly by local authorities and health authorities has declined.

Over the past decade the growing number of elderly people needing nursing home care have felt enormous benefit from this change in delivering services through the voluntary and independent sectors rather than through local government and health authorities. However, although the running of these services has now moved predominantly into the independent sector, it is important to emphasise that this remains an area of care mainly funded from the public purse. As my noble friend Lady Gardner of Parkes has already mentioned, contributions from those who can afford it have been a longstanding feature of our system, not a recent phenomenon.

In turning to the more recent history of community care, I would like to pay tribute to the foresight and tenacity with which the late Sir Roy Griffiths worked with the Government to introduce the new arrangements. In April 1993 the progressive transfer of funding from central Government (that is, the Social Security fund) to local government began. When the transitional funding period of four years is completed, the budgets of social services departments in local authorities will have been increased by about 40 per cent.

The health authority of which I am chairman—here I must declare an interest—is coterminous with three London boroughs—Ealing, Hounslow, and Hammersmith and Fulham. All three boroughs have taken on these additional responsibilities with enthusiasm and commitment. In the 18 months since the new arrangements came into being the number of patients in hospital awaiting transfer to nursing homes has reduced.

These developments in the care provided for elderly people have produced many visible benefits and we can take great pride in them. However, I believe that there is a need for a stronger regulatory framework. Local authorities and health authorities need effective powers to make sure that the standards of care provided in the independent and voluntary sectors are those that you and I would wish to see for our own elderly relatives. The current registration and inspection regulations, while allowing health and local authorities to exert considerable control over the physical standards of such homes, are at present relatively ineffective in ensuring that adequate standards of care are provided by staff.

Another important area is being considered at present through a draft circular issued for consultation by the Department of Health. This circular is not the one to which the noble Lord, Lord Ashley of Stoke, particularly referred; it is a second circular which is out at the same time. This circular discusses the financial framework within which health and local authorities operate. At present we are relying on financial arrangements drawn up in two Acts dating from 1968 and 1977.

In response to consultation on this draft circular my authority has taken the view that new financial arrangements are needed which will allow local government and health authorities to reflect the reality of the care that so many elderly people need, which is a combination of health and social care. Furthermore, the same elderly person may, over time, require different proportions of the costs of his or her care to be met by local and health authorities. In many cases on admission to a nursing home it is appropriate for costs to be met by the local authority. However, towards the end of the person's life the health service should in many instances be providing a good deal of the care and meeting the costs.

We recognise that inevitably the boundaries of the NHS have been changing ever since it was created nearly 50 years ago. Community care policies have resulted in better care for elderly people, albeit now predominantly provided outside the NHS. At the same time funding in the NHS has increased dramatically over the years and there are many areas where the boundaries of the NHS have expanded. If I had time, I would have liked to have cited some of those. The concept of the next generation contributing to the costs of caring for their elderly relatives is being faced by many European countries. So too is the issue of how far individuals should make financial provision to allow for the cost of their own long-term care to be met through insurance or other arrangements.

In conclusion, I believe that we can be proud of the developments in community care which have taken place in recent years and which now provide, still it must be emphasised mainly through public funds, far higher standards of care and infinitely improved physical facilities. However, like all great social issues, it needs periodic reassessment. I believe that we have a particular responsibility to inform and guide the development of policy in this fundamentally important area of life. I very much hope that the new guidance referred to earlier, in its final version, will not miss the opportunity to provide a financial framework which matches the excellent multi-disciplinary service which we are committed to delivering.

5 p.m.

Baroness Farrington of Ribbleton

My Lords, I am grateful to my noble friend Lord Ashley for introducing this subject and providing the opportunity to discuss the very real problem which people face.

I agree with the noble Lord, Lord Jenkin, that it would be possible to debate at great length the many examples of success in the field of care in the community. I am particularly grateful to those who have referred to the fact that we are not speaking about an additional amount of public expenditure but a switch of resources from one public expenditure head to another, a transfer of funding from social security into care in the community through the local authorities.

It is extremely important that in this debate we recognise that care in the community could only ever be a success were it to be conducted against a background of the recognition of need and not against a background of a reduction in public expenditure. In addition, for there to be faith between the partners who were to work together, it was essential that the Government recognised that when local authorities told them that in the current financial year the sum that was needed was £1.2 billion to be told that £0.7 billion was all that was available, leaving more than a 40 per cent. shortfall, would inevitably lead to the problems to which the noble Lord, Lord Mottistone, referred.

In the current year an additional problem has been faced by some authorities. Because of a late switch, without consultation, which was mentioned by the noble Lord, Lord Mottistone, the money which was expected by some local authorities was suddenly cut dramatically. The authority of which I am a member—Lancashire County Council—was in that position. A late decision, announced without consultation, left only £6.5 million for new demands during the current year.

It is against that background of not being able to meet new demands that we must view the problem of the blurring of the distinction between that which is clinically determined to be health care and that which is rightly the province and the responsibility of the local authority social services departments.

As a new Member of your Lordships' House I listened very carefully to all the expressions that have been used. The one that causes me gravest concern is the constant reference by Members on the Government Benches to "having regard to resources". We are discussing people who are clinically determined to be ill and in need of health care. The decision as to whether that health care can be provided by the health authorities free of charge within a different setting from the hospital is to be governed by judgments about resources and not clinical judgment.

I remember when care in the community was first discussed. I happened to be with a friend who is older than I am, whose husband was in a long-stay mental hospital suffering from Alzheimer's disease. To my surprise and distress, she burst into tears. I asked what the problem was. Her prediction was that the hospitals would be closed down without alternative provision being made. She predicted that the government of the day would use the resources from the sale of assets of the long-stay psychiatric hospitals, in one of which her husband was a patient, to fund other policies, and there would not be a clear and distinct switch of that money into funding for other services.

My friend feared that she would see the day when she would be forced to give up her small savings and her ownership of her home in order to help to fund the cost of caring for her husband were he not in a hospital. Her ultimate distress was her fear that she was asking for her husband to be kept in a place which was not the most appropriate because she could not cope with the changes that she feared.

I worry because I reassured my friend that there would never be a question of curtailing resources for patients with Alzheimer's disease and there would never be an attempt to place a charge on their families in order to fund their care, either in the community or in alternative residential accommodation other than a long-stay hospital. Her husband is now dead, but if I were to give advice to someone else in that position today I might be more constrained in my enthusiasm.

We do not face the future with hope in those authorities which are struggling to find the resources necessary to make care in the community work. Gloucestershire, Lancashire, Hereford and Worcester, Bury, Bradford and all the authorities on the Isle of Wight have problems. The noble Lord, Lord Mottistone, was so right when he referred to the problems of the Isle of Wight. I ask the noble Baroness not to say, in answering the debate, that it is a matter of local authorities using their judgment in respect of their own resources.

The Isle of Wight has been challenged by a Government Minister for underspending on education against its SSA. It has been told by the Home Office—the noble Earl, Lord Ferrers, was mentioned—that it must spend more than its SSA on fire services. Now, doubtless it will be told that if only it switched funding from somewhere else it could cope with this unexpected pressure on its social services. It is critically important that the Government recognise the need to fund care in the community.

5.7 p.m.

Lord Ashbourne

My Lords, I have been asked by the noble Baroness, Lady Ryder of Warsaw, to speak on behalf of the Sue Ryder Homes this afternoon as the noble Baroness is unfortunately unable to be in your Lordships' House in person this afternoon owing to a series of previous engagements. She has asked me to thank the noble Lord, Lord Ashley of Stoke, for putting down today's Motion and for giving your Lordships an opportunity to discuss these critical matters.

The nub of the matter is that the noble Baroness is greatly distressed by the effect that the implementation of the National Health Service and Community Care Act, which came into force on 1st April 1993, is having on the finances of the Sue Ryder Homes. Perhaps I may refer to one of the Sue Ryder Homes budget reports. It states: The income from fees is only marginally above that of 1993 despite intensive negotiations with Social Services and Health Authorities. The Home has 35 residents which receive only basic income support which cannot be increased. This arises because the residents have been in the Home for some time and are not affected by the new regulations … Consequently it is not possible to obtain top-up payments from Social Services or Health Authorities or from the Department of Social Security. In most of these cases, the amount received is £356.95 per week, but some are only £290. Since these have been long-term residents, the majority require substantial nursing and would be clearly in the middle or upper fee band—£500 or £575 per week. The shortfall of income over expenditure is therefore approximately £350,000 in a year, so in this Home of 35 residents, about £10,000 per resident". I apologise for the length of that quote, but it seemed important that the Minister had the information in some detail so that she can reply. I understand that out of 24 Sue Ryder Homes in Britain, this affects 14 of them. Consequently the average deficit amounts to £120,000 per Sue Ryder Home.

It has been estimated that the losses resulting from the Government's decision only to partly fund those patients who were in Sue Ryder Homes before April 1993 currently amount to £1.7 million per annum. That figure is likely to increase in future years as the disabilities of those patients increase and government funding is frozen.

Potential residents of Sue Ryder Homes are either being kept in acute hospital beds, or at home, without nursing care, rather than going into Sue Ryder Homes where the basic social services funding is insufficient to cover the costs. With the finances of social services in many counties being overstretched, it will not be long before the welfare and wishes of potential residents are ignored in favour of the cheaper option. For example, Cambridge social services are forecasting an overspend of approximately £3 million and have started to cut back on funding, including for respite beds which are urgently needed by desperate patients whose families or neighbours simply cannot cope any more.

As I was unable to give the Minister more than the most cursory notice of those concerns and questions perhaps she will write to the noble Baroness, Lady Ryder, and myself giving the Government's views on the multiplicity of problems which affect the Sue Ryder Homes.

5.12 p.m.

Baroness Robson of Kiddington

My Lords, I, too, wish to thank the noble Lord, Lord Ashley, for introducing the debate. I add my best wishes for his recovery from his present problem.

We have had 17 speeches. Those speeches leave no one in any doubt that confusion exists about who is responsible for providing long-term community care in our society. In the past, we have asked the Government for guidelines. They have now issued guidelines. However, in my view those guidelines have done little, if anything, to clarify the situation.

I regret the lack of specific national guidelines. It means that access to long-term care now depends on where one happens to live, not on what one needs. It also means that standards vary enormously between different authorities. The guidelines seem even to encourage different standards. On page 2, the guidelines state: Different models of care may be appropriate in different parts of the country". I can understand that. But they also provide the escape clause that, because one cannot afford it, one does not have to keep up to the national standards laid down by the Government.

When we changed the emphasis from hospital to community care, most of us agreed that it was the right move to make. We have since moved away from the principle of an NHS which is free at the point of need. The noble Lord, Lord Ashley, referred to the large decline in numbers of long-term care beds in the NHS. In 1990 the figure was 73,000; in 1993 it was 59,600. Before the implementation of the community care legislation, large numbers of elderly people were transferred to private nursing homes. Many of them have now become the responsibility of their local authority. At the risk of being boring, I wish to emphasise yet again that we should have introduced the community care legislation before we started the reform of the NHS so that we did not run the risk of a large number of people being without adequate support. Perhaps I may plead with the Minister that there should be no further reductions in hospital beds or long-term care until the problem has been resolved.

The final paragraph on page 2 of the guidelines refers to the need for hospitals to take account of the needs of other patients in deciding how long a patient can stay in an NHS bed. Of course, one can understand that if and when the number of beds is reduced to such an extent that there are not enough, long-term patients may have to be given alternative accommodation. But that is because we have failed to provide them with long-term beds in the NHS.

Some long-term patients in the NHS regard such a place as their home. How does the removal of patients from the place in which they are presently being looked after fit in with previous guidelines which stated that, no NHS patient should be placed in a private nursing home, or residential care home against their wishes if it means that they or a relative will be personally responsible for the home's charges". A large number of elderly people are cared for at home by relatives or friends. When they require greater care than can be provided in their homes and are referred to a nursing home—almost all of them now private homes—those elderly people are means tested to see what they can afford to pay. It is not only what they can afford to pay, but what their relatives can afford to pay. Occasionally the result is the sale of the patient's home. The former carer —in many cases someone aged between 70 and 80—who has lived in that home all his life, stands the risk of losing it. Some private nursing homes have helped patients to stay without forcing the sale of the house. However, when the patient dies there is frequently an enforced sale of the home in order to pay off the debt incurred in the nursing home. Those are earth-shattering experiences for people. We must do something to solve the problem.

The guidelines, under the heading "Action" state: Health authorities, and … GP Fundholders, are required to review, in consultation with local authorities … their policies for meeting long term health care needs". That is right. They are the people who look after those in the community who need long term care. But up to the present time GP fundholders have not had any responsibility for residential nursing care, although they have responsibility for district nursing service care. If GP fundholders are to be made responsible for the provision of residential nursing care they will need to have their budgets increased. Without that they will be unable to perform their duty.

I began by saying that guidelines must contain nationally determined criteria about who is eligible for NHS continuing care to avoid discrepancies in care between areas. Above all, the Government must acknowledge that increased finance will be necessary because the number of people who require continuing care is increasing year by year. The funds must be made available.

Yesterday, we had an announcement of an increase in funding for the National Health Service. That is very welcome. I plead with the Minister that a large part of that funding should be devoted to long term care in the community, whether provided by the NHS or by local authorities.

5.21 p.m.

Baroness Jay of Paddington

My Lords, I should like to give my particular thanks to my noble friend Lord Ashley for his great personal courage in introducing the debate on this crucially important subject this afternoon. I am sure I am joined by noble Lords all round the House in wishing him a speedy recovery.

In his powerful opening speech, my noble friend showed his customary deep concern for vulnerable people—and vulnerable people is what this debate is about. Although the words on the Order Paper could suggest that we are discussing rather arcane complexities of local and health authority finance, what in fact my noble friend and many other speakers have vividly demonstrated is that the Motion reflects the considerable alarm felt, certainly on these Benches and I think all around the country, at the way in which those who are most in need in our society are being treated following the changes in the NHS and community care. The fear is that we are seeing what has been described by the Association of Metropolitan Authorities as, the stealthy withdrawal of free health care". My noble friend Lord Hollick repeated the quotation from the remarks of the Secretary of State for Health on 15th April this year: The NHS provides services for everybody, on the basis of their clinical need and regardless of their ability to pay. There are no exceptions to that rule". The problem is that what the Government have done is simply to redefine words like "services" and "clinical need" to suit their new legislation. As we have heard from several speakers, health authorities and social services are now required to differentiate, on what often seems an almost arbitrary basis, between health and social care, and, as we have also heard, that has serious financial implications.

We had another Labour debate on community care in your Lordships' House earlier this year and we predicted that there would be an acute crisis as social service departments literally ran out of money to finance their new responsibilities. My honourable friend Mr. David Hinchliffe tabled an Early Day Motion in another place just recently on the Government's failure to fund the new social responsibility adequately. I should like to thank my noble friend Lady Farrington and the noble Lord, Lord Mottistone, for highlighting the problem so authoritatively and cogently in your Lordships' House today.

The fundamental uncertainties which we are discussing are caused by the Government's determination to see the essentials of service provision and finance resolved exclusively at a local level. Ministers argue that this is an appropriate devolution of powers and the way to ensure that local needs are met most effectively. On these Benches, we see this more as the Government abrogating their national responsibilities and creating a situation where cost-shunting between individual health authorities and social service agencies leads to patchy provision and considerable inequity.

As the noble Baroness, Lady Robson, has just pointed out, the quality of long-term continuing care now depends on where you live and not on what you need. We could have no clearer evidence that the nationwide security of the National Health Service is disintegrating and, in my view, being replaced by the small business ethics of local hospital trusts and independent providers, many of them in the private sector.

There have been many demands for the Department of Health at least to set national standards for continuing care and, as several speakers have mentioned this afternoon, we have now seen new draft guidelines from the department which were issued this summer. The consultation period has now closed and the responses from both the voluntary and the statutory sectors must make gloomy reading at the Department of Health. The general tone of the response is summarised by one London health authority, and I quote the chief executive's written reply: The guidance claims to clarify but in our view, it leads to greater confusion". I make no apology for going over some of the details of that guidance again this afternoon and the main points raised about those guidelines during the consultation. I hope that when the Minister replies she may be able to answer some of the very practical concerns which have been raised by organisations outside your Lordships' House and echoed in contributions this afternoon.

As my noble friend Lord Ashley stated at the beginning of the debate, the guidelines state: The NHS remains responsible for meeting"— with this extraordinary caveat— within available resources, the needs of people who require long term physical or mental health care". As he also said, superficially this seems to restate the basic understandings about NHS responsibilities. But the alarming caveat about "within available resources" suggests that decisions about individuals will be driven more by financial priorities than by clinical needs.

In the next paragraph the document produces another caveat: Different models of care may be appropriate in different parts of the country". As the noble Baroness, Lady Robson, has just mentioned, that could lead to local flexibility. But Age Concern and other organisations have argued in their response that: to include matters such as local circumstances and resources in the guidelines makes it likely that decisions about care will be dominated by the concerns of managers and not by medical judgements". The problems about precisely defining those who require physical and mental care are, of course, central. Several noble Lords pointed out that the guidelines do nothing to help.

How does the Department of Health define, those with complex or multiple care needs"? Who do we say will qualify for, continuing and specialist medical or nursing supervision"? Surely to be of any use at all the guidelines must, as several speakers have said, give specific national eligibility criteria which can be applied by every purchasing health authority, every social services department and every provider in the country. I should be grateful if the Minister could elucidate some of the definitions in her reply and also explain the force of the provisos in the guidelines about "local circumstances" and "resource contraints".

The other major area of concern which again has been much referred to this afternoon is about hospital discharge, about how decisions are taken to discharge any patient from health service care into means-tested social care and, very importantly, what rights and choices a patient and his or her relatives have when those decisions are taken. Once more, the draft guidelines are frankly bald and unhelpful, and I quote from page 2: Where a person, in the view of the consultant … no longer requires acute treatment but is likely to need intensive long term support, including the possibility of nursing home or residential care, they should be eligible for a multi-disciplinary assessment of their needs". Rightly, the British Medical Association and the Royal College of Nursing are unhappy that the paragraph seems to suggest that "acute treatment" can be properly defined as medical care appropriate for an NHS hospital, but that, "intensive long-term support", possibly in a nursing home, is seen as social care. Frankly, once more the problem is one of inexact definition, with all the ensuing and important complications of free versus means-tested treatment.

Under the same heading, "Hospital discharge", the guidelines raise but do not answer the difficult question of patients who refuse options for care outside the health service. Again, I do not apologise for repeating the quotation that was given by my noble friend Lord Ashley; namely, that, the health authority and hospital will need to take account of the needs of other patients in determining how long the person can continue to occupy an NHS bed". Again, there are no eligibility criteria, and, as many of those who have been consulted have pointed out, there is an implication that patients could be forced to leave an NHS bed against their will.

Very importantly, there appears to be a contradiction between these draft guidelines and a previous circular which was issued five years ago—HSG (89/5)—which I understand is still in force and which states that: No NHS patient should be placed in a private nursing or residential care home against his/her wishes if it means that he/she or a relative will be personally responsible for the home's charges". When the Minister replies perhaps she can tell us whether that circular is to be withdrawn and whether the new guidelines in their final form will be clear about the choices that are available to patients and their relatives.

Overall, I can only echo the views of the AMA, the purchasing health authorities, Age Concern, the BMA and RCN, the Alzheimer's society, the Association of County Councils and many others that the new guidelines have simply added to the confusions about long-term health care which were created by the new Acts. The UK Central Council for Nursing, Midwifery and Health Visiting has gone slightly further. It has written to the Department of Health urging that a completely new text be prepared for further consultation. Perhaps the Minister will tell us this afternoon if that is what will happen.

It is possible to establish clear eligibility criteria for continuing NHS care, and I am pleased to report that the health authority of which I am a member has successfully done that in conjunction with our local social services departments. Clinicians, social services assessment staff and care managers were involved in developing a written statement which is based on using the so-called Bartell indices of physical and mental capacities. If you qualify on those grounds, you are eligible for NHS continuing care facilities. It has been pointed out to me that the success of this system is not based just on the formal protocols, but on strong, practical day-by-day working relationships, with regular meetings on individual assessments. It has meant that the health authority and the social services departments have not had to use the agreed arbitration procedures at all in the past 18 months.

When I asked the chief executive of the health authority for his views on that model, he told me that he had no doubt that it could be of much wider application; and interestingly, the Health Services Journal annual awards have just given a commendation to that initiative as one that could be worked on a national basis. It seems to me that it can only be dogma about local autonomy or, perhaps more sinisterly, about undermining the national quality of the health service which prevents the Government insisting on similar criteria across the country.

At the Conservative conference in October, the Prime Minister defended his support for a comprehensive NHS by asking, Is it likely that I would take away the security of mind that was of such value to my parents?". Sadly, that is precisely what is happening. On Monday of this week, the Association of Directors of Social Services held a national conference which it called "From the Cradle Almost to the Grave". If that is not to be a true description of all our care services, the Government must act quickly and decisively—not only to help health and social service professionals but, most importantly, to restore security of mind to our most vulnerable citizens.

5.34 p.m.

Baroness Cumberlege

My Lords I am very grateful, too, to the noble Lord, Lord Ashley, for raising this very important subject for debate this afternoon. Like the noble Baroness, Lady Jay, and other noble Lords here this afternoon I hope that his courage will be rewarded and that he makes a speedy recovery. I am also very grateful for the very thoughtful contributions that were made by many of your Lordships who I know have personal expertise and experience in this particular field. I will try to respond to the various points which have been raised.

The noble Lord, Lord Ashley, is right in highlighting that, ever since the creation of the welfare state, there has been a division in responsibility between the National Health Service and local authority social services—a division between people who need medical and nursing expertise and those who need support and help with everyday activities. Ever since the creation of the welfare state, people who have been cared for by the NHS have received clinical care free at the point of delivery, while social services have been able to seek contributions towards the cost of care, and have done so, from the people who can afford it.

As my noble friend Lady Seccombe reminded us with her usual clarity, this boundary between health and social care is not new. It has been well recognised and has been part of our system since 1948. Although sometimes difficult to define, it is recognised by those responsible for planning, purchasing and delivering care. It has been recognised, too, by governments and by other commentators. Indeed the recently published report of the Social Justice Commission established by the Labour Party with some Liberal Democrat membership states that: Although the dividing lines between treatment and care can be difficult to agree, the distinction offers the basis for a clearer approach to funding. And it goes on to say: Given the many demands on resources, however, it is not feasible to extend the founding principle of the NHS—that treatment should be free at the point of use—to the comprehensive provision of care and help with everyday activities. While a boundary in the division of responsibilities between the NHS and social services is necessary, it need not jeopardise a sensible and comprehensive service to individuals. Many people will need both health and social care and will want to move from hospital into a nursing or residential home or indeed, with enough support, return to their own familiar home with friends and relatives around them. It has always been a challenge, both for governments and for agencies, to improve collaboration between health and social services and to ensure that people benefit from a seamless service. Local health authorities working closely with social services and the private and independent sectors have achieved some notable successes—as was outlined by some noble Lords here this afternoon—but only in some parts of the country. In others, we know, there has been room for improvement.

The need to strengthen local collaboration has been a central feature of the community care arrangements. Local authorities have been given the lead responsibility and it is essential that they work closely with the NHS and other agencies such as housing, in planning and commissioning services, in assessing individuals needs and in arranging the support necessary to meet those needs.

We have strengthened the incentives for close working by requiring local authorities, as a precondition to receiving the Community Care Special Transitional Grant, to reach agreement with their local health authorities, not only in the arrangements for hospital discharge but also in clarifying their responsibilities for long-term care.

It was only 18 months ago that the new community care arrangements were introduced, and we have been encouraged by the progress already made. This is a view endorsed by the Association of Directors of Social Services, which has repeatedly declared the first year of community care to have been a success. My noble friend Lady Macleod of Borve was absolutely right. It is clear that people are being offered more choice and appropriate support. She is also right in saying that more people are choosing to stay in their own homes.

Not only are more people being cared for in their own homes, but 10 per cent. of people who would have gone into a care home under the old arrangements are now being supported in their own home. Health and local authorities are working together to offer more imaginative support which is tailored to meet the needs of individuals and their families and carers. We are witnessing schemes which involve arranging for someone chosen by the dependent person to visit in the morning to get them up, to cook meals during the day or to help with gardening or shopping—whatever is needed to help preserve a person's independence and allow them to stay at home. These schemes are flexible. As my noble friend Lady Gardner of Parkes advocated, some involve volunteers; others are funded by local authorities.

My noble friend Lord Jenkin of Roding is also right when he says that we should not underestimate the work and effort which has been invested by local social services departments and health authorities to achieve these changes. His view is endorsed by the independent Audit Commission and the Association of Directors of Social Services, as well as the department's Social Services Inspectorate and the National Health Service Executive. They have all confirmed that the careful preparatory work undertaken prior to the Act coming into force has meant a sound start in most places.

The noble Countess, Lady Mar, suggested that the community care Act was not welcomed. That was not so.

The Countess of Mar

My Lords, I am sorry to interrupt the noble Baroness. I did not mean to imply that the Act was not welcomed. It is very welcome and working well in a great many parts of the country. Just a few are not getting the funds to meet their liabilities.

Baroness Cumberlege

I am grateful to the noble Countess. I misunderstood her. I thought she said that it was a question of, "We told you so". Clearly I misrepresented it. I shall look it up in Hansard. It is a policy that has been widely welcomed from many quarters.

The noble Countess suggested that the community care grant was not ring-fenced. It is ring-fenced. She also highlighted the difficulties in some shire counties which are experiencing some of these problems. I should like to issue a word of warning here to local government. I feel that local government needs to be careful. There is a body of opinion in this country which does not want local government to be responsible for community care. It is not a view that I share. I spent 28 years in local government and I know its value, especially when an authority is well run. But, if people lose confidence in local government's ability to deliver services, especially within increased resources, the temptation to review its new responsibilities will be very great. I for one would be sorry if community care were thought to be an inappropriate responsibility for local government.

Turning to resources, local authorities have been well funded to meet their new responsibilities. Over £1.2 billion has been made available this year, which includes £20 million extra for respite and home care. Next year the budget will be over £1.8 billion for community care alone, which will include an extra £30 million allocated for home and respite care. Those are substantial increases by anybody's standards. They mean that since 1990–91 the total resources for social services, including community care, will have gone up from £3.6 to £6.4 billion, an increase of 48 per cent. after allowing for inflation. There is no local authority which has not had increased resources.

No one hearing those figures could doubt the Government's commitment to resource community care fairly. The noble Baroness, Lady Farrington, will know from her close connections that local authorities fought hard for those new responsibilities. They now have the task of carrying them out successfully. The vast majority are doing so and as a result are making a tangible difference to the quality of some very dependent people's lives. But one or two are finding it difficult to cope with the range of their new responsibilities and the need to plan their spending over a full year taking into account the build-up in the numbers of people whom they are supporting.

The noble Lord, Lord Ashley, was right to highlight the damaging effect of squabbles between agencies. My noble friend Lord Jenkin also reminded us of what can be achieved when people are imaginative and determined and work effectively together. When that does not happen, it can be disastrous, as the Health Service Commissioner's report concerning the Leeds case illustrated. The Government took that report very seriously. The commissioner was critical of the fact that the health authority failed to secure long-term health care and inappropriately discharged a very severely incapacitated man who had had a stroke. Although the health authority's action took place before the introduction of the community care reforms, we considered that the report raised wider issues. In the summer we issued draft guidance for consultation which reminded health authorities of their responsibilities for securing long-term care, an issue which has been widely discussed this afternoon.

The draft guidance, as we hoped, stimulated debate— a national debate. We received many thoughtful replies to our consultation paper, which will influence the final version of the guidance. But there have been some misunderstandings and misinterpretations of the guidance and I should like to take this opportunity to correct them.

First, I can assure the noble Baroness, Lady Jay, that it was not our intention to change the responsibilities of the NHS for long-term health care but to reinforce them. We are clear that health authorities do have a responsibility, which includes long-term in-patient care, whether in an NHS hospital or funded by the NHS in the independent or private sector. Following this guidance, all health authorities will be required to review their arrangements and to ensure they are securing adequate provision. If they are not, then we shall insist that they make the necessary reinvestment. I understand the dilemma which the noble Baroness, Lady Robson of Kiddington, and the noble Lord, Lord Hollick, outlined in terms of standards.

Secondly, we are setting a clear framework at the centre, but it must be right that health and local authorities, working closely together, should determine precisely where local responsibilities lie and who will fulfil them.

Local services will always vary depending on the facilities available. For instance, in some areas services have been centred around an old long-stay hospital; in other areas such a facility has never existed. In some areas the independent sector is well developed; in others it is almost non-existent. It is right, therefore, that local people, who know the strengths and weaknesses of their communities, should decide in close partnership with the populations that they serve what is provided and where. That is the whole principle of population needs assessment.

Thirdly, we are interested in transparency, an issue that was raised by the noble Baroness, Lady Hamwee, and the noble Lord, Lord Thurlow. After local policies have been developed in consultation with local interests—local authorities, providers of services, GPs, voluntary organisations and other representatives of users and carers —the draft guidance states that a clear statement must be published by them which offers local people an explanation. We agree with the noble Lord that people need to know on what basis doctors and other professionals involved in individual cases will take decisions. They need to know the eligibility criteria for long-term care.

Finally, the draft guidance emphasises the need for clear policies in hospital discharge. For many patients, leaving hospital is a straightforward event involving, probably, an out-patient appointment and a follow-up visit with their GP. That is not the case if people are not able to support themselves at home. They may need to be cared for in a residential or nursing home, or require a range of services in their own home for a long period of time. Those decisions are important and far-reaching. They need to be made not only by the vulnerable person concerned but by their family and their carers.

We have required health and local authorities to reach agreement on integrating hospital discharge with local authority procedures. Recently, we have produced and issued widely the practical Hospital Discharge Workbook, which sets out ways in which arrangements for hospital discharge can be reviewed and improved, recognising the key roles of different agencies and the need to take full account of the needs of patients and their families. In addition, the draft guidance reinforces a number of issues for health authorities and hospitals which must be taken into account. Finally, we shall continue to look at this area closely in our monitoring of the new community care arrangements. In the light of the national debate we want to finalise this guidance soon. I can assure your Lordships that the views expressed this afternoon will be taken into account. In an attempt to answer specific questions, I feel that it would be wrong for me to pre-empt the final document, but I do not believe that it will be possible to give my noble friend Lady Eccles the assurances that she seeks in the light of it requiring new legislation.

The noble Lord, Lord Brimelow, raised the issue of Camden and Islington district nursing services. I am always very reluctant to comment on individual reorganisations unless I have had the opportunity to talk to those involved, both staff and their managers. Whether the current workforce is of the right capacity in terms of numbers or of the right level of skill is impossible for me to judge. I shall certainly write to the noble Lord. I am sure that he will also be interested in the views of my noble friends Lady Gardner and Lord Jenkin of Roding, who have experience of these issues.

The noble Baroness, Lady Masham, after giving a very moving account of a particular case—I am pleased to say that such a case is very unusual—raised the issue of time limits for assessing individuals. We recognise that in some areas there are lengthy waiting times for assessments, especially by occupational therapists. We take that matter seriously and the Minister for Health, my honourable friend Mr. Malone, has already started a round of talks with interested groups, including local authorities and the College of Occupational Therapists, as to how we can make some improvements speedily.

The noble Baroness, Lady Nicol, and my noble friends Lady Macleod and Lady Seccombe were right to focus our minds on the carers and their crucial contribution to community care. I can reassure them that they are at the very heart of our policy. The noble Baroness, Lady Nicol, asked also about the sale of property to fund nursing home and residential care, as did the noble Baroness, Lady Robson. Though local authorities must look at the value of a resident's property —in most cases it is their former home—they must ignore it if it is still occupied by the resident's partner, a relative who is 60 or over or who is incapacitated, or a child under the age of 16. Local authorities have discretion to ignore the value of the property in any other circumstances where someone is still living there and it would be reasonable for them to do so, for example, when a former carer continues to live there. A resident cannot be forced to sell their property without a court order. However, in most cases local authorities put a charge on the property so that when it is eventually sold they may recoup what they have paid in fees on behalf of the resident.

The noble Baroness, Lady Robson, asked about the opportunity that people have to refuse to be placed in a private nursing home. Patients can refuse to be placed in a nursing home or residential care home where there is a charge. In such cases social services and the health authority should try to find a satisfactory alternative, such as a range of services to support them at home. Patients never had a right to stay indefinitely in a hospital bed when doctors and others decide that they do not need continuing in-patient care.

My noble friend Lord Mottistone raised the issue of funding in the Isle of Wight. Since 1st April 1993 the total resources for social services on the Isle of Wight have increased by 12.5 per cent; from £14.3 million to £16.1 million. Since 1991 the increase in total social services resources on the island has been 90 per cent. Those are substantial sums which demonstrate the Government's commitment to community care and social services generally. Though I accept that the increase in the grant this year is not as large as the council had hoped, it is its responsibility to manage those increased resources carefully and effectively.

My noble friend Lord Ashbourne spoke of the difficulties faced by some of the Sue Ryder homes. Last summer I had discussions with the noble Baroness, Lady Ryder of Warsaw, and I am disappointed that the issues have not been resolved. I shall certainly write to my noble friend and to the noble Baroness.

This has been an important debate. The provision made for the care of the elderly, frail and disabled people in our society is of crucial significance to us all. The community care reforms, widely seen as the most ambitious legislation in social care since 1948, are beginning to take shape. After only 18 months there is clear evidence that things are beginning to change for the better. But there is still a long way to go. These changes were not meant to happen overnight: it is a programme for the next 10 years. But your Lordships can rest assured that this Government are committed to ensuring that the full benefits will be delivered and a seamless service given.

Lady Kinloss

My Lords, before the noble Baroness sits down, perhaps she can say whether or not she will look into the case for more consultants for younger people suffering from dementia.

Baroness Cumberlege

My Lords, I apologise to the noble Lady. I shall certainly do that. I shall also take up her point regarding the leaflets for long-term care. They are around and I shall ensure that the noble Lady receives copies.

5.54 p.m.

Baroness Jay of Paddington

My Lords, with the leave of the House, I thank the Minister on behalf of my noble friend Lord Ashley of Stoke for her detailed and careful reply. On his behalf also I thank all noble Lords for taking part in what has been an authoritative if somewhat disturbing debate. Knowing the deep concern of my noble friend in this regard, he may want to return to some of the issues raised this afternoon. In the meantime, I beg leave to withdraw the Motion.

Motion for Papers by leave, withdrawn.