§ 5.57 p.m.
§ Baroness Barker
rose to call attention to the case for reviewing the present level of investment in social care; and to move for Papers.
The noble Baroness said: My Lords, I should first declare an interest as an employee of Age Concern England. I am most grateful for the opportunity to introduce this debate on a subject that has been largely neglected as attention has been focused on the headline-grabbing issue of NHS funding. I am also most grateful to the many noble Lords who have agreed to participate. I look forward to many wise and knowledgeable contributions.
Some may question the topic of today's debate, coming as it does so soon after publication of the Wanless report and the subsequent Budget Statement. Indeed, there was an almost palpable sense of relief when the Budget Statement recognised that there has been chronic underfunding of social care. However, as contributions from these Benches will show, this debate is more necessary now than ever. Although there has been an increase in resources, the increase is neither adequate nor strategically directed at the deep-seated problems in social care.
Those with an interest in personal social services who made it to page 92 of the Wanless report, and some of us have, were in for a pleasant surprise. It says that,In planning the delivery of care, health and social care must be considered together in order to ensure that both provide high quality services for the individuals receiving care and make efficient use of resources".Coupled with the headline announcement of a 6 per cent increase in social care funding, some might well have thought that Christmas had come early. However, this is still the Government of spin and recycling and, on the morning after the night before, there was a dawning realisation that it really was too good to be true. Of the £3.2 billion announced, £800 million had already been promised and was 817 being re-announced. After taking into account the existing commitments of local authorities and the increases in national insurance, local authorities will still be £500 million short of what they already spend. Furthermore, while services across all clients groups are overstretched, all the increased funding is to be directed to older people's services via a very peculiar mechanism of penalties. Therefore, before addressing other issues, I should like to take this opportunity to ask the Minister whether the £3.2 billion is separate from the Comprehensive Spending Review or an early announcement of the CSR, and for how long will the commitment last?
The social care system is now close to collapse. The outlook for many social services departments is as bleak as that of a Nationwide football club. In the year to March 2002, local authorities will have overspent their budgets by £218 million, in addition to a planned overspend of £1 billion to meet deficits in the SSA. For example, in Oxfordshire, the social services SSA is £85 million. Council spending on social services is £105 million, which is made up from increased council tax and raiding other departments. The amount needed solely to cover existing commitments is £114 million, while the quality of services continues to be driven down.
The eligibility criteria for services are tightening all the time, with the effect that only those with the most severe needs are included. Those with moderate needs and the needs of carers are increasingly being overlooked and preventative services are being squeezed. Local authorities that have for years subsidised under-funded care services from environment, transport and other budgets are running out of ruses.
Not only are older people's services stretched. Across the country, children's services account for two-thirds of the social services overspend. Between 1996 and 2001, the number of looked-after children rose by 15 per cent to 58,100, and there has been an increase of 55 per cent in the number of looked-after children who have suffered abuse or neglect. Increased poverty has had its effects, and, according to the HBAI survey, an increasing number of children live in households with incomes below half the national average.
Two-thirds of looked-after children are placed in foster care. But there is a growing shortage of foster carers and an evident need for increased training, support and remuneration for people willing to give much needed support to troubled, challenging children, who will otherwise end up in residential care.
The child protection system is in urgent need of resources. Thirty-six thousand children are on child protection registers at any one time, and, although few make headline news, one or two children die weekly from neglect or abuse. Whatever priorities they may be dealing with now, social services departments are rightly gearing themselves up to deal with the results of the Climbié inquiry. However, some departments will informally admit that when the report of the noble Lord, Lord Laming, is published, resources will be switched from current services. Furthermore, it is 818 evident that the child protection system desperately needs an increase in frontline staff, properly supported and supervised and capable of bringing experience and continuity to its work and its clients.
There is an underlying problem of staffing across all social services. Your Lordships will note that 1.1 million people work in social care, many of them part-time and among the lowest paid people in our society. The LGA report, Care to Stay, published in February this year, reported vacancy rates of 20 per cent and turnover rates of 17 per cent for home care staff. In London and the South East, the problem of recruitment and retention of care staff is acute.
The Minister and other speakers from his Benches and elsewhere will no doubt reel off a list of initiatives and a raft of figures to show how the Government have allocated money to health and social services. The Department of Health, the DTLGR, the DES, and sometimes even the DCMS, launch initiatives that all have relevance for social care in its widest sense. Funds with new titles crop up all the time. It is impossible to keep track of them—so much so that people who work in the field spend weeks of their time simply chasing pockets of money. There are many short-term funding schemes, which rarely last for more than three years. For some funds, such as winter pressures money, the timescales are so tight that the allocation disappears into the ever-open chasm of the NHS before anyone else has had an opportunity to benefit from them. Even when funds are conditional on partnership bids, the process is so time consuming that success or failure is often a matter of chance. That kind of short-term, piecemeal funding masks the structural deficit that lies beneath.
The Government's response was set out in the Budget Statement—a system of penalties for delayed discharge from hospital. The idea of a perverse, internal health and social care market is intriguing. I look forward to learning from the Minister why the Government opted for that mechanism and, in so doing, chose to ignore the evidence from the LGA to the Health Select Committee, in which it said,The funding shortage that faces Personal Social Services is not caused by the need to support people in the few weeks after discharge, but by the lack of funding for preventative services.That statement is borne out by a recent survey of local authorities, in which fewer than 20 per cent were able to find the resources necessary to implement the Carers and Disabled Children Act 2000.
Since the Budget announcement, people throughout the care sector have tried to envisage how this new system of penalties will work. How will it be possible to prevent inappropriate discharges to residential homes of people who, with a little more hospital care, may be able to return to their own homes? What will happen when discharge from the acute sector is delayed because of a lack of community health services? Will local authorities also have to pay for that? What will happen when residential care beds are available but not enough qualified staff? What is the position of care homes whose registration has been delayed by the backlog of applications at the National Care Standards Commission? What will happen to 819 someone who is recovering from a stroke but cannot return home because of a need to wait for physical adaptations to be made to his or her home? Will people who are discharged from hospital take priority over people who are waiting to go into residential care from their own homes? Above all, how will the Government, who want to reduce health inequalities, stop the creation of vicious and virtuous circles, whereby areas with many problems have more delayed discharges and fewer resources to fund preventative services, while areas without problems have resources and can thereby cut demand?
The Treasury may be satisfied that its announcement has solved the problem of social care. It has not. The problem has been ducked. The Treasury has not come up with a way to control or limit the need for social care. It has simply passed the hot potato of the immediate crisis of insufficient care home capacity to local authorities. I say "local authorities"—not the NHS—because it is impossible to see how anyone other than a clinician could determine that an inappropriate readmission was the result of an inappropriate discharge.
Mr Wanless was half right when in his report he said,While the review considered it vital to extend its terms of reference to begin to consider social care, it has had neither the information nor the resources to be able to develop a whole systems model".There is an urgent need for review of social care and social care funding. But, more than that, there is a need to change the basis on which social care is valued and evaluated. Social care is always overshadowed by arguments about the NHS. However, it is increasingly measured only in relation to the occupancy of acute hospital beds. That is a narrow definition of health and a short-sighted strategy. Social care covers a range of clients. It could be evaluated equally well by a comparison with the cost of custodial sentences, the cost of delinquency in terms of police time, the cost to employers of working days lost by people suffering mental health problems, or by the true cost of caring.
There is an urgent need to consider the efficacy of social care, as part of health in its very widest sense, and to evaluate the efficacy of low-tech services, such as home helps, before they disappear entirely. There is a need to ensure that social care practitioners have sufficient time and resources to evaluate work and disseminate good practice. If a quarter of the time and money spent on consultation about needs—usually the same needs and the same consultation, with the same answers as have been given for years—were spent on research and the training of staff, many of the social care tragedies that hit the headlines could be avoided, and morale in the care sector, which is at an all-time low, could be restored.
The Social Care Institute of Excellence has to be encouraged not only to develop best practice, but to halt the increasing medicalisation of old age before it becomes irreversible. There is a need to realise that rehabilitation cannot be measured by four or six weeks' intensive therapy by a practitioner. Intermediate care needs to be based on evaluating 820 judgments about people's ability to reintegrate back into their social care systems, their social networks. There is a need to demonstrate that funding for a handyperson scheme is an investment that will pay dividends, not just in the fewer number of broken femurs, but in the peace of mind that would enable older people to continue to live independently in their own homes.
This debate is deliberately and rightly centred on the factor of funding. Social care only ever seems to be reported when there has been a tragedy or when economists look at demographic projections and envisage a negative balance sheet. But just as in the health service where there has been a recognition that it is possible to turn around from a reactive approach and by bringing together good practice in the form of NSFs focus on the encouragement and promotion of good health, so, too, in social care it must be possible to move away from crisis and reaction to a system which positively promotes well-being.
Mr Wanless is right, there is an urgent need for review. However, there is an even more urgent need for injection of funds to keep basic services from going under. It is time to take a longer term strategic view. Unlike a rather more famous Member of your Lordships' House, I really do believe that there is a thing called "society". More than that, I believe that all members of the population have a right to take an active part in that society, no matter what their age. I believe that the Government's reaction to the Budget has been short-term and incomplete and that the re is a desperate need to re-evaluate social and healthcare in a wider setting. On that note I beg to move for Papers.
§ 6.11 p.m.
§ Baroness Pitkeathley
My Lords, I have spent a great deal of my life working either in social care or at the margins of its provision as a social worker, a campaigner for carers who actually provide most social care and, most recently, as the interim chair of the General Social Care Council. I am a fan of social care and those who provide it and II am most grateful to the noble Baroness, Lady Barker, for giving us the opportunity to debate this issue. I share her passionate commitment to it.
Social care services operate in areas of conflicting values and ethical dilemmas. Staff work with groups who are often marginalised, tackling difficulties which most of us would prefer not to admit exist and at the boundaries between public and private interests, individual and family interests, trying to strike a balance between autonomy and dependency and between choice and control. The work involves judgments about risk, priorities, competing and conflicting interests in the most stressful of circumstances and where political and public opinion, especially as expressed in the press, can be volatile, inconsistent and sometimes even vicious.
I want to take the opportunity, therefore, to praise social care services, both statutory and voluntary, for the diligent and responsible way they carry out those onerous duties and also for the fact that many of them 821 remain, even in the face of that tremendous pressure, able to embrace new ideas and be innovative in their approach. So if you ask me whether more resources are needed for social care, I shall certainly say yes. What is there is never enough. However, unlike the noble Baroness, I believe that there is some good news to report. As the noble Baroness reminded us, the level of spending on social care has just been reviewed and a three year settlement agreed. I believe that the level of spending agreed demonstrates the Government's firm commitment to social care.
We should remember that between 1992 and 1997 the average real terms increase for social care was 0.5 per cent. In the previous spending review resources increased and the latest Budget delivers average growth in real terms of 6 per cent from the next financial year to the years 2005–06. So there is some good news there for social care, but not as good for sure as those of us who work in it would like. However, as I doubt that the Minister who will reply to the debate will announce a great new tranche of resources, I thought that I would try to draw attention to some of the issues which are perhaps almost as important as money.
The first matter concerns the status of social care which has always been much lower than it should be, as the noble Baroness reminded us. At last we are beginning to hear the Government talk about health and social care as though it is one word. I believe that we have at last begun to establish in government thinking and policy making what many of us have known all our working lives; that is, that provision of healthcare and provision of social care are inextricably entwined and must be considered together. I have lost count of the number of times I have heard lip service paid to that not very revolutionary idea and of how many times I have heard Ministers say that divisions between health and social care must be overcome. However, there are at last signs that the message has been received and understood. The division has famously been called "The Berlin Wall" and older people, as the noble Baroness reminded us, are often victims of a failure of co-operation between services.
It has always been the experience of those of us who work with users of social care that they neither know nor care who provides the services as long as they are of the right quality and are available at the right time. What is also vital, of course, is that services are interlinked and co-operate with each other. Some recent improvements in that regard include the National Service Framework for Older People; the heavy investment in intermediate care to build a bridge between hospital and home for older people; reducing delayed discharges with extra funding and improved co-operation between health and social services through pooling of budgets. I believe that about £1 billion is now spent in that way.
I want to draw attention to the good practice which does exist and to the willingness and commitment of health and social services to work together. Further incentives to do that are to be introduced by the imposition of charges to social care agencies if they fail 822 to meet agreed time limits on hospital discharge. That is, of course, a controversial proposal, which is why I draw attention to the good practice which already exists. I have reminded Ministers before that in my view carrots work better than sticks when it comes to promoting co-operation. I hope that the Minister will give a further assurance that it is envisaged that those penalties will be used only as a last resort.
I also think that it is a pity that emphasis on the connection between health and social care on the part of the Government focuses so heavily on hospital discharge. Care at home and how it is provided is, of course, crucial when it comes to ensuring that delayed discharge is addressed but it is even more important to older people and their carers at home in order to prevent admission to hospital or to care home and to maintain independence at home, which is what most people want.
Most social care is provided by family carers and your Lordships will perhaps have seen the new report by Carers UK—I declare an interest as a vice-president— Without Us, which gives revised figures for how much carers save the nation. For many years we have been working on a figure of carers saving the nation £34 billion, but the estimate is now revised upwards to £57 billion. Some of the reasons for that huge increase are that more carers are providing significant amounts of care; the costs of replacement or respite care have increased enormously; and the fact that although more home care is being provided, it is concentrating on fewer people; that is, those with the greatest need and carers are having to make up the shortfall.
So we must ensure that the increased levels of funding for social care result in an increased range of services as well as more of the existing ones. We must have better packages of home care and faster assessments of the need for home care. Too many local authorities are still not giving carers the services to which they now have a right under the Carers and Disabled Children Act 2000. The reasons that they give for that is that they lack adequate resources or they have had to use the resources for more urgent need. That is simply not good enough. What more urgent need is there than to give carers a brief respite from caring duties which will enable them to go on caring, as most of them want to do, for many more months and years? Supporting carers makes sound economic as well as moral good sense.
It is also the case that systems for monitoring the effectiveness of social care must be established and kept under review. Important changes have just been announced as regards how that will be done. While some of us might have wished that the review period for the newly established National Care Standards Commission had been a little longer, the establishment of the new Commission for Social Care Inspection has been widely welcomed. That will carry out inspections of all social care organisations, as your Lordships will know. We must ensure that there is the utmost cooperation between that commission and the Commission for Health Improvement Audit Committee and that the voices of users are strong as 823 regards the way it operates. As legislation will, no doubt, be required, this is an area on which there will be much more discussion in this House. But I hope that the Minister will assure us that the Government are committed to co-operation between the two commissions and to strong user involvement.
I cannot let the opportunity pass to single out for praise the establishing of the General Social Care Council of which I have the honour to be interim chair. One million people work in social care and it seems incredible that until now no government were willing to set up such a body as exists in most professional caring fields with the task of regulating standards, conduct and practice. The GSCC has got off to a flying start thanks to the commitment of its council members and staff.
Nor should we forget, as the noble Baroness reminded us, the work of the Social Care Institute for Excellence. It is undoubtedly the case that as the quality of social care and those who deliver it improve, so more demands will be made on resources for more trained staff and more wide-ranging provision. I may be an optimist but I believe that the Government now understand the importance of social care. That, coupled with the initiative and commitment that have always been shown by my colleagues in the sector, together with the strong voices inside and outside this House devoted to lobbying continually for more money, will change social care from the Cinderella services seen hitherto to take its deserved place as the most important contributor to the health and welfare of our most vulnerable citizens.
§ 6.21 p.m.
§ Baroness Fookes
My Lords, I congratulate the noble Baroness, Lady Barker, on bringing forward this important and worrying subject at a crucial and opportune moment. In the short time available I want to concentrate on the old rather than the young.
Before attending the debate, I asked a friend involved in the care sector what she thought. I mentioned the level of investment. "What is really needed", she said with a great deal of indignation, "is an emotional investment by government and politicians. If you have that, then money will follow". That is right; there must be concern for the plight of many elderly people.
Unlike the two previous speakers, I have no professional knowledge of the subject, but I saw a number of elderly people during my time as a constituency MP. For me, it is always the individual that matters; usually an older person whose health is threatening to give way, perhaps with relatives who do not care or cannot because they are too far away. The future seems bleak and uncertain for such people. We must never forget that when talking about policy.
People matter; individuals matter. That must always be at the forefront of our minds. Against that background, it disturbs me to see how quickly care places—I do not like to call them "beds"; that sounds like a hospital—in residential homes are vanishing. That shows no sign of abating. Since 1996 it is 824 estimated that some 50,000 places have disappeared. The pincer effect is continuing. First, there is often a mismatch between what social services are able to pay for those who cannot pay for themselves and what is actually needed to run homes; secondly, there is the increase in national insurance contributions resulting from the Budget on a sector which relies heavily on staff more than on equipment. About 80 per cent of a care home's costs are on staff.
There is the additional pressure of the minimum wage. I do not suggest that people are not worth the minimum wage, but if it is taken with the other factors bearing on the care home industry there is a problem. I have been told that many care home owners are worried about the development—again, admirable in itself—of checking would-be staff for criminal records. I am told that the theory is fine but in practice it takes several weeks for clearance to come through, by which time the potential employee has found a job somewhere else; perhaps in Tesco or some other place where it is easy to find employment. Therefore homes lose staff before they have even acquired them.
It is hardly surprising that with property prices rising, many home owners feel that it is hardly worth carrying on and that they might as well take the money they can get for their property and depart. I see no reason why that situation should not continue, although it is a worrying and unnerving trend when one considers the need for residential care homes for the most vulnerable in our society.
Ideally we should keep people in their own homes, but that can be expensive, not only in financial terms but in terms of the time of short and hard-pressed staff. It is not always an option. There is another pincer movement; the imposition of new physical care standards. I do not quarrel with the principle but it is a further worry for home owners. Perhaps I may give an example. A home owner was required to put in a lift. Admirable no doubt, but the format of the house meant losing three rooms. Therefore he lost the income from those three rooms, coupled with the need to borrow heavily from the bank to install the lift— £150,000 or more. Is it any surprise that home owners wonder whether it is worth while trying to carry on?
Another home owner found himself up against the desire for single rooms. In his home he had three married couples and two other people who wanted to share. However, he was over the set quota. It is absurd; if people want single rooms it is good to have the choice, but if people want to be together—and many do—why should they not be? Surely choice should be more important than some quota which may not meet the facts in an individual case?
For all those reasons care homes are being squeezed. The noble Baroness, Lady Barker, ably illustrated the issue of bed blocking. I marvel at a system that imposes penalties and charges as though the various organisations involved were criminals. I am sure that every NHS hospital, authority, local authority and social services—anyone involved—is anxious to do the best that it can, so why treat them to such penalties? As 825 the noble Baroness pointed out, that can only be bureaucratic and will probably have unfortunate side effects.
I cannot think of a more Alice in Wonderland solution to a problem that could probably be solved by more money being available where needed. That is the key issue. It is no good looking as though we have the money if it is not there. It is unfair to penalise either local authorities or the NHS, which I believe is to be penalised for emergency readmissions. As has been pointed out, who is going to decide whether an emergency readmission is due to premature discharge? I would like the Minister to explain carefully who is to undertake that task, how it will be evaluated, whether there will be an appeal system and who on earth is going to find the time to do all that amid the other pressures.
It is a lunatic system. I urge the Minister to bring pressure on the Government to think again. It is madness; quite the wrong road to go down. I am reminded of the plight of the ancient Hebrews in Egypt who were given materials for making bricks. Suddenly the authorities said that they were no longer going to supply the materials but they must still make the same number of bricks. Bricks cannot be made without straw, as the old saying goes.
§ 6.30 p.m.
§ Baroness Masham of Ilton
My Lords, I thank the noble Baroness, Lady Barker, for initiating the debate. It comes at the most appropriate time, just after your Lordships have discussed some of the very important responsibilities which are being moved from the NHS to local authorities by the National Health Service Reform and Health Care Professions Bill. If the local authorities are successfully to undertake the new duties, they will need the resources to do so and investment will be needed in training people so that the jobs are done well.
The Minister will be aware that the Local Government Association is concerned to know how the Government intend to ensure that the Commission for Patient and Public Involvement, particularly at the local level, will make full use of and work effectively with existing local authority systems to achieve community leadership, consultation and scrutiny. I hope that there will be no fragmentation and that the Minister can reassure the House that vital health matters, where local authority bodies are involved, will not fall through the net and be neglected, such as happened in the case of Victoria Climbié whose care and well-being were neglected by a social service department. Many people, when they hear of such tragic cases, lose faith in their local authorities. What happens to the elected democratic members? I wonder whether they feel guilty and I wonder whether they will be interested in scrutinising the NHS. What will they know about public health and dust under hospital beds? For example, will they be able to highlight the deficiencies in the care and management of people with epilepsy?
826 The Government want to do away with community health councils. Will the expertise that has been established over many years within community health councils be used and incorporated into the new arrangements, or will it just be lost? Will the Government define the responsibilities for the four regional directors of health and social care?
There are questions about social care functions, in particular any implications for the Social Services Inspectorate and other parts of the Department of Health. What happens when the Commission for Health Improvement inspects NHS hospitals or other service providers and finds that they are unacceptably poor and are failing? Will it close them down? It would perhaps have been diplomatic for an NHS body to scrutinise the working of the social services while local government scrutinises the NHS? I welcome, as I think most people will, the fact that the inspection body is independent.
I want to bring to the attention of your Lordships a problem which I hope the better working together of the NHS and social services may be able to solve. However, it involves not only those two departments; it involves the local housing authorities too. There should be joined-up working between departments, not negative brick walls.
Many seriously and permanently disabled people who have been treated in hospital encounter delay in returning to the community because they do not have suitable accommodation to go to—the so-called "bed blocking" situation.
I declare an interest as president of the Spinal Injuries Association. Many people, paralysed mainly as a result of accidents, remain in hospital because their home accommodation is not suitable and they cannot get a disabled facility grant because the social services will do nothing until the patient has a discharge date. He—or she—may need only an extension to the house, but in order to get an assessment he has to wait for a local authority occupational therapist to assess his home situation. He may have to wait months, if not years, to get out of hospital. More occupational therapists to speed up the assessment process would be a very good investment in social care.
Once a patient is ready to go home, it is psychologically damaging and very frustrating to have to stay in hospital, apart from the expense to the NHS and the blocking of acute beds when they are needed for new patients. If the local authority had to pay the cost of the hospital bed because it had not provided the necessary accommodation, that might make it get a move on and put the wheels in motion before the disabled person received his discharge date. The hospital could be given at least the disabled facility grant to help fund the hospital costs.
It is a major problem. If the Minister will look into the matter, the Spinal Injuries Association can provide many case histories of frustrated disabled people. Even the people who can pay for themselves are tied by bureaucracy, having to wait for assessment and 827 permission to rebuild. If the Government can unravel some of the red tape which has evolved over the years, it will help the situation.
I was very pleased that the noble Lord, Lord Filkin, took the trouble to visit Wandsworth prison. When I raised the matter in a debate some weeks ago he said that he would. In many prisons throughout the country there are prisoners who are disabled or mentally ill. I welcome the proposed closer working between the NHS and the Prison Service. That will also involve the probation service and local housing authorities and housing associations. Without a range of services for resettlement in the community, there could even be cell blocking in prisons in the future.
Many care homes closing because of the extra expenses they face. Those costs are not being met by social services. So there will not be as many places for long-term sick, disabled and elderly people.
On Monday, as I came to your Lordships' House in a taxi from King's Cross station, I saw someone lying under a pink blanket in a doorway—not an unusual sight these days. But there was no movement. I have been thinking that should he have been dead, how long would he would have remained there with people passing by? With an increasing elderly population and many social care problems due to alcohol and drug abuse, apart from disabled people, there must be a good case for reviewing the level of investment in social care.
It seems that local authorities are not aware of the scale of the problems. Or are they turning a blind eye and shutting the door because those problems have become so great? I hope that the debate will help alert a few people to the immense swell of social needs which can be passed by when people in authority do not have time to stop and look.
§ 6.39 p.m.
§ Lord Addington
My Lords, I thank my noble friend for introducing this important debate and for doing it so well. The title of the debate draws an incredibly broad brush across a whole section of our society. The noble Baroness, Lady Pitkeathley, enhanced that point by showing how wide we can go. We can talk about social care, health and what happens if things are not done properly.
As regards health and social care, one can make a strong case for saying that a public gymnasium with skilled instructors should perhaps be included in the health budget. I come from a city that has lost all its public gymnasiums, although it is true that we have some nice, interesting housing developments where they were. I shall try to draw that to the attention of the new Liberal Democrat council in Norwich.
When we discuss these problems there is a tendency to go to the worst case scenarios, looking to where the problems are most intense and most readily identifiable. When I saw the title of the debate, I immediately thought of the elderly. It was then pointed out to me that those dealing with the elderly are often in a defensive situation, trying to prevent the loss of independence of living or of standards and dignity. We 828 should cast an eye more intently at the situation of the young. Children receive a great deal of attention when we deal with subjects such as education. I have been through many education Bills on which we have dealt with disability, as well as Bills dealing specifically with special educational needs and disability and the problems that such children encounter throughout the education system.
I shall break a habit by giving some figures. The Royal Commission on Long-Term Care of the Elderly estimated in 1999 that there were 340,000 disabled people below the age of 29 in this country. The number gets progressively higher until, by the age 59, we reach a total of 1,918,000—just under 2 million. That is a huge number of people who cannot be described as elderly. They should be participating fully in our society.
Of course, statistics do not show issues such as how severely disabled the people are or what help they want. However, that group of people, especially the younger ones, should be receiving help to enable them to be as independent as possible so that they do not become a burden on society. We have already addressed that in various Acts of Parliament—the primary example being the Disability Discrimination Act 1995—and accepted the argument that somebody who has a disability should be given support and allowed to work and maintain their dignity, or should at least be allowed to take as full a part in society as they can.
On support services, we start to run into problems. They are often locally based and locally focused. People often find themselves dependent on carers, parents and others who become their localised support system. No doubt it is commendable that people wish to take on that role, but we are talking about adults who should be living independent lives wherever possible. They should have the ability to move round to find education, employment or even simply a change of scene if they want. That should be our aim. Unless we make sure that care packages are able to follow from area to area, we will have problems and we will let those people down.
That does not currently happen very easily. We have a localised structure under which it is not possible to assume that because something has been granted to one person, it will also be granted to someone else. We have to try to bring the system to the young so that they are able to move.
The number of organisations and bodies that provide social care is bewildering. I shall not even start to explain it to your Lordships. I was about to start, but I realised that I was not sure how many were covered. We have to start to address that now to make sure that these people gain the benefits of other aspects of legislation.
Under all the governments that I have seen in this House, any Minister who is asked a difficult question responds with a list of that government's achievements and what will be done. Of course the current Government have done better things than the previous one and of course the previous government did better 829 things than their predecessors in many areas. There is a line of progression. Governments should do better than their predecessors. I hope that the Minister will take that on board and tell us how the Government are at least thinking about how to follow round the care support services for younger people. Those 340,000 people under 29 should be involved in training and finding new career paths. If we help them to establish themselves, we will relieve some of the pressure on caring and some of the problems of respite care. We hope to make them economically viable. At the moment, the system is very bitty. One bit is got right, but the whole system is not dragged together. Departments suddenly have to talk to each other. On many occasions I have talked to people in one department who have said that something is a great idea, but often they have not dealt with the problem before. When they then go to the department that was initially dealing with it, they say, "Oh, we can't do that". It is a universal Whitehall problem.
Will the Minister give us some idea of the thinking in the department about how the support structures can follow education and training needs, so that at least the start of the process is being dealt with?
§ 6.46 p.m.
§ Baroness Greengross
My Lords, I add my congratulations and pay tribute to the noble Baroness, Lady Barker, for initiating the debate, which is about vital issues. Like the noble Baroness, Lady Fookes, I shall concentrate on older people in the short time available. It is essential that the difficult role played by those providing social care must be recognised and properly valued, whichever group or sector of society they are called on to care for.
Like the noble Baroness, Lady Pitkeathley, I welcome the increased expenditure that was announced in the spending review. For many, especially for older people, a greater investment in social care is essential if we are to ensure that the increased survival rates and longevity in our population is the good news that it should be and that we face the challenges that it creates. We know that the greatest increase in our population is among the very old. In that group, we will have more chronically sick and very frail people.
Our challenge is to maximise the autonomy of that group of people, to give them a feeling of well-being and to give them choice, particularly about whether to stay in their own home or to go into a care home.
The Government have declared their determination to avoid unnecessary long stays in hospital. To stop frequent delayed discharges we need more preventive care. The whole spectrum of care needs more investment. That starts with health promotion, intermediate care of a high standard, including long-term rehabilitation and, above all, more and better trained staff with increased capacity in the community or in care home settings.
The noble Baroness, Lady Barker, quoted the Wanless review. I agree with her that he wanted a whole systems review of the NHS. That must include 830 social care and the other areas of social provision that have big gaps in them such as housing. It must cross boundaries and fill those gaps if we are to meet the multiple needs, particularly of older people, who often have multiple pathologies and do not fit into neat boxes.
We know that there is a lot of discrimination against people who fund their own nursing care. Only 22 per cent of those who do so receive the highest band of nursing care funding of £110 a week. Some get no benefit from that, as the fees have increased in line with NHS increased payments. These are powerless people. Sometimes they are discriminated against compared with those who are paid for by the local authority. Indeed, they often subsidise those people, who are denied a proper needs assessment and care management by the local authority. As has already been said, they are obviously extremely badly affected by home closures. Their vulnerability is obvious. They have to move at a time when it is hardest for them to do so. The numbers of home closures are decreasing their choice daily. We need procedures that are fair to ensure that they have certain rights as residents.
Those who have to fund their own care need advice on the management of their care plan by the local authority. Vulnerable people need protection and the local authority can give them that, although it is often apparently reluctant to do so. The fact that younger residents of care homes have higher fee levels than older people is most unfair and represents a form of age discrimination. We must look at the needs of the individual regardless of age; the point is their needs and their need for care.
We know that older people in social care do not always get properly trained staff to look after them. Clock watching and minimal intervention is often all that is provided. Older people need personal care and a service that incorporates much love. It has been established in case law that the local authority has a duty to provide good social care. However, there are gross anomalies and many problems—for example, if the NHS budget runs out and people are transferred to a local authority.
The noble Baroness, Lady Pitkeathley, mentioned carers. I shall discuss only one aspect of that issue. There should be a statutory disregard of property when a longstanding carer is in residence. I hope that the Minister will keep that under review. The issue causes an immense amount of distress. I hope that he will consider a mandatory disregard of property when a longstanding carer remains in the home. That is part of the investment in social care that is needed.
I turn to shortfalls in the funding of social care. Because the fees in care homes have been going up, desperate relatives are often approached to make up the shortfall. In this country, relatives are not forced to pay for the care of someone else. However, one would not believe that that was the case when local authorities almost force them to pay. The local authority has the responsibility—it is the contracting body—but sometimes it will not pay the higher amount. The Government should as a matter of 831 urgency consider the levels of payment by the local authority and set them realistically to comply with the guidance on standards. That is one reason why so many care homes are going out of business. The practice must stop. That is particularly important for those people who were previously funded under preserved rights.
Yesterday's press release from the Government stated that transitional protection of the residential allowance and of part III rates will end in October next year. Those rates were ridiculously low. The proposal will be fine if it leads to a simple transfer whereby the local authority picks up what the individuals lose. I believe that that is the intention. I hope that those people who have made their own arrangements and are using a combination of income support and attendance allowance to do so will not suffer any losses through the move. I also hope that the transfer will include extra costs to the local authority, which will need to reassess large numbers of residents who have transitional protection. That is intended to increase flexibility through the reallocation of money, but that will be needed to make up the loss of the residential allowance to pay for the care home.
People face other difficulties, including those associated with attendance allowance, which may disappear after four weeks if someone is transferred to the local authority and becomes its responsibility. Such complexities are not rare. Attendance allowance needs to be paid according to the needs of the disabled person, not the setting in which he or she lives.
To conclude, we now have a good opportunity, which is greatly helped by the transfer of resources to the NHS. That is intended to develop intermediate care and to improve social care to meet the aims of the National Service Framework for Older People and the standards that the General Social Care Council and the National Care Standards Commission will undoubtedly demand. Older people can no longer suffer lower standards of social care than other groups. The Government cannot afford to ignore them and do not, I believe, wish to do so. I hope that the measures will be successful.
§ 6.55 p.m.
§ The Earl of Listowel
My Lords, I, too, am grateful to the noble Baroness, Lady Barker, for giving us this opportunity to discuss investment in social care. I was saddened by the many eloquent speeches about the problems facing our elderly citizens. I shall concentrate on the essential partnership between child and adolescent mental health services and social care, and the consequential need for greater investment in both of those areas.
The noble Baroness, Lady Pitkeathley, made explicit the fact that health and social care must work in strong partnership. I once met a hostel resident outside the hostel at the beginning of my shift. He was apoplectic because he had been excluded. On previous occasions, I remember playing table tennis with that young man. Always crowned in a blue baseball cap, he seemed almost mute. Of about my height but of great 832 bulk and strength, I see him now doing pull-ups on the bar above the men's lavatory cubicle. I cannot remember the details of his exclusion but I recall that the staff were wholly unequipped to deal with their challenging clients. Most had merely had an induction of a day or two. The lavatory in the hostel was blocked by the accumulation of needles but there was no clear drugs policy. The staff did not have the least understanding of the basics of mental health issues. There were many exclusions. Young people returned to sleep rough on the streets as a result of the ignorance of the staff and their employers, although the staff were of course doing their best. I was told that that was a widespread practice. The least qualified staff often worked in temporary winter shelters.
The Government's Rough Sleepers' Unit and Louise Casey, its director, appear to have turned the situation around. However, there is still a vast need for greater training and support of staff caring for vulnerable children and young people. For example, Young Minds, a charity for children's and young people's mental health, cites the fact that 98 per cent of looked-after children in residential settings and 66 per cent of children in foster care have mental health problems. Despite recent increases in investment, fosterers and residential care staff are still often under-trained and unsupported, compared with our continental neighbours.
A mental health worker charged with developing a specialist mental health service pretty soon adjusted her ideas on arrival in post. She realised that what was most needed was not a specialist service but an understanding of mental health among frontline workers. She found that staff were understandably afraid to question young people about drug use, self-harm and abuse. The consequence was that young people's needs were going unrecognised. Hard as it is to be explicit about those matters, it is essential. She is now investigating training and procedures for hostel workers and training advisers so that they can ask questions, recognise needs and, where necessary, refer the young person on. Dealing with such troubling issues is also disquieting for staff. Means to better support them and to help them manage the troubling feelings provoked by their work are also being examined.
Several years ago I met a mental health nurse who was working in a hostel for young drug users in King's Cross. What she said was so difficult to listen to that I found myself unable to concentrate on my work the following day. She and three of her fellow mental health nurses had been placed in the hostel at the beginning of the year. No thought had been given by the management of how they might be supported. Twelve months later, she was the only nurse who had not resigned; and she was clearly deeply marked by her experience. The organisation appeared to have had no idea of the emotional needs of the client group. It therefore had no inkling of how the staff should be supported.
All these experiences persuade me that social care of vulnerable or challenging children and young people needs to be permeated with an understanding of 833 mental health and what makes for mental well-being, from its top to its bottom. The surviving mental health nurse put it to me in this way,Without a psychological understanding of these children and young people, staff are working blind".The charity Young Minds has been providing children's mental health consultancy and training services for local authorities and other agencies for several years. The director of these services writes—I paraphrase:While not all looked-after children need specialist psychiatric care, they do need adults who are aware of mental health issues and are working to build children's resilience to mental health problems".I leave the last word with the manager of a project for care leavers. A child psychotherapist, trained at the Tavistock Clinic, she had managed a children's residential unit for 18 years before taking up her present post. Her plea to me was that more should be done in terms of therapeutic work for looked-after children before they leave care—I remind the House that the noble Baroness, Lady Barker, pointed out that the number of children in care is rising. The manager said that, once out of care, it was virtually impossible to help the young people to develop the emotional language to allow them to express and come to terms with the neglect or abuse that many of them had experienced. The relative containment of care placement was the great opportunity to begin to make up for the emotional deficit that many had experienced.
I beg the Minister to consider more investment to promote the essential partnership at all levels between child and adolescent mental health services and social care. Such investment should be made with particular attention being paid to the needs of children in public care.
§ 7.3 p.m.
§ Baroness Howarth of Breckland
My Lords, I am grateful to the noble Baroness, Lady Barker, for introducing a topic that is so close to my own heart. As a social worker, a former director of social services, a previous director of a charity, and now a member of the board of the National Care Standards Commission, I seem to have some background in this matter. However, I am never sure why I seem to be placed at the end of debates when all the relevant points have been made. I hope that noble Lords will bear with me if I repeat some of them, because I shall approach them from a different perspective.
The past decade has seen directors of social services spending much of their time worrying about how to cut back services while facing an every-increasing demand. Much of the work undertaken does not carry the popular weight of acute health services: if it comes to a competition about allocation of resources, they usually lose out. Although I have always advocated partnership between health and social services, in some ways I am nervous about it—nervous that the social services aspect might well lose out when it comes to the consideration of priorities.
834 In her recent Reith Lectures, my noble friend Lady O'Neill of Bengarve drew attention to the apparent lack of trust that those charged with serving the public in our society experience. I do not wish to repeat the arguments about finance because I believe that they have been covered. I wish to draw attention to other areas of investment; namely, trust, recognition, and support.
Like my noble friend and colleague Lady O'Neill, I believe that we need measurement and monitoring. They may help to bring focus to the work and provide a measure through which the Government can find out what is happening. However, when they are faced with so many—I gather that social services have 290 plus at present—it can distract from the general work. Too much bureaucracy takes away from the core task, and destroys the capacity for innovation and new ideas. It will be interesting to hear from the Minister whether there are any plans for reviewing or rationalising these targets, and giving greater flexibility in the way that need is met. However, trust is not blind; it brings with it responsibility for all partners. There is a need for external inspections—but, as a member of the National Care Standards Commission, I would say that.
Recently, I welcomed the Government's new plans for super regulators. I should say that I am not so sanguine about the way that the announcement was made. On the question of consultation, I believe that there are lessons to be learnt in management as regards how you value staff when exciting and innovatory projects are being taken forward.
In accepting the need for accountability, I must repeat the infamous example of bed blocking. There is evidence to show that putting resources into this area delivers results. Last October, the Government provided an extra £300 million to help councils reduce the number of patients whose discharge was being delayed by the lack of alternative residential or domiciliary help. The extra resources have helped to free up 1,000 beds in health provision—yes, it works. But instead of encouraging the continued progress that a trusting partnership would demand, the idea has been developed that local authorities would have to pay the cost for elderly people to stay in hospital for every day following a decision by a consultant that he or she was medically fit to go home. That seems to be punitive. I simply draw attention to the questions put by my colleagues previously.
Anyone who has worked in these areas will know that there is very little consistency about discharge and that consultants will want to meet their own targets of throughput. Who will make decisions about whether the discharge was appropriate? Will there be proper time to plan complex placements for elderly and disabled people going from hospital to care? Will there be enough resources available fast enough to ensure that people are not discharged into unsuitable and even dangerous alternatives? Particularly for those with complex needs, who have an assessment of high dependency and for whom residential provision is essential, the maintenance of existing placements as well as the development of new 835 ones will require injections of funds. There are some myths and legends around what the National Care Standards Commission is expecting at present. Clarity will emerge as the months go on; indeed, we are still very young. However, that does not mean that there is no serious need for more funds for specialist provision.
For many years I have worked with the John Grooms Trustees to provide for people with severe disability. For too long, these placements have been subsidised by fund raising. In today's world this is increasingly difficult to maintain; indeed, there are many who would say that it is inappropriate. So my association, along with others in this field of provision, now have to charge the full cost of placement. I should point out to the noble Baroness, Lady Fookes, whose contribution I welcomed, that trained staff need to be paid more than the basic wage. They are expensive, and we need to value them if we are to retain them. It is only by retaining such staff that we shall be able to provide these very expensive and specialist facilities.
Alongside the need for trust goes a requirement for consistency. I have been associated with the field of social care for 40 years—I started young. The most striking recollection that I have of those years is one of constant reorganisation and change. Yet I believe that change is necessary for development and that it can bring interest and innovation. But too many front-line workers have found themselves concerned about their job and place of work and, most importantly, about being moved from one caseload to another in the middle of vital work with families and children.
While we are focusing today on services, we should remember that, when we divert skill and attention away from work and into reorganisation issues, it is the users of services who lose out in the long run. There are good ways of managing change but, too often, the priority is political expediency and personal whim rather than evidence based on implementation. While I recognise that much of this is within the remit of local government, I should like to see programmes of reorganisation vetted for the benefit that they will bring to end-users. Perhaps the Minister will comment on that point.
Earlier I mentioned that the drivers in the health service tended to minimise the less immediately responsive parts of social care. As we see pressure to improve delivery in acute services, some other parts of provision can become Cinderellas. I believe that social services are in an ambiguous situation, both in their position and direction of travel within local government and in respect of their position within health services. Do they travel with leisure, with housing, with health or what else, or do they have something to do in their own right?
I cannot allow a discussion about resources to pass without mentioning children, and especially looked-after children. I am grateful to my noble friend Lord Listowel, who always graphically illustrates their cause. As the noble Baroness, Lady Barker, said, their numbers have increased significantly. Indeed, I believe 836 that the Association of Directors of Social Services recently said that the numbers were going through the roof.
The Government's Quality Protects programme has had an impact on the service delivery to those children. I ask the Minister for reassurance that, as the spotlight continues to focus on acute and adult services, there will be no reduction in the resources or the attention paid to this most important group of social service users.
The debate has illustrated the complexity of the issue. It is steeped in values and attitude as well as cash and demand. I hope that the debate will at least have helped us to think about how we develop services before we simply implement the next ideology. Ultimately, it is about services to vulnerable people and about those who deliver the services.
§ 7.13 p.m.
§ Lord Clement-Jones
My Lords, I also congratulate my noble friend Lady Barker on initiating the debate. Not only did she make an utterly persuasive introductory case; she succeeded in eliciting this afternoon what I considered to be extraordinarily expert contributions. They have been a pleasure to listen to, despite the subject matter of the debate.
There is no doubt—I believe that noble Lords have illustrated this throughout the debate—that there is a huge amount of evidence of under-investment in so many areas of social care. Even the Treasury, on the advice of Derek Wanless, who, by his own admission, was going beyond his remit, seems to have accepted the charge, first, that social and health care have not been sufficiently integrated and that, secondly, social care expenditure needs to keep pace with health expenditure.
He makes the case, which many of us have been arguing since this Government came to power, and earlier, that health and social care are inextricably linked. Planning for both must be considered together. He said that we need to understand interactions between health and social care. He states:The key demand driver for future spending on social care for older people is the assumption about their future health".Yet, at the same time as making those observations, he noted that the information that he needed to consider the care system as a whole—a number of noble Lords have mentioned the "whole system" approach—was simply not there. But that is in the context of a government who have prided themselves on inventing the phrase "joined-up government".
The truth is that, until the Chancellor announced a 6 per cent rise in social services expenditure from next April—it should be emphasised that this is not immediate money—in resource terms, social care has been grossly neglected. The gap between social and health care has been widening inexorably over the years. Even in the context of the rise in resources which has been announced, my noble friend Lady Barker demonstrated that much of the so-called "new" money 837 is, in fact, old money and that, even with the new funding, social services will still be grossly under-funded.
The evidence of under-investment is all around us. Help the Aged recently published its report, Nothing Personal: rationing social care for older people. It says that resources have not kept pace with need over the past 10 years. Only those most in need are receiving adequate support. Low-level services have been cut back, services have been highly variable and long-term care is effectively subsidised by those who pay. Those are just a few of its conclusions.
Ultimately, it concludes that the key problem boils down to one of central government funding and chronic under-investment. That is clearly borne out by the facts. Even in the past year there has been a drop of 5 per cent in the number of care home places for older people. In total, 9,700 care home places were lost in 2000. As the noble Baroness, Lady Fookes, pointed out, over the past five years that has amounted to 50,000 places. The situation has been worse in some places, such as the North, than in others because there are fewer self-paying residents to subsidise state provision.
I and my colleagues in both Houses—not to mention the noble and learned Lord, Lord Mayhew, in December last year—have warned of meltdown in this sector as a result. If 4,500 beds blocked came as a surprise to Mr Wanless, it did not on this side of the House.
In his report, No Room at the Inn, my honourable friend Paul Burstow demonstrated the sheer number of people over the age of 75 who had been affected in a single year from March 99 to March 2000. There were 21,500 such people. In that report, he demonstrates the awful human cost and absurd economics involved in delayed discharge by keeping those older people in hospital rather than paying a fair rate for a care home bed. In addition to the issue of delayed discharge highlighted in the report, there is also the major problem of the massive 18 per cent rise in emergency readmissions over the past two years—another symptom of problems in the care system.
As a number of noble Lords have pointed out, the Government are now promoting an ingenious Swedish system for penalising local government where delayed discharge from the NHS occurs. It was described graphically by my noble friend and, indeed, by the noble Baroness, Lady Howarth. There are huge question marks over that system. But would it not make better sense to start by funding the system properly?
I shall concentrate mainly on the issues surrounding older persons, but a number of noble Lords have made extremely powerful points in relation to children's services. My noble friend Lady Barker and the noble Earl, Lord Listowel, raised that issue: the rise in the number of children in care since 1999; their continuing poor educational achievement; the massive increase in the amount of abuse suffered by looked-after children; and the fact that two-thirds of the over-expenditure in local government is attributable to that area.
838 We could mention the whole area of mental health. The Sainsbury Centre for Mental Health and others have pointed out that cash designated towards care in the community for mental health service users is simply not getting through. My noble friend Lord Addington made some trenchant points about services for the disabled.
Even when it comes to major government initiatives, funding is not getting through where it should. The King's Fund made the point in its report, Future Imperfect?, published at the end of last year. It said that the Government had failed to establish a sustainable system for funding long-term care by not implementing the Royal Commission proposals.
Already the inadequacies of the system in England are showing up and the strengths of the free personal care policy in Scotland are coming through. The free nursing care pledge of the Government was always thought to be second best. It is now clearly fourth-rate and in some cases little more than a hoax. As the noble Baroness, Lady Greengross, pointed out, only 22 per cent of the 42,000 people who fund themselves in care homes have been put on the top band of £ 110 per week for nursing care. Nor have all those seen the benefit even of the lowest band of £35 per week, as some homes have absorbed the payments in fee increases. The banding assessments by themselves have taken the time of 1,500 nurses from their front-line duties.
The Government's guidance suggests that people should seek redress for this through the law of contract. Having devised an unworkable system, that amounts to washing their hands of the problem. In Scotland, by contrast, residents have the choice to contract through local authorities for all services or direct themselves for accommodation, with the local authority contracting for personal and/or nursing care. The money is going where it should. At the very least, the Government should adopt a system of direct payment in England.
As regards the standards of care in residential homes, throughout the passage of the Care Standards Act we backed the concept of higher standards. Yet the fact is that the Government have not been prepared to devote the necessary resources to this. Their initial regulatory impact assessments were grossly inadequate. For example, as regards the standards for care homes for younger adults, they initially said that the cost was £52,000 per home but it turned out to be £52,000 per room. The assessment had to be quietly replaced after representations from key organisations such as Leonard Cheshire.
Home owners have neither had the assistance with investment to meet standards, nor have they received the fees necessary to meet the financing costs of the additional investment required. As pointed out by the noble Baroness, Lady Fookes, is it any surprise that so many home owners sitting on a property asset in those circumstances are selling up and getting out?
At the moment, there is no doubt that the charity sector is propping up the costs of state placements. Surveys carried out again by my honourable friend Paul Burstow show that that figure could amount to 839 some £200 million. All this adds up to the fact that a proper national strategy is badly needed. There should be an urgent review of care home capacity; the adequacy of fee levels needs to be examined; assessments should be checked; direct payments should be available for self-funders; a proper assessment of need should be carried out and resources allocated to match; and those awaiting banding—and there are many—need to be assessed urgently. I hope that the Government will examine the operation of the scheme in Scotland which was agreed by the coalition government.
My noble friend Lady Barker pointed out that we need to change the basis on which social care is valued and assessed. We need to look at social care as part of health in its widest sense. We need more access to preventive care. There must be a choice in terms of independent living. Home surely is the optimum solution which, in her words, avoids the "medicalisation of old age". That highlights the importance of carers. The noble Baroness, Lady Pitkeathley, made a strong case on the matter. As she said, the latest report showing the value of that care of £34 billion is quite overwhelming. There is a need for joined-up working, a point which the noble Baroness, Lady Masham, also raised.
So, in summary, we need to move from crisis to a system which promotes well-being, in the words of my noble friend Lady Barker. Finally, we need an injection of more funding. Whatever figure the Chancellor may have already announced, it does not appear to be adequate to meet the expectations not only of those in the Chamber who have spoken today but those outside. We desperately need a proper assessment of what funds are required to fund a high-quality social care system.
§ 7.23 p.m.
§ Lord Astor of Hever
My Lords, this has been an excellent debate. The noble Baroness, Lady Barker, always speaks eloquently on social care issues. I congratulate her on introducing this important and, as my noble friend Lady Fookes said, worrying debate.
A number of concerns have been raised tonight—bed blocking, inappropriate discharges, the care home crisis, the shortage of foster carers, the lack of occupational therapists and children's mental health problems. That shows how wide and complex this subject is. I hope that the Government will listen and be able to act on many of the constructive suggestions made.
The shape of social care will be deeply affected by the Government's recent proposals to end bed blocking, and so will the coffers of social services departments.
Since the Secretary of State's announcement, there has been widespread criticism of the proposals, especially by the LGA and the Association of Directors of Social Services. Despite that, the Government have remained eerily silent about the details of the proposals. When the Minister winds up, I hope he will give more detail on them. I understand 840 that they seek to transfer the financial responsibility of NHS acute care patients who have received their treatment to local authority social services departments.
According to the Command Paper— a matter touched on by the noble Lord, Lord Clement-Jones—Sweden is being used as a model for the Government's proposals. When similar reforms were introduced there in 1992, 20 per cent of the total cost for healthcare was transferred from counties to municipalities. Bed blocking has been eliminated by making it more profitable for local authorities to find a care place than to leave an elderly person in an expensive hospital bed.
In Sweden the ÄDEL, reforms provided that, once a hospital has completed a patient's medical treatment, the community has three days' grace after notification before assuming financial responsibility for that patient. What notification period have the Government in mind? Will it be one day, three days or three weeks?
Statistics from the Department of Health for the third quarter last year show that 40 per cent of delayed discharges from hospitals in England are delayed by more than 28 days. The implications of that, when considering the potential cost to local authority social services departments, are alarming.
Further analysis of the statistics shows that 15 per cent of patients waiting to be discharged from hospital in England are awaiting public funding, and 25 per cent are waiting for a nursing or residential placement. The regional variations cause even more concern. In County Durham and Darlington Health Authority approximately 60 per cent of delayed discharges are awaiting public funding; in Walsall the figure is a staggering 71 per cent; and in St Helen's and Knowsley it is 57 per cent.
In the light of those statistics, can the Minister reassure the House that local councils w ill not be forced to reduce any social care services in order to pay for the Government's inability to tackle bed blocking?
Can the Minister tell the House whether discussions were held, by him or his colleagues in the Department of Health, with their opposite numbers in Sweden or Denmark, about the proposals for cross charging. For example, did anyone from the department seek the advice of Gert Alaby who, according to the specialist press, was the architect of the Swedish model of reform? Or are they relying solely on the advice of Mr Wanless? What estimate has the department made of the current cost of delayed discharges to the NHS? How much of that cost will be transferred to local authorities.
The Command Paper states that the Government will consult with local government on implementation of these changes. Does that mean that the Government do not intend to consult local government about any other aspect of the proposals? Is it a fait accompli?
841 I hope that the Minister can reassure the House that the Government's plans to tackle bed blocking are rooted in sound research and not, as has been suggested, cobbled together in a panic to satisfy the Treasury.
Plans to ease bed blocking will be further undermined by a shortage of accommodation in care homes. Much of the blame for that lies with the Government. BUPA have warned that the increase in national insurance contributions will cost the private care sector £50 million. That may be too onerous for smaller care homes to cope with. The National Care Homes Association has voiced its concern that stealth taxes are killing its members. Smaller care homes in England are already running at a 5 per cent margin, but for an average care home, wages are 80 per cent of costs and the increase in national insurance will reduce their margins by almost one fifth.
Care homes have felt the financial effect of the national minimum wage, as my noble friend Lady Fookes said, and of the working time directive. Soon, they will have to fund improvements, if that is the right word, to comply with the Care Standards Act 2000. My noble friend gave an excellent illustration of the problems. Due to high levels of non-compliance, closure rates of care homes are likely to accelerate. Now they face fines for bed blocking in the acute sector—Labour's latest stealth tax.
A shortfall of at least £150 million a year in government funding for residential and nursing care in south-eastern England is rapidly cutting local authorities out of the market because they cannot afford private sector prices. Last year, my county of Kent lost 22 per cent of its nursing home places. Care places are being bought by London boroughs, which can pay more because of the local government funding arrangements.
In the Budget, the Government announced a 6 per cent increase in social care funding for local authorities. Can the Minister give an assurance that the majority of that funding will be applied to services for the elderly—in particular, to the funding of care homes? Without that level of commitment, more places and care homes will disappear. Hospitals will face increasing numbers of misplaced, frail, vulnerable people with inadequate, suitable care accommodation to which to be discharged.
The current level of funding that local authorities provide severely limits the ability of care providers to invest in training and the continued development of staff. That makes it more difficult to recruit and retain staff who could build a rewarding career in care, not just hold a transitionary job. Attracting and retaining social workers is an area that really needs investment—and an emotional investment—from the Government. The number of staff working in social services departments in England has fallen by 10 per cent in the past 5 years. The biggest fall has been in residential workers—21 per cent.
842 Working in social care is sometimes a job for masochists—the pay is rotten and everyone condemns them if anything goes wrong. But every day, social workers help and protect thousands of vulnerable people. The Government have recently launched the second phase of their awareness campaign to help recruit more social workers. That initiative is vital if we are to develop a strong social care system to support people with serious health issues: older people, people with mental health problems, and abused or homeless children.
Universities and colleges need to take on some of the responsibility and be much more aggressive, particularly in recruiting social work students with disabilities and from ethnic minorities. Do the Government have any plans to encourage that? If students do not come through the system in the first place, there will not be a diverse pool of social workers from which to recruit.
§ 7.34 p.m.
§ Lord Filkin
My Lords, I welcome this debate, which the noble Baroness, Lady Barker, secured, on the issue of investment in social care. It has been an example of the House bringing to bear a wide range of experience and talent, which is helpful to all who are concerned with the issue.
The noble Baroness, Lady Fookes, spoke powerfully, arguing that this is a debate about individuals and that it is individuals who matter, rather than institutions, organisations or government. Those involved are among the most frail individuals in society: children, the frail elderly, adults with disability and, as the noble Earl, Lord Listowel, said, vulnerable children and young people. The issue is therefore of particular concern to us. It is true that, as the noble Lord, Lord Clement-Jones, said, in some areas, an increase in need is being expressed for both children at risk and some of the frail elderly.
The debate has tended to focus, although not solely, on money. Money and investment are important and necessary, but we do not do justice to the issues if we imply that money is the only issue. It is as much one of people. Several noble Lords have spoken eloquently about the contribution of people in public service—whether employed by local authorities, the NHS or the voluntary sector. The question is how one harnesses their talent and how organisations can work better together to meet needs other than their own. Lastly—and this has hardly been mentioned—it is about how we make better use of the resources that we have, as well as making the case for more resources.
First, let me deal with the issue of resources. It is not true that the position has stood still. Between 1996–97 and the current year, personal social service resources have increased by more than 20 per cent in real terms. I challenge noble Lords to find a recent period when there has been anything like such a comparable increase in resources. The picture that is sometimes painted is one of standstill budgets. That is untrue. Budgets may not be adequate but they have certainly 843 not been at a standstill. Many public services would relish the increased investment in PSS over recent years.
This year, the resources available to PSS have increased by £647 million, which is an increase of 6.2 per cent in cash terms, including a 21 per cent increase in cash terms in the carers' grant and a 13 per cent increase in cash terms in the children's grant.
The Chancellor's Budget Statement said that PSS resources will increase by an average of 6 per cent a year in not cash but real terms over the next three years. That is not short-term funding, as was alleged; it is a platform of consistent, significantly above-inflation funding for a priority service—again, the like of which we have not witnessed for many years. That gives us the opportunity—especially if we can move beyond arguing that it is simply a question of money—to make a significant improvement in social care services.
The issue is also about how local authorities perform and make judgments. They are not simply agents of central government in that respect. I hope that most of us believe in locally elected authorities. That means that they have scope to make significant decisions. We hope that that is recognised and valued and that they make those budgeting decisions responsibly and understand their role in introducing reform strategies to get better value and use from their resources.
The Government are seeking to motivate and support that change in performance in local authorities. We will reduce ring-fencing for those councils that are performing well. The first set of social services performance star ratings will be published soon—before the summer Recess. To begin with, three star councils will have greater freedom to spend their share of the new social services performance fund. Monitoring will then be proportionately less, because there is no sense in having a uniform monitoring and inspection regime. Those who perform well should be inspected much less. Other freedoms will follow.
Noble Lords did not speak about changes to the grant allocation formula, so I shall not either, given how tight is the time, but we shall consult on that in the summer and hope—although it is often a vain hope—that that will lead to more of a consensus that we have as fair a system as possible.
I turn to the debate about late discharge. I warmed to what the noble Baroness, Lady Masham, said when she spoke about the evidence given by the Spinal Injuries Association. Yes, we should be pleased to receive that. She reminded us that this is about people staying in inappropriate locations in the system when they should not be. None of us could argue that the current situation works adequately. The argument that we can stay where we are is flawed, unless we hear from local government collectively that there is a set of coherent plans to crack the problem. We deal daily with 5,000 people who are held in hospital when they need not be there.
844 I have been asked many times how it will develop. In true ministerial fashion, I shall tell noble Lords to wait and see. The Government will consult fully and—I promise—properly on the proposals in the summer. Officials have met the Swedish authorities and discussed their experience. That has been of interest, but, of course, we do not intend to follow blindly what Sweden does. It is, however, interesting that, in Sweden, councils and health authorities tended to squabble over responsibilities, and people were not getting help. The point is not to say that the NHS is at fault or that local government is at fault but to try to motivate both to work better, so that the public do not suffer as a consequence.
Cross-charging was introduced in Sweden to ensure that the system worked smoothly to give municipalities an incentive to put the right range of community services in place, so that patients could move out of hospital as soon as they were ready. The capacity for caring for people in the community expanded rapidly after the reforms were introduced, and the number of delayed discharges fell. It is our interest to see whether we can make things work better, and I am sure that it will also be the interest of local government. That is our focus. If, on consultation, people suggest that there are better systems, we will want to hear about them. However, the argument that nothing needs to change is bankrupt.
The better use of resources is an issue that was neglected in the debate. We have a substantial body of evidence from what the Audit Commission and the Social Services Inspectorate have been doing for years, not just under this Government, but under the previous Government too. That work commands high respect from all parties, and no one has rubbished it.
The evidence provided by the Audit Commission about delayed discharges is interesting. In short, it says that the current system tends to operate perversely, so that high-cost options are used, although they are not the ones that the public want. There is a tendency to put people in hospital and keep them there, when they do not particularly want that and when, in some cases, it is avoidable. There is also a tendency to discharge people more often than is necessary into residential accommodation, which is more expensive and is usually not what they want. That is the nub of the issue that we must address, not simply in the interests of doing it more cheaply, but in the interests of giving people more appropriate care.
My noble friend Lady Pitkeathley—or perhaps it was the noble Baroness, Lady Greengross—spoke about the importance of preventive action so that people could avoid going into hospital and of early intervention in hospital. The noble Baroness, Lady Masham of Ilton, also spoke about it. It is an appalling situation in which there is no contact until a discharge note has been given. That is nonsense on stilts. We must motivate public bodies to behave differently, as we know from elsewhere to be possible. I have said enough about that.
There have been problems with care home capacity, but it is not good to exaggerate them. They tend to be localised in the South East, where the escalation of 845 property prices gives some people another choice for the use of their capital. Overall, the number of residential care homes has fallen by 1 per cent, by the Government's latest figures. There will be hotspots, and no one is saying that there is no problem. It is not, however, an impossible situation.
§ Lord Clement-Jones
My Lords, is the Minister denying that we have lost 50,000 care home places in the past five years? Is that not a significant problem?
§ Lord Filkin
My Lords, I would need to wade through my mountainous file to find out whether I agree with that. As I do not want to detain the House any longer than I am already doing, I shall write to the noble Lord about that.
I respect the important points that have been made about the implementation of care standards. The last thing that anyone wants to do is implement clumsily the improved standards and damage the market in the short term. Jacqui Smith wrote to the National Care Standards Commission to give it guidance that homes that provide care of a high standard should not be penalised because of specific environmental standards. We always expected that the NCSC would operate flexibly to reassure home owners and other interested parties. The changes will be implemented with care and intelligence, rather than blindly.
I was asked what we were doing to support carers. A new grant was introduced in 1999–2000. There will, progressively, be £20 million, £50 million, £70 million, £85 million and £100 million a year. DWP improvements to financial support for carers bring in extra resources through the carers allowance.
The noble Lord, Lord Addington, spoke powerfully about the important issue of what we do for young disabled people. There is a particular concern to achieve the better co-ordination between partner agencies that he seeks, hence the New Deal for Disabled People to help them into employment and local welfare-to-work joint investment plans. I hope that the noble Lord will also be pleased to hear that we will shortly publish guidance on fair access to care services. One of the eligibility criteria for all adults who seek help will ensure that people receive care fairly, regardless of their age, health condition or location. That was the noble Lord's particular point. That should facilitate the movement of disabled people around the country.
The noble Baroness, Lady Greengross, spoke about the abolition of residential allowances. I am pleased that she welcomes the change. It will simplify complex benefit rules and will help customers and families to understand what they can claim. Many practical details are still to he worked out, and the DWP is consulting about that. The noble Baroness also referred to mandatory property disregards. They are already there for wives and immediate dependent relatives. It is up to local authorities to go further if they wish, as the House knows. The Government will keep under review the question of whether it would be appropriate to take mandatory disregards further.
846 The noble Baroness, Lady Masham of Ilton, asked what CHI would do if it found a hospital that was failing. It will highlight a problem in a particular service, comment on it, analyse the problem and make recommendations such as modernisation to address it, if appropriate.
The noble Baroness, Lady Howarth of Breckland, like one or two other noble Baronesses, spoke with some of the greatest experience of the issues that exists in the House. I endorse her comments about the importance of trust, recognition and support, if we are to get the investment in social care to work effectively. Staff must be valued, supported and trained. We must move away from a culture of vilification towards one that recognises talent and commitment. That cannot, of course, be blind trust; there must be standards, values and inspections. The noble Baroness recognised that and is playing a full part in that.
The star rating that I mentioned would significantly reduce for those authorities the need to produce plans and targets. We are signed up to reducing the number of separate grants to be made to local authorities in the next few years. That is sensible.
I think that I have answered the question asked by the noble Lord, Lord Astor of Hever, about consultation with the Swedes. He asked a good question about the cost of delayed discharge. We do not have the figure to hand, but we will make an estimate and share it with him.
The noble Earl, Lord Listowel, spoke about promoting more partnerships between child and adolescent mental health and other services. The Government have invested an additional £85 million in child and adolescent mental health services over the past three years. We will invest an additional £5 million in 2002–03 in the CAMHS mental health grant for local authorities. That takes us up to £20 million per year. CAMHS has a development strategy. I cannot go into it now, because of time constraints, but I shall write to the noble Earl with more detail.
Building partnerships with the NHS is an issue that we need to mark. It was touched on by some noble Lords in the debate. It is about recognising that there is value in the involvement of local government and the voluntary sector and there is value in having a National Health Service, which very few in this House argue against. It ought to be possible in the future for those separately accountable agencies to work better together, without the need to enter into yet more organisational change. That point was made by the noble Baroness, Lady Howarth. The serious challenge facing us all is to try to prove that that will be possible. Therefore the issue of how to adopt a whole-systems approach, referred to by the Audit Commission, focused around the needs of the public—the client—rather than in response to institutional defensiveness, will be a challenge. In the past, public sector bodies have not had a strong track record on this.
I cite here the problems of interface, where difficulties can arise. The needs of many of the people referred to in the debate sit on the interface between 847 public services. Unless we can find non-organisational and institutional ways of changing those defects, people will face problems. Therefore the issue of instituting more joined-up inspection processes is relevant here. That will involve the Commission for Patient and Public Involvement and the local authority overview and scrutiny committees mentioned by the noble Baroness, Lady Masham. I shall spare the noble Baroness and the House a repeat of all that has been said in the debates on NHS modernisation. It is possible, of course, that we may have a future opportunity to debate the matter.
The other side of the penny is resourcing for the NHS. I shall not go into detail, but noble Lords know well that the NHS has had a sustained level of significant real increase in resourcing, matched by a guarantee of a future funding platform stretching five years ahead. Arguably that is as significant as the current increases. Along with the slightly shorter elevated platform for social services at three years, we hope that that will offer a significant opportunity to build capacity and strengthen our provision of services for those who are most vulnerable.
In conclusion, I have argued that we need to look at this not only in terms of money, but in terms of how we can make better use of those resources, how organisations can work better, how we will build capacity in staff—a great deal is being achieved through social workers now moving to a three-year professional qualification and other significant increases in training—and through the work of registration and standards that the General Social Care Council will provide. As the noble Baroness, Lady Pitkeathley, pointed out, an effective inspection and improvement mechanism will also play an important part.
Above all, we have to put resources to better use. We have to focus on the needs of the public, not on the interests of organisations. Furthermore, we have to move beyond describing the problem and then simply throwing money at it. We cannot solve the problem merely by throwing more and more money at it. Money will play its part, but simply to claim that the difficulties concern only money does not do justice to those whom all in the House seek to serve.
§ 7.53 p.m.
§ Baroness Barker
My Lords, as I anticipated at the beginning, this has been an extremely interesting debate filled with wonderful contributions from knowledgeable and experienced people. One theme ran throughout the speeches; that is, there is a need for a review of social care. That is extremely important. Such a review must be undertaken on its own terms. I do not think that we have asked for increased spending commitments; we have asked for a coherent whole-systems review. I thank all noble Lords who have contributed in their own ways to that request.
I should like to call for Papers, but I suspect that if I did so at this point then I would be hanged by a silken cord. Perhaps I may say, as a Scot, that in the interim before a whole-systems review and papers come 848 forward, a great deal of what is now happening in England is resting on the experience of the Swedes. Let us hope that the World Cup does not let us down and let us hope also that the Swedes have their healthcare system right. I beg leave to withdraw the Motion for Papers.
Motion for Papers, by leave, withdrawn.