§ Mr. Simon Hughes (Southwark, North and Bermondsey)
I am grateful for the opportunity to debate standards of care in nursing and residential homes, although Parliament has spent some time discussing the topic in recent years.
In the past 10 years or so, two constituents of mine—one is over 60 and the other is well under 60—have always begun conversations with me by saying, "What are you doing about the old people?" and this debate is about exactly that.
I am pleased to have secured today's debate and was prompted to do so by a series of events that began in December last year, when some colleagues and I visited Guy's hospital, residential homes and old people's homes as part of a Christmas visit programme. I have made such visits in all but one year since becoming the Member of Parliament for Southwark, North and Bermondsey. Indeed, I inherited from my predecessor, the late Bob Mellish, the tradition that the local MP spends Christmas day at work, and I am very happy to do so. Such visits seem to be much appreciated by those one sees.
This year, Denise Capstick—a colleague who is a state registered nurse and a local councillor in the ward in which I live—and I visited several old people's homes, some of which cater for old people in general, and others for the particularly old or frail, or for those with mental illness. We were troubled by the lack of stimulation, personal attention and care that certain elderly residents in my constituency were apparently receiving. It seemed that minimal interest was taken in them, and that in some cases only mealtime and toileting needs were attended to. They were left staring at a loud television in overheated accommodation—and this was Christmas day—with little else in the way of activities. So troubled was my colleague that she resolved to pay further unannounced visits.
Since then, a particular incident has significantly raised the local profile of the issue. In February, constituents whom 1 already knew approached me and others about the apparent lack of care for, and potential violence and assault on, Walter Cook, a 70-year-old resident of a nursing home in my constituency. The assault on Walter Cook, which took place at the relatively new Tower Bridge care centre, gave publicity to his case, and led to on-going police investigations and to Mr. Cook's removal to other local accommodation.
Concerns arising from our Christmas and subsequent visits, and from the complaint made by the Pitts family—Mr. Cook's family—raised the general profile of the issue. Denise Capstick and her opposite number, Vicky Naish—deputy leader of Southwark council and the person with responsibility, under the cabinet system, for health and social care—resolved to work together to ensure that their concerns were adequately addressed. I should point out that there is no party political division in respect of this matter, which has become one of general concern. There has been the greatest collaboration between Vicky Naish, Denise Capstick and other councillors.
24WH As a result, one local paper—Southwark News—to its credit ran the story about Mr. Cook. Publicly and privately, I suggested to the council that an independent inquiry or a review of the standards of care in the borough's residential nursing homes would be a good idea. As a result of that correspondence, I wrote to the deputy leader of tile council and she replied positively and helpfully. She accepted my invitation to attend a public meeting in the Beormund centre in Bermondsey about two and half weeks ago and came with the director of social services and other local authority officers. Also in attendance were the chief executive of Lambeth, Southwark and Lewisham health authority—Martin Roberts—and his staff and other councillors, including Denise Capstick who had been with me in the first place. A significant number of people at the meeting had—or had hail in the past—relatives in local residential care and nursing homes. The meeting, which I chaired, was not easy. It was full of angst and difficulty as people recounted stories about discovering that the care and attention offered in homes was not up to the standards that they had expected. I should add that the stories were about events of the past two or three years and so did not necessarily reflect the current situation. However, several unsettling and troubling stories were told and they have prompted me to ask questions and raise issues about the existing situation, before the full impact of the Care Standards Act 2000 takes effect.
I want to mention two other pieces of background information. First, I am conscious that Parliament has paid considerable attention to the matter and I pay tribute to the previous Administration who started the work and to the Government who have continued the work to ensure that we have a better regulatory system for dealing with nursing and care homes. The 2000 Act—I do not pretend to be an expert on it—is, by and large, a good and satisfactory piece of legislation that promises well. A regulatory inspection regime will be in place from next April—in fact, it began as a shadow regime three days ago.
We are looking forward to something that promises a better system of regulation, but as we all know, it takes time to get such systems up and running. I initiated this debate in order to ask Ministers and other hon. Members what we can do between now and next year to ensure that best practice is not delayed while we wait for the new regime to be introduced next April, and for its necessarily later implementation across the country. The process is bound to take a while and it may develop like the Ofsted regime. Not all Ofsted inspections occurred in the first months of the new system and, if we follow the Ofsted principle, there may be some years, certainly some months, before people can carry out the inspections ordered under the Act.
§ Mr. Philip Hammond (Runnymede and Weybridge)
The hon. Gentleman talked about the new regulatory regime, but will he also talk about resources? Does he recognise that, without the appropriate resources available from local authorities, those who operate homes—whether they are local authority or privately owned—will struggle to meet regulations that are handed to them from this place?
§ Mr. Hughes
I absolutely accept that point, which was the second issue that I wanted to flag up.
25WH There were two local concerns in December, January and February. One was connected with the private Southwark Park nursing home in Southwark Park road, Bermondsey, which is near where I live, and the other related to Tower Bridge care centre, which is run by Southern Cross Healthcare and has been open for two or three years. I received a letter from the chairman and chief executive of Southern Cross Healthcare, Mr. Moreton, which raised the issue to which the hon. Gentleman referred. I shall quote from the letter because it concerns a proper issue, which also arose in a local authority context. Mr. Moreton stated:You will remember that you attended the formal opening of the above home in October 1998 … As you are no doubt aware, over the last two years since the home opened, various factors have contributed to the deterioration of business conditions for the care home sector, and it is extremely worrying that, still, local authorities are not increasing fees to the necessary rate of inflation we are experiencing due to such things as the minimum wage, working time directive, minimum standards etc.
I am extremely concerned that we are not likely to achieve the very necessary local authority fee increases that we require this year to meet these exceptional costs. While I applaud many of these initiatives, given that employment conditions are substantially improved, the reality is that without the necessary fee increases we will face some difficult decisions. In the case of Southwark, they are paying way behind the going rate for fees and I just hope our representations to them will be heard as we need to pay the right rates to get the right staff, otherwise care starts to deteriorate and that we will not allow. We have had an offer for Tower Bridge for another use and although this is not the way I want to go we are giving it serious consideration. This situation is clearly ridiculous given the need for the beds in the area.
Our current request is for a 6 per cent. increase, which is not at all unreasonable given the exponential growth in costs we will realise this year. The letter ended with a plea for help, which is one reason why I am here today. It was a plea no only on behalf of that particular nursing home, which was also where the alleged assault happened, but on be half of the whole sector.
At the meeting held in March, there was intensive debate about another nursing home called D'Eynsford House, Camberwell, which is a nursing and residential home run by Age Concern, Southwark, situated in the constituency of the right hon. Member for Camberwell and Peckham (Ms Harman). As far as I am aware, the council currently proposes to withdraw placements and funding because it cannot afford to pay for the home. Eileen McNally, who is the director of Age Concern, Southwark, attended the meeting. She said that costs are higher than the local authority pay, but that those costs are necessary to provide decent care. Residents' family representatives are fighting an intensive battle to ensure that the home stays open because it is a good home where there is great satisfaction with the levels of service. They do not want their relatives to be moved away to other places, but they understand that decent care must be paid for.
The hon. Member for Runnymede and Weybridge (Mr. Hammond) has prompted me to ask a question that arises out of that case. We have started the new financial year and money has been allocated to local authorities, but in Southwark there are relatively high costs because of land values. Furthermore, there are few nursing and residential homes in the local authority, private or voluntary sectors, which has always been a 26WH problem. What guarantee is there that Southwark council—and others in a similar position—can find the money to guarantee the necessary staffing levels, pay and decent conditions to provide the care wanted by residents and their families?
Local authorities must battle with voluntary sector and private sector providers if they cannot afford to pay what is being asked for placements. They may threaten to place people elsewhere, but where is not apparent to me because I do not know where other beds are available. What can we do in such circumstances?
The second problem relates to what we can do to ensure that between now and implementation of the 2000 Act we can go above the minimum standards of the 1984 legislation. I accept the premise that the 1984 legislation is out of date and does not provide a sufficient base because the threshold is too low. However, that is the present threshold and a local authority or health authority, depending on whether the home is residential or nursing, inspects twice a year. If there is any reason for concern as a result of regular or on-the-spot inspections or in response to complaints, they will return. They then have a blunt choice. They may be able to close a home immediately, but only in the most draconian circumstances—I am aware of the necessary criteria for that—or they must serve notice, after which there is a long drawn-out appeal process.
During our debate a few weeks ago, it was clear that there was sometimes considerable dissatisfaction with the level of care, but if the health authority and local authority cannot find sufficient criteria to enable them to serve an immediate closure notice, they can only start on the long, expensive and ineffectual route for dealing with generally low standards of care.
§ Dr. Peter Brand (Isle of Wight)
Does my hon. Friend accept that local authorities are sometimes loth to act because they cannot manage without the care that the home may be providing? That applies particularly to nursing homes, because there is a grievous shortage in some parts of the country and that may cloud the judgment of how immediate the action should be.
§ Mr. Hughes
My hon. Friend's expertise in the matter is greater than mine because of his professional experience on the Isle of Wight. My hon. Friend the Member for Sutton and Cheam (Mr. Burstow) also takes a great interest in the subject, but, sadly, cannot be here today.
There is a conflict of interest in that local authorities must protect their budgets and they want their money to go as far as possible. If they withdraw a contract, they may be unable to place people elsewhere locally. In constituencies such as mine there are very few beds and a great demand for care to be provided locally. That is the case in every community because people prefer their relatives to be cared for in areas that are easily accessible and, if they have no private transport, they need to be able to reach them on foot or by public transport at a small cost. They do not want to have to go out of London or to the south coast where, traditionally, there are more residential nursing homes.
§ Mr. Hammond
Just to develop the argument, does the hon. Gentleman agree that the key to a sustainable 27WH increase in quality is to increase supply and not simply to regulate from above? If supply outstrips demand, quality will be forced up as suppliers compete.
§ Mr. Hughes
That general market economy argument is controversial. If supply is greater than demand, that does not always mean better quality. Logically, that should deal with some of the problems mentioned by my hon. Friend the Member for Isle of Wight (Mr. Brand) and local authorities should then have a choice, but a proper regulatory regime is necessary. Adequacy of supply is important, but we do not have adequacy of qualified and competent people to work in existing homes.
Privately run care homes—or even those in the voluntary sector—need to keep their costs down, so they may employ the least qualified staff because they are cheaper, and offer the poorest quality of care. I have done some work and have examined the legislation, but I am still unclear about the requirements, so should be grateful for a specific answer from the Minister today.
I discovered in a meeting that it is sufficient to have only one qualified nurse responsible for 24 residents in one of those nursing homes. I understood from that meeting that, although the nurse on duty had to have assistance, there was no requirement for any of the assisting staff to have qualifications. I accept that Southwark, like other local authorities, has specifications for the provision of nursing care homes, setting out matters to do with staffing and so on. However, can families be certain now—without waiting for the new regime to kick in—that every member of the full-time, part-time and agency staff working in a care home has no relevant criminal conviction or a previous employment record, rendering them unsuitable or undesirable for work in that environment? What guarantee is there that the staff have sufficient qualifications to do the job properly? Several issues that have been gathering over the years strike me as troubling, such as the issue of general qualifications and capability.
It has been pointed out to me that there have been advertisements for German students to work in a care home as a holiday job, for example. Often residents and retired workers who have tried whistleblowing have let us know that care workers have been found asleep when they should have been awake, that they look after themselves before the residents and do not pay attention to what is going on. I have been told that some residents have found it almost impossible to understand what care workers are saying, as their level of English is so poor. I appreciate that there may be a racism issue underlying that complaint, but whether someone comes from Finland or Zaire, a resident's care is not helped by not being able to understand what is being said. Therefore, we must consider the important issue of basic literacy, numeracy and intelligibility in carrying out care functions.
How can the public get quick, effective, authoritative checking and inspection of homes and achieve resolution of issues of concern? When the community health council in Southwark has had matters brought to its attention, the general secretary has gone to check and look round homes, often amid considerable 28WH antagonism. An extraordinary story was told by the deputy leader of the council when she and my colleague, Councillor Capstick went to Southwark Park home. They went in without being checked and wandered round. When a fire alarm sounded, the only people who moved were the staff. The person on duty appeared to believe that the two councillors were agency staff and started issuing them with instructions, even though they had never been seen before. That sort of thing causes considerable concern.
I do not pretend that looking after old people is easy. It is tough and I know that I could not do the job well. Some old people can be extremely demanding. I have done my stint as a hospital porter and looked after old people as part of a holiday jobs when I was a student. I know how difficult it is. The objectives of the Care Standards Act 2000 must be achieved. The quality standards are urgently needed. I have heard too many complaints over the years about the standard of care in geriatric wards of good hospitals like Guy's and St. Thomas's. I have been in too many residential and nursing homes, some very expensive ones, where there is no stimulation and very little personal care. People are got up, put in a chair in front of a television, given their food and sometimes assisted with the toilet, although they may have to wait a long time for that. Even though geriatricians say how important it is, residents never enjoy the stimulus of being with young people or animals or of going out in the fresh air.
Having cared for relatives who have become senile and suffered badly from the aging process, I know the frustration that families feel when their elderly relative grows old with no dignity. I had an aunt in an old people's home who was surrounded by people who did not know what day of the week it was and who were talking nonsense. It was sad and depressing and I remember thinking, that I would far rather that she was taken out for a ride every day in her wheelchair with the risk that she might not live as long, because at least she would have been having a good time. If she had a bit of a bumpy ride and a caught a cold while out in the fresh air, it might be far better than sitting cocooned indoors all day in that sterile atmosphere.
There is no difference of aspiration between hon. Members. The debate is not meant to be critical of either Labour or Conservative Governments. We all strive after the same thing, but my concern is what we can offer now until the higher standards to which we aspire are legally required. For some people it is already too late and others need a response urgently. We are going to have an inquiry in Southwark. The local authority will have a scrutiny panel. The local council and the health authority have accepted my request for an independent inspection and an independent inquiry. I hope that that will be carried out soon by someone who does not have a vested interest in the finances. I hope that it will raise the standards. I should be grateful if we could know what the minimum standards are now and what we can do if we find homes where there are so few qualified staff. What can we do to ensure that there are enough good places in nursing and residential homes, which we will need as we have more and more older people?
§ Mr. Russell Brown (Dumfries)
I am grateful for the opportunity to take part in the debate initiated by the hon. Member for Southwark, North and Bermondsey 29WH (Mr. Hughes). I was somewhat anxious when I thought about this because there are significant differences between social care provision north and south of the border. My local authority of Dumfries and Galloway was the first in Scotland to externalise all its homes. I want to comment on that and to describe some of the difficulties that it has created.
I was elected as a local councillor in 1986. Social work costs in my area were then the lowest per head in the whole of Scotland. Some people might say that that is because it was a well-off area but, on further reflection, it is because we were not spending enough on the family, child care or the elderly. I remember an inquiry into a residential home called Moorheads in Dumfries. One of my colleagues had a traumatic time listening to relatives talk about the regime—I can put it in no better terms—that operated in that home.
Standards in residential homes are important. I agree with the hon. Member for Southwark, North and Bermondsey that the way we treat our elderly people is a reflection of our society. Whether the elderly are frail or still active, the manner in which we treat them affects their day-to-day well-being. It is right to judge society in terms of the provision it makes for elderly people. Each and every one of us in the Chamber should take an interest because we all look forward to growing old gracefully and with dignity until we reach our final days.
The relationship between public and private sector residential homes has been strong in my constituency. Arguments arose from time to time, hut everyone knew that they were trying to provide a service. In the early 1990s, we discovered that some local authority residential homes needed significant capital investment of about £5 million. That might seem a small amount, but it was significant in Dumfries and Galloway. The bottom line was that the council could not afford it, so it had to discover other ways—rebuild, for example—of improving the homes. At the end of the day, the answer amounted to externalisation, which some people call privatisation—selling off or giving away. Whatever phrase people use, the result is that Dumfries and Galloway no longer has any residential homes. They are now all in the hands of other organisations.
The decision to externalise was not taken lightly. Coopers and Lybrand was brought in to carry out a study and it later reported to the council. All that activity was going on in the background. The people who really matter can be placed in three categories—residents, residents' families and staff. All three work closely together, and no one of those categories should be placed above the others. People with an elderly relative in care want to be sure that when they are at home during the evening, their relative is being properly looked after.
I distinctly remember visiting a residential home in my home town in early 1996 and being grabbed by staff to explain the council's proposals to families who were also visiting. In the end, the decision was that two companies would take over the 11 residential homes. A local company called Burnfoot nursing homes took over two homes near its base—one in Lockerbie and the other in my home town of Annan. As it was closest at hand, it was appropriate for the company to do that. Another firm, called Community Integrated Care, took over the other nine homes. The package that was pulled together by the local authority meant that, in effect, all 30WH the homes would be guaranteed payment for the beds, irrespective of whether they were occupied. Early in the financial year 1998–99, we discovered that the private sector was anxious about not getting referrals. Clearly, people were not being given the choice to which they were legally entitled and the council, through social services, was channelling people towards the homes that it had externalised. We discovered 12 months down the road that one of the homes would not receive its annual pay rise, despite the fact that the council had handed the money to the company. We later discovered that there were serious problems; anxious staff had been promised the world, but the new employer was not prepared to go ahead with the terms of the agreement.
Eventually, the company decided to buy out people's terms and conditions, and we found that people were seeing between 30 and 50 per cent. of their normal earnings being slashed. That is astounding. When we examine the standard of care, we can see that employees' hearts and souls must be in their work. I am not convinced that people's hearts and souls will be in those jobs for much longer.
§ Mr. David Drew (Stroud)
That is not only a problem in my hon. Friend's locality. A similar situation arose in Gloucestershire some years ago. As a result, there was on-going distrust of the local authority because the smaller homes feel discriminated against in getting placements. That must be overcome quickly if we are to have the full diet of provision in each area.
§ Mr. Hammond
I just wish to complete the picture, because I have similar experiences in Surrey. Can the hon. Gentleman say whether there was a differential in the fees being paid in those externalised homes compared with other independent homes in the locality? The market is distorted not only by the local authority's desire to keep the places filled, but often—certainly in Surrey—by the fact that the local authority has agreed to pay higher fees to those externalised homes.
§ Mr. Brown
The answer is yes. Those distortions exist and have caused severe problems.
The initial study that was conducted by Coopers and Lybrand clearly overestimated the number of beds needed in our locality. That has already led to the closure of one home and could lead to the closure of another one or two. The impact of that would not be great but the other company, CIC, is implementing more savage cuts. Some of the staff are taking a case, through their trade unions, to the Advisory, Conciliation and Arbitration Service. Three members of staff came to see me recently and one of them said that her earnings had been cut from £16,000 to £8,000 a year. She continues to work constant night shifts and is wondering whether she should stay in the care sector.
As has been said, it is important to provide proper care in a regime based on good standards. What I and other hon. Members have seen does not convince me that such provision exists in all areas. It is tragic that the poor provision reflects on those who provide excellent care in other parts of the country. In my area, 31WH privatisation has been seen as a quick fix—a way of having some excellent buildings built and others upgraded—but it has not been the answer to providing care in residential and nursing homes. It has been a bad move and staff in the caring sector are beginning to feel the rough end of it. They have had a raw deal. I appreciate that the Minister cannot speak about terms and conditions, but they are vital in regulating how people carry out their day-to-day work, which is then reflected in the care and service that we provide for our elderly people.
§ Mr. Roger Gale (North Thanet)
Before injecting my usual note of discord, I start by agreeing with the hon. Members for Southwark, North and Bermondsey (Mr. Hughes), for Dumfries (Mr. Brown) and with the Minister. I have had the fortuitous opportunity of listening to him speak on the subject for many hours. The hon. Member for Southwark, North and Bermondsey is right to say that one could not put a cigarette paper between the objectives of all hon. Members on both sides of the House on the care of the elderly. We all want our elderly constituents to end their days in dignity and comfort and with a high standard of care.
When I was first elected in 1983, I represented a constituency with a large number of residential and nursing homes, many of which I visited very quickly after the election. I was appalled at the standards that I found. They stank of urine, the control over drugs was minimal, the so-called care staff had little or no training—they did not know how to make a bed, how to change an inco pad or how to lift the clients in their care, leading to back strain for the staff and bed sores for the elderly people. All in all, it was a very depressing picture and the standard of care was well below par.
With others, I began a campaign to change that situation. The Registered Homes Act 1984 went a long way towards improving conditions—even if it did not make us friends. I was assailed by many proprietors of what became revoltingly but appositely named granny farms, who felt that they were being forced into investing vast sums of money. However, the net result was that partition walls made of hardboard and chipboard, which were fire hazards, were taken down and standards of decoration, furnishing, cleanliness, general hygiene and nutrition improved. Most importantly of all, the self-respect of the people working in the homes rose dramatically. My local technical college—Thanet tech, as it then was—introduced a course to teach young people working in the homes, who tended to be between 18 and 22, how to carry out basic tasks. It does not take long to teach that, but it makes a great difference to the standard of care. We quickly found that, apart from anything else, the elderly people liked having bright young people around them who took a pride in their work, and the atmosphere changed dramatically.
The fees being paid increased. Some bad homes went out of business, but the good homes—those that invested—made more money. It is probably fair to say that, by the back end of the 1980s or the early 1990s, a reasonable balance had been struck in most cases 32WH between a fair return on investment and a fair price for a fair standard of care. It was the standard of care that was important—not the quality of form-filling, bean-counting or political correctness, but the manner in which people were looked after. They are generally elderly, but not exclusively; sadly, there are some younger people with premature senile dementia.
I do not pretend any more than any colleague in the House that I was entirely happy with everything. There were still bad homes, which were being winkled out by the inspection regimes and people such as us visiting them unannounced. I doubt whether any hon. Member who has residential or nursing homes in his or her constituency does not visit quite a few of them over Christmas, if at no other time.
The hon. Member for Southwark, North and Bermondsey made a point about the need for stimulation and an interest in the environment. At the time, that need was being met, because people had time to care. They would go round everyone regularly and ask them whether they wanted a cup of tea, whether their inco pad needed changing and whether they were all right. They had time to talk, help with crossword puzzles and do all the other little things that make the difference between real caring and "looking after" in its loosest sense.
Since that time, however, we have fallen into a downward spiral. It is fair to blame home owners only in part if at all, in many cases—because if we want such care, it must be funded. It is all very well to say that we have a lot of homes, but there is a free and good market. The commissioning local authority and county council can go into the marketplace, drive down prices and get the best deal possible. For the council tax payer, that may, superficially, be a good thing. However, if we are to have the staffing levels and trained care staff that we need and if nursing homes are to have the nurses that they need and at the levels that the law requires, they must be paid for.
I am certain that most medium-sized residential and nursing homes, particularly the nursing homes in my constituency, make their profit on the last three beds. All the rest of the money that goes into the home is spent on running costs. We are no longer talking about a licence to print money and the bad old granny-farming days, but talking about marginal businesses. If those homes are denied their last three beds or clients, who make the difference between being viable and not viable, there can be only one outcome. Looking the Minister straight in the eye, I must tell him that the standard of care falls, because people start to cut corners on food, cleanliness and staff.
If, as in Kent, the local authority is then competing with London boroughs—which appear to us to have riches beyond the dreams of avarice when it comes to dumping their problems on someone else—we cannot win. The homes closer to London become stuffed full of those whom the London boroughs neither wish nor care to provide for. They are quite prepared to write out a cheque with someone else's money, but we are left picking up the pieces. We cannot and will not go on doing that. Indeed residential and nursing home proprietors are not continuing to do that. They are burdened by bureaucracy, red tape and continual inspection—not of the care given to the elderly ladies and gentlemen, but of the form filling and whether there 33WH is another half a metre of floor space for someone who will never be able to get out of bed to use it. That is why those people are giving up and going out of business. During the past nine months or so, Kent has lost hundreds of residential and nursing home beds. The result was that, through the winter crisis, the hospitals were jammed full of people who should not have been in a hospital at all, but who had nowhere else to go.
So-called care in the community—in theory, a good idea—in practice, has turned into neglect in the community. Care assistants who would like to be able to care have half a dozen clients to visit first thing in the morning. They rush around, allowing about 20 minutes for each. They need to travel by Tardis—there is little time to get from one to another—get the old girl out of bed at half-past 6 or 7 o'clock, potty her, stick her in a chair, give her a boiled egg and say, Bye-bye, dear, no time for conversation." Somebody else comes in at lunchtime and throws something into the microwave oven saying, "There you are, dear, there is your lunch, and at half-past 4 you go back to bed." The fact that one might not want to go to bed until 9.30 or 10 o'clock at night is neither here nor there. There is no choice but what is imposed by a system that is out of control.
The moment that such people become ill, they are faced with practice nurses and general practitioners who do not have the time, energy or inclination, in many cases, to look after them. Where do they go? They go straight into a hospital, where they clog up the beds that are needed for patients who need elective surgery. They used to go into good, caring, well-funded residential and nursing homes, but that no longer happens. It is a great sadness that, having gone so far forward—we now have a real prize within our grasp, notwithstanding the fact that we have an ageing population and more people who require care—we now deny choice and do not allow even those with a little money of their own to go into home B rather than home A. They are prepared to pay a top-up from their limited resources, but must pay all or nothing. When their money has dwindled to a level such that they can no longer pay, they go where the local authority tells them to go.
I have heard the Minister speak long and often about the subject, and I believe that he cares. He must impress upon his friends in the Treasury that money is required. Counties cannot take on more and more responsibility and statutory duties from Government: for trading standards; for inspection of this, that and the other; for dog wardens, traffic wardens, wardens for whatever and more parking schemes introduced by legislation. Counties cannot do all those things and, in the case of Kent, continue to pick up the b for the fringe requirements that are not paid for by Government of all the asylum seekers who come into the county, and still be expected to have the money that is needed to provide care for the elderly.
East Kent has an inadequate supply of nursing care for the elderly and mentally infirm My constituents have nowhere to go, other than a mental hospital—the very situation from which we tried to move away—because the homes have closed. They have closed because it now costs £500 a week to care for such a client, but the going rate is about £3110 to £320 a week. In the middle of the winter crisis, the Government gave Kent £850,000. They said, "Here is more money, buy some care." The first problem was that the care was no 34WH longer available because the homes had closed. Secondly, what happens when the short-term money runs out?
I listened very carefully—I had the opportunity to do so—to the debate on the Care Standards Act 2000. I believe that there is much good in that, which hon. Members on both sides of the Chamber would wish to support. However, to echo the point made by my hon. Friend the Member for Runnymede and Weybridge (Mr. Hammond) and others, it will fail unless it is backed up by real, hard cash. If it fails, we shall be failing to ensure that our elderly constituents are provided with the care to which I, the Minister, and every other hon. Member aspires.
§ Dr. Peter Brand (Isle of Wight)
I congratulate my hon. Friend the Member for Southwark, North and Bermondsey (Mr. Hughes) on initiating the debate.
The contributions of the hon. Members for Dumfries (Mr. Brown) and for North Thanet (Mr. Gale) made it clear that market forces have not worked and are unlikely to work, because in most cases the user of the service is not the commissioner of the service. I recognise that there is a move towards allowing more choice, but ultimately people tend to go where there is a space. In the early days, there was massive over-provision. When the tourism industry became less successful in seaside towns, people turned to granny farming, as the hon. Member for North Thanet said. Over-provision does nothing for standards. Matters started to improve only when standards were introduced through inspection and registration regimes. I am glad that some of the homes that I used to visit have closed, because their standards were appalling.
One cannot rely on market forces and not regulate. Regulation is important, and the Care Standards Act 2000 will make a big contribution to that—not only in terms of bricks and mortar, but through training and the way in which employees are valued as a result of the minimum wage. It is right that such measures were, and will continue to be, introduced. However, not every residential or nursing home can continue to subsidise its local authority placements through cross-subsidy from self-funders or top-up fees from relatives, which will be allowed in the near future. The essential point that the Government must recognise is that it is no good taking the view that local authority fees are similar around the country and are therefore right. My local authority justifies its fee levels by saying that they are comparable with those of all other local authorities in similar circumstances. I have had representations from at least six parts of the country in which that argument has been used. There appears to be a conspiracy among local authorities to keep fees down.
Market forces are beginning to work in a negative way. People are moving out of care home provision. Even a respectable organisation like Methodist Homes is shutting its care home on the Isle of Wight because it cannot be bothered to upgrade it. That is extremely worrying.
§ Mr. Hammond
I am not here to speak on behalf of Methodist Homes, but it is a little harsh to say that it could not be bothered to upgrade the home. I believe 35WH that its position is that it cannot go on indefinitely subsidising local authority underpayments from its own charitable funds.
§ Dr. Brand
It is a charity that should feel an obligation to people who have been in its homes for many years, and should offer some degree of stability.
We need care homes and nursing homes. The national health service depends on them and the care of people depends on them. I welcomed the Government's establishment of the royal commission on long-term care, which recognised the continuum between acute and chronic and long-term care. However, I am disappointed that they did not accept the commission's recommendation that personal care—the care that people need owing to their disability or infirmity—should become the responsibility of the NHS. In reality, we have created not care in the community, but a way to enable the national health service and the public sector to shuffle off responsibility by pushing people into the private care sector. Like the hon. Member for Dumfries, I went through the same, extremely difficult process of externalising a group of homes.
If the royal commission's recommendations had been accepted, there would have been greater expert input into residential and nursing homes. Occupational therapists, specialist nurses and community psychiatric nurses would have been much more proactive in the residential part of community care. There would have been many more community geriatricians, particularly psycho-geriatricians. When expertise is brought into such settings, a lot can be done. The use of community pharmacists has to some extent revolutionised older, often confused people's over-dependency on drug regimes. Drugs increased their confusion, so they had to be drugged further to render them confused and quiet rather than confused and disturbed.
The Care Standards Act 2000 will take us a great deal further forward, but without proper funding from the centre, there will be care standards for non-existing provision. That would be tragic. Not everyone can be maintained in their home, although such efforts are indeed welcome. However, not everyone needs to be in a district general hospital or a reconstituted long-term ward. It is right to allow people to remain in their locality in sensitively run residential provision, and the private sector has demonstrated that, with adequate funding, it can provide a service.
It is very worrying that home closures in my island constituency are threatening people with rehousing not only in a different community or village, but away from their own island, on which they may have lived for 70 or 80 years. I hope that the Government will take urgent action and review available residential and nursing home provision. The Minister cannot simply say that the problem affects only 7 per cent. of the population; he must consider the pain felt in different parts of the country and take steps accordingly.
§ 12.3 pm
§ Mr. Philip Hammond (Runnymede and Weybridge)
I, too, should like to congratulate the hon. Member for Southwark, North and Bermondsey (Mr. Hughes) on securing this debate. He expressed the principal worry that something needs to be done immediately—before implementation of the provisions in the Care Standards Act 2000—to ensure higher standards. My concern, which other hon. Members have already articulated, is that it is questionable whether the 2000 Act and the minimum standards that it will introduce will prove deliverable, given t he financial constraints on the sector and local authorities.
I pay tribute to the hon. Gentleman and to others for their contributions, particularly my hon. Friend the Member for North Thanet (Mr. Gale), who must have found it painful to mask his evident knowledge of, eloquence on and passion for this subject during the many hours in which he has chaired relevant Committees. He put his finger on the key issue when he talked about quality of care—it is indeed a question of measuring not size of rooms or numbers of staff, but the quality of care. Although I entirely agree that there is not a millimetre between the positions of the different parties and individuals in our ultimate aspiration to offer dignity and proper comfort to elderly people in their declining years, there are some differences about how to tackle the issues involved.
One of the important differences is the distinction between measuring inputs and outcomes. If we have a criticism of the Government's approach with the Care Standards Act 2000—and the national minimum standards set with in it—it is that it is too prescriptive and too focused on measuring inputs. The Government have too much of a check-the-box mentality, ignoring at their peril the quality of care being delivered, which my hon. Friend the Member for North Thanet emphasised so strongly.
The Minister wrote to me recently in response to a letter that I sent regarding a nursing home in Essex that was under threat of closure. The letter said:homes which provide good quality care should have nothing to fear from the introduction of national standards.There is a narrow definition of what constitutes good quality care. It is evident to me, to people in the sector and to my hon. Friends that homes that provide perfectly good quality care will fail to meet the mechanistic, bureaucratic tests laid down in the national minimum standards regulations. I question the use of a regulatory approach to drive up care standards. None of us disputes that regulations are required to ensure proper minimum standards and the safety and well-being of people living in residential care homes, but the Government seem to believe that we can legislate for everything, including good-quality care. While we need minimum standards to pick out rotten apples and protect people in residential care, it is essential to foster choice and diversity to ensure good standards of care.
Good standards of care are not only about measuring objective things; they are about empowering people. We must remember that residents in homes are people, not numbers or statistics. They will have different needs and wants, some of which may seem strange to those of us from a different generation, but which must be respected none the less. An essential prerequisite of achieving that 37WH choice and diversity and ensuring that quality provision can be purchased by responsible local authority purchasers is to secure the supply base and the volume of supply. Unless we can ensure that there is such a supply base, we shall run into the trap identified by the hon. Member for Isle of Wight (Dr. Brand) that local authorities will be faced with the dilemma of what to do with a provider who cuts corners and does not comply with the minimum standards regulations. Such local authorities will be placed in an impossible position. They must provide care for the people who need it, but the crisis in which the industry finds it self means that in many parts of the country—although not Dumfries, apparently—there is a significant under supply, which dominates the balance of power between purchasers and providers.
I want to highlight the fact that some of the minimum standards that are laid down under the Care Standards Act 2000 address the matters that need to be considered in a set of minimum standard regulations, and others effectively constrain choice in that they define for people what their choice should be. I put it to the Minister that in practice a prescriptive set of national minimum standards is stifling, not fostering, choice. We believe that that will not enhance the overall quality of care.
§ The Minister of State, Department of Health (Mr. John Hutton)
I apologise to the hon. Gentleman for interrupting his speech because I know that he, like me, does not have much time left. Have I rightly interpreted his remarks as meaning that he is now opposing the national minimum standards that we have published? Does the Conservative party not support those standards?
§ Mr. Hammond
Some of the national minimum standards address issues that are genuinely the preserve of a regulatory regime. We believe that genuine and sustainable quality will be fostered by the promotion of diversity and choice. We have had this debate many times, and the Minister knows my views. To the extent that the national minimum standards me limiting choice and diversity of supply, and certainly to the extent that they are reducing the amount of supply available, they will do nothing to enhance standards
I am grateful to my hon. Friend the Member for North Thanet for making the obvious but important observation that quality costs. The Government have not recognised that the regime to whit h they aspire has a huge price tag attached to it. In Committee, I repeatedly asked the Minister whether the Government recognised that they must pay for the substantial increase in costs that both independent and local authority homes will face in delivering the quality agenda. No one disagrees with the quality agenda, but it is living in a cloud-cuckoo world to imagine that one can impose it without dealing with the cost issue. Cost pressures have become more acute since we debated the Care Standards Act 2000. The increase in the national minimum wage, which has not had a significant impact on London and the south-east, has had a huge impact outside that area on an industry that incurs 70 per cent. of its costs in wages and salaries.
Most local authorities have increased their fees to independent sector providers in line with the preserved rights fee level increase, which will be 1.8 per cent. from 38WH this April. Yesterday, the Secretary of State for Social Security interestingly indicated in a written answer that the Government intend to increase preserved rights benefits by a further 1.9 per cent. as soon as possible this year, which would give a total increase of 3.7 per cent. I welcome that, and so will the industry. However, can the Minister tell us how he intends to ensure that local authorities, which have traditionally taken their lead in setting the following year's budgets from the preserved rights settlement announced by the Department of Social Security in the autumn, are encouraged and enabled to follow that lead when they have already set this year's budgets? Most of those budgets do not leave any slack to provide further uplifts in payments to home operators.
The Minister will, of course, quote overall levels of Government support for social services and the level of funding to social services in general. The figures that he will quote are, of course, correct. However, he will acknowledge that there are other pressures on those funds. Even within the social services area, huge increases in the cost of children's services are squeezing available resources for care of the elderly.
I should like to quote to the Minister from a letter sent recently from the leader of Kent county council to the Secretary of State, in which he outlined two additional costs that all local authority social services departments will be facing as a result of legislative changes. The letter states:an increase to the capital limits would result in a loss of income, as people with capital between £16,000 and £18,500 would no longer be expected to pay the full costs of their care, but would be part subsidised by us. For that reason … a prudent sum of £1 million was budgeted. In the event, the fact that capital limits for the purposes of assessing income support have not been increased in tandem means that the loss of income is far greater. In effect, this represents £4-£6 per week for every client with capital of between £10k and £16k; and more significantly, £170-£180 per week for every client with capital between £16k and £18.5k.The total cost for Kent will be about £2.5 million, compared with the £1 million originally budgeted. That is just an example of the pressure from all sides that the sector faces. Will the Minister deal with that point? He will have had a chance to consider it because he has seen the letter from the leader of Kent county council.
There is a crisis in the care sector. Some 15,000 beds were lost in the year to April 2000 and we estimate a loss of up to 40,000 beds in the current year. The impact on the national health service is serious, as the hon. Member for Isle of Wight mentioned, with delayed discharges from hospitals and, perversely, the reopening of the Nightingale format geriatric wards in NHS hospitals to take the patients who cannot be discharged. Those wards offer the kind of conditions that the Government are committed to stamping out, to which end they introduced the Care Standards Act 2000.
Time does not permit me to rehearse in detail all the aspects of the national minimum standards that are causing huge concern to the industry, but the Minister knows what they are. They include physical standards, room sizes and sharing ratios. Although those are not necessarily bad things, they are unrealistic given the inability, or unwillingness, to fund the changes and capital investment required. If rigorously enforced, they will lead to a contraction of the sector and to a reduction in its diversity. Independent family-run homes will 39WH close, especially those located in listed country properties that cannot be converted easily to meet the standards, and Posthouse-style, corporately owned care homes will take over their role.
Perhaps that is the Government's agenda. Perhaps they find it easier to deal with a handful of big corporations than a large number of independent providers. However, that appears to me to be destructive of choice and diversity and it will not lead to the improvements in care standards and quality to which we all aspire.
I shall give figures from two local authorities that summarise the problem. The cost of delivering care in Coventry's local authority residential care homes is £470 a week. It offers independent sector care providers £121 a week. The London borough of Hackney spends £851 a week on its own homes. It offers independent care providers £284 a week. To anyone with an O-level in economics, it is obvious that the outcome will be a rapid and continuous contraction of the sector, and an inadequacy of supply that will make it impossible for anybody—local authorities or national care standards commissioners—to enforce the quality standards that the Government, and all of us, want.
If the Government cannot address the supply problem, the 244 specific standards required for registration under the national minimum standards will be the straws that break the camel's back in many parts of the independent care home sector.
§ The Minister of State, Department of Health (Mr. John Hutton)
I congratulate all hon. Members who have contributed to what has been a well-informed debate. A lot of common sense has been spoken, but I shall refer specifically to what was said by the hon. Member for Runnymede and Weybridge (Mr. Hammond) because many of his figures were wrong and his arguments were less than persuasive.
In essence, the hon. Member for Southwark, North and Bermondsey (Mr. Hughes) raised three related issues. He referred to the need for adequate funding and asked whether the funding available to Southwark council would be sufficient this year. He also referred to his concern about existing registration and regulation arrangements, particularly during the interim period between now and April next year when the National Care Standards Commission comes into operation. He then asked some important questions about training arrangements.
I agree with much of what was said during the debate about quality through registration and inspection being an important part of the overall equation, but we must not lose sight of the fact that about 80 per cent. of those who work in social care have no recognised qualifications. Given the importance of the care sector, the essential infrastructure of our wider care system is unacceptable and we must improve the training and qualifications of the social care work force.
Funding is central to everything that has been said during the debate. The hon. Member for Runnymede and Weybridge rightly anticipated, as he usually does, 40WH that I would read out a long list of statistics about spending on social services. In fact, I shall not do that today because the figures are on the public record and he and other hon. Members are aware that by 2003–04 the money available for social services spending will increase from just under £10 billion to just under £12 billion. That is a substantial increase. The hon. Gentleman and his hon. Friend the Member for North Thanet (Mr. Gale), who spoke well on the subject, particularly when requesting more money, will anticipate what I am about to say. We are making substantial additional resources available. I can tell them, for example, the amount of extra spending that is available for Kern this year. The arguments about additional resources to fund not only national minimum standards but the wider range of services commissioned by local authorities would stack up a lot better if they would say that they would match the resources that we are making available over the next three years.
§ Mr. Hutton
I shall not give way just yet.
I have repeatedly asked the hon. Gentleman and his hon. Friend to say that they would match the resources that we are making available for social services during the next three years and they have conspicuously failed to do so. However, they say that they would match our spending rises on education, which is also a local government financial responsibility.
§ Mr. Hammond
The Minister quoted a significant rise in Department of Health spending on social services to £12 billion and I am pleased to repeat the assurance that my right hon. Friends the Members for Richmond, Yorks (Mr. Hague) and for Kensington and Chelsea (Mr. Portillo) have given that we are committed to matching in full the total Department of Health budget, including social services spending within that budget.
§ Mr. Hutton
Yes, but the hon. Gentleman knows, because I have said before, that of the £12 billion only about £2 billion is Department of Health spending. The other £10 billion is local government spending. We are making that resource available to local government to spend on social services. He and his hon. Friends have conspicuously failed to say that they will match that level of commitment.
§ Mr. Hutton
No. I will not. I gave the hon. Gentleman a chance to make his point, but he did not do it terribly well.
To be fair to the hon. Gentleman and his hon. Friend, I accept that more spending is required on social services, but we are doing that in an unprecedented way. To compare like with like, let us examine the record of spending on social services during the previous Parliament because that will provide a reasonable indication of the Conservatives likely commitment if they return to office. During the previous Parliament, spending on social services rose by 0.1 per cent. in real terms. That is the reality. We are providing additional resources as quickly as the country can afford and that is a result of the state of public finances and the 41WH improved state of the economy. Those resources are coming on line. If we compare like with like, social security resources are experiencing unprecedented growth and that is the reality. If the hon. Member for North Thanet is saying that he wants more than that to be made available, he should have that discussion with his Front-Bench spokesmen.
§ Mr. Hutton
I guess that that is something we will never know because there will not be a Conservative Government to put that theory to the test. I am as concerned as the hon. Gentleman to minimise bureaucracy, and what can loosely be described as red tape. I am not in favour of a red tape system of regulation for the care home sector and that is why we have worked closely with care home providers to produce national minimum standards. Contrary to what he says, such standards have been widely welcomed by the care home sector. They represent a substantial step forward, particularly in the difficult area of fiscal standards. We have tried to compromise to reach a sensible set of working standards that will improve the quality of care, which we all want, without imposing unworkable burdens. That is why the original proposal of 10 sq m as the minimum useful floor space has been reduced to 9.3 sq m where there is compensating space elsewhere in the care home; that is a sensible compromise. We are not trying to drive anyone out of business; we want to support diversity and choice of provision across the sector.
The hon. Member for Southwark, North and Bermondsey's point about spending was well made. I share his concern that there must be adequate resources available to local authorities. As I am sure he knows, there will be a 6 per cent. cash increase in resources available to Southwark social services—a sufficient resource envelope that is available to the local council to address some of his concerns. I am aware of the concerns that he raised about the two care homes. I will make sure that my officials maintain close contact with Southwark council to ensure that his concerns, and those of his constituents, are properly addressed as work progresses.
The training issue is also important. The hon. Gentleman might want to examine the national minimum standards—I see that he h as that information with him. He will see that standard No. 28 addresses how we might improve the training qualifications of staff in care homes. We have said tit t from 2005, 50 per cent. of care staff, excluding registered nurses, should have a proper professional qualification—initially a national vocational qualification at level 2. That will be a substantial improvement. I accept that there will be resource implications attached to that, which is why we have begun funding the national training strategy about which the Training Organisation for Personal Social 42WH Services published information last year. That will be a three-year programme of investment and we will examine ways of proceeding with such investment. We must start somewhere, and we would obviously not have chosen to start from our current position where we find that there are not enough properly trained care staff. I think that the hon. Gentleman's description of care standards in Southwark is pretty accurate, and could apply to other parts of the country. We must start from this position, but we are making improvements.
Wider concerns have been raised by many hon. Members relating to the general efficacy and efficiency of the existing registration and inspection arrangements. We changed the law because we are not satisfied that the present arrangements are sufficiently independent or robust. The hon. Members for Runnymede and Weybridge and for Isle of Wight described the dilemma of local authorities finding themselves in the catch-22 position of being inspector and regulators, while also being commissioners and providers of care. Those are difficult roles to discharge simultaneously, which is why we have removed the inspecting-registration function from health and local authorities and given it to the new National Care Standards Commission.
§ Mr. Hutton
With respect, I will not give way because I have only a short time left.
We have removed the Hobson's choice that faced local authorities and allowed them to concentrate on what they should be concerned with: the commissioning process. In some cases, local authorities are still directly providing services, which is a local choice.
§ Mr. Hutton
With great respect to the hon. Gentleman, I will not give way.
Through the Care Standards Act 2000 we want to remove the difficult dilemma that local authorities face, and put in place robust independent inspection arrangements. The difficulty raised by the hon. Member for Southwark, North and Bermondsey will be addressed by what is to happen in April next year. He knows the answer to his question about what will happen between now and then. It is currently the responsibility of both local and health authorities to apply their local standards and to inspect homes against set criteria. From next April, that function will transfer to the National Care Standards Commission and a new set of national minimum standards, that have been set centrally in the Department of Health after consultation, will form the benchmark against which care homes will be inspected. We have consistently told local authorities that in the next 12 months or so as we move from the current arrangements to the new system, no one must take their eye off the ball. Change is difficult—