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Lords: 10 May 2007
Volume 691: debated on Thursday 10 May 2007
Baroness Pitkeathley
rose to call attention to developments in social care provision; and to move for Papers.
The noble Baroness said: My Lords, the second slot on a Thursday, especially on a day of momentous news and after such a passionate debate as the one led by my noble friend, is never a particularly popular time, so I am most grateful to all noble Lords who have put names down to speak on what to me is a very important topic, and I know to many other noble Lords as well. I have worked in social care almost all my life, so I do not intend to declare all my interests; that would take too long. I will confine myself to saying only that I am chair of the Children and Family Court Advisory and Support Service and vice-president of Carers UK.
I reflected this morning that the words "social care" have passed into our professional and political language fairly recently. Many of us grew up using words like "care in the community", "care outside of hospital", "care when you go home" and very possibly "family care" to cover all the areas we shall be addressing today.
This debate is an opportunity to celebrate the many advances that have taken place in social care over the past 10 years and to set out the challenges that the sector faces in the next 10 and beyond. The background to the debate is the Commission for Social Care Inspection's State of social care report published in January of this year. It reflects the diversity of social care, covering the public, private and voluntary sectors. I am sure colleagues in the House will make reference to this report and join me in saying how useful it is for the regulator of social care to have the duty to report to Parliament on the current state of social care. The three messages from its report are: that social care services continue to improve and modernise but improvement is gradual; that progress is being hampered by pressures on the sector; and that there are concerns about the impact of a shift of responsibilities onto individuals and families.
There is much to welcome in social care today and there have been some significant advances in the past 10 years. The starting point is the central role of the people who use the services and their carers. It is about putting people first. Social care has led the way on the public policy debate around choice and personalisation. Direct payments and personalised budgets which are being piloted around the country are an example of this. The Government's White Paper, Our Health, Our Care, Our Say, published in 2006, set the tone when it said:
"People will have real choices and greater access in both health and social care ... Services will be integrated, built round the needs of individuals and not service providers, promoting independence and choice".
In all the progress that has been made in putting users, carers and patients absolutely at the forefront, those who develop and provide social care have been pioneers, and we should congratulate them on that. We should not forget that, when we talk about putting users and carers first, we are talking not just about changing structures but about changing fundamental attitudes and cultures. We must acknowledge the progress that has been made in that area and recognise how difficult it is to change those attitudes and cultures. In spite of the progress made, we know that we need to go further and faster in ensuring that these aspirations are delivered on the ground.
While more people than ever who want direct payments are able to get them—the numbers doubled between 2004 and 2006—the commission's recent report also found that only £1 out of every £100 spent in social care is a direct payment. If people want direct payments—and it seems that they do—we must make it easier for them to have access to them and ensure that they get them.
Another welcome initiative was the Government's Dignity in Care campaign launched in November last year. The care services Minister in the Department of Health, Ivan Lewis, said:
"The generation that built this country have a right to expect services where personalisation, dignity and respect are not the latest buzzwords but a living, breathing reality. Our society needs to once again value older people as active, positive citizens who may require support, but have so much to give to their families and wider community".
Social care services are, on the whole, improving. The Government introduced national minimum standards for social care and a regulator, CSCI, to measure performance against those standards. The number of providers meeting the standards has increased, and that is a great credit to the sector. However, we should note that the rate of improvement has slowed down in recent months; the whole sector must double its efforts to show continued improvement. I am afraid that too many services are still not meeting the minimum standard, and that means that some people are receiving sub-standard care. I understand that the commission is modernising the way that it inspects services, which will mean fewer inspections for well performing providers and more attention spent on poor performers. Let us hope that the providers respond positively to these proposals and see them as a way of driving up their performance.
At the end of April, the Department of Health published a review of the status of social care, Blueprint for Social Care Excellence. The review was carried out on behalf of the Government by Dame Denise Platt, who, as your Lordships know, is the chair of the commission, but the report was carried out in a personal capacity. When the Government published it, they announced a five-point plan to put excellence at the heart of social care. I very much welcome this report and the Government's positive response to it. It is appropriate that the sector looks to itself to raise its game, and that will include a social care skills academy, which will look at skills across the public, private and voluntary sectors.
There are many skilled and committed staff in the social care professions but we have fallen short in our nurture of them: we must provide them with more opportunities for training and learning. I believe that these proposals provide the possibility for social care leaders to develop world-class skills. These leaders are providing a vital service and we must ensure that they are equipped with the skills to carry it out.
One important issue on which I want to focus today is one that CSCI and other notable bodies, such as the King's Fund, have begun to talk about. I know that it is also an issue in which the Government are very interested. I refer to the major and unresolved debate about the balance between state and individual responsibility for funding social care, especially for old people but including other categories of people also needing social care.
Sir Derek Wanless's review of social care funding on behalf of the King's Fund concluded that the current system is unsustainable. The care services Minister has called for,
"a sustainable funding system. A funding system which clarifies the responsibilities of the state, families and individual users of services".
The review found evidence of significant unmet need in the current social care system. The report said that ultimately,
"the choice of funding mechanism depends on value-based choices about the relative importance of containing public sector costs, maximising equal access to care, and balancing outcomes between high- and low-income groups".
The Wanless review also said that there needed to be a commitment to reconfigure services, demonstrating value for money and fairness. The Government might consider that investing more in social care could realise benefits and savings in acute healthcare and reflect people's choice to have care closer to home. I should very much welcome the Minister's views on that.
The reality is that the state will probably not be able to pay for all social care but, if we make that decision and we make it openly—that is the key point—we need to ensure that we offer other means of support to people using care services, including those who can pay for their care themselves. I am aware that colleagues in the House have their own views about this and I look forward to hearing their contributions.
The role of the informal carer—family member or friend—is an essential part of today's debate and it figures large when we address the issue of where responsibility should lie. Your Lordships will not be surprised if I now turn to the role of carers.
There have been a number of major and very welcome developments for carers in social care over the past decade: three Acts of Parliament, including the groundbreaking Carers (Equal Opportunities) Act 2004, which recognised that carers have a life outside caring; the national strategy for carers, launched by the Prime Minister in 1999; and the carers grant, which provides funding for carers' breaks. That grant has totalled £1.1 billion over nine years and has really made a difference through broadening out and developing a breaks service. However, a small-scale survey by Carers UK showed that these developments are now under threat by the shortfall of funding in social care generally and that several local authorities are now starting to cut back on carers' break services in order to balance their budgets. That is not a trend that one would wish to encourage.
The main problem facing social care from the carer's point of view is that funding has not kept pace with the needs within the community. As the Local Government Association and the Commission for Social Care Inspection reported, two-thirds of councils are cutting back on eligibility for services. Through Carers UK's information and advice line, we know that that is starting to impact on carers, who will have to take on an even greater share of caring.
Some very welcome new developments for carers have been announced. The Government, through Gordon Brown, have pledged to review the national strategy for carers and ensure that it has a 10-year vision. He has also put some very welcome cash alongside that, including funding for an expert carers programme, a helpline and emergency care to cover the inevitable emergencies in a carer's life. It is vital to take the opportunity now to achieve real change for carers.
The social contract that exists between the individual and the state must be clear. We need a new settlement where we have an honest debate about the relationship between private, public and the individual. The work carried out by the Disability Rights Commission revealed an enormous gap between people's expectations of what they think they will receive and what they actually get. People still do not plan for the support that they might need if they become frail or disabled. In particular, they do not expect to become carers, when that is what almost every one of us will indeed become. There has to be long-term investment in social care, however it is funded. All the projections point to more funding being needed in the system. The Government need to link their care agenda with an employment agenda in the same way as they did with child care.
Leading employers are becoming increasingly concerned about how we deal with demographic change. Carers UK has estimated that by 2034 an additional 3.1 million people will be carers; in other words, a 50 per cent increase on the numbers today. In the next 10 to 15 years, the economy will need an extra 2 million workers, only 500,000 of whom will be school leavers. Carers who are aged 54 and above are more likely to give up work in order to care, often at the peak of their careers, and one in four people currently between the ages of 45 and 55 are combining paid work with caring duties. The arithmetic of that does not stack up. We have to provide more support for carers and more support that will enable them to continue with their working life. There are many more arguments why we need to support carers better, but I shall conclude with one staggering one: that they save the nation £57 billion a year.
In conclusion, I repeat that there have recently been many significant and welcome developments in social care. In an age when older people are rightly demanding that their voice is not only heard but acted on, when people with disabilities are not prepared to be passive recipients of social care, and when more people are caring for their loved ones, it is correct that we have the opportunity to debate "What now?" and "Where next?". I believe that the Government are on course. The personalisation and choice agendas are correct, but we need to go faster and further in ensuring that more people who are entitled to services know exactly what they are entitled to. We must discuss urgently the roles of the state, the family and the individual, so that the voices of the family and the individual can be added to the many others who want to express their views. I beg to move for Papers.
Viscount Tenby
My Lords, the noble Baroness, Lady Pitkeathley, is to be warmly congratulated on initiating the debate today. She has introduced it so ably, with such knowledge and in such a measured way, at a time of justified anxiety, when the Local Government Association has estimated an overspend by local authorities to the tune of £1.7 billion, when MENCAP is reporting cuts from all over the country and when there are disturbing reports of young carers not receiving the support that they so desperately need.
I declare interests as chairman of the trustees of a non-profit-making residential home for women with learning and physical disabilities, in which my daughter is a resident, and as an honorary vice-president of MCCH Society Ltd, which provides social care for those with disability in Kent and other parts of the south-east. Consequently, I intend to speak only about provision for those with learning and physical disability.
Although I have been involved with men and women in this category for many years now, I am acutely aware that I am only an amateur. I take this opportunity to pay tribute to the many talented and dedicated people in social services and charities alike who have given, and are giving, their lives to make a better life for people. Nevertheless, it might be helpful to have the views of someone who is able to speak from a user's point of view.
The flip thing to say—but perhaps no less true because it is flip—is that the three most crucial things in short supply over the whole area are common sense, cash and collaboration. In the Griffiths era, some 20 years ago—I am fully aware that the noble Baroness, Lady Pitkeathley, has a far greater background knowledge of this than I do—it was agreed on all sides to do away with large residential homes, many of which were survivors from the Victorian age. A combination of purpose-built homes, with five to 10 residents, for those needing 24-hour care and supported sheltered housing with assistance for those living in the community, was put in their place.
Clearly, many homes like the one with which I am associated, although very willing to adapt—I emphasise that—did not fit into that pattern, and the obstacles to overcome were, and are, very considerable. For example, pulling down a perfectly serviceable and comparatively modern building, which in our case can house 20 residents who have lived in amity for the best part of their adult lives, at a time when the financial cupboard has never been barer, must be a worrying leap into the unknown, to put it mildly. But to stay as we are is not an option. As we do not conform to the right size and, through a quirk of history, as the home is not multi-sex, we get no referrals to fill vacancies. Numbers and, therefore, income, drop with the financial consequence of closure. To whose benefit is that?
How different it is in the NHS. There, LBHUs—locally based hospital units, as they are called in some parts of the country—are relatively thick on the ground and come in all shapes and sizes. They are financed, not through social services, but via primary care trusts, for the most part. For example, according to the Sutton report, Orchard Hill Hospital has some 95 residents. Incidentally, anyone wanting to see how inadequate and unjoined-up our administration has been for those with learning and physical disabilities in recent years, under whatever Government have been in power, has only to read the contents. That hospital is now due to close in 2009. At least, it has now been inspected, although with dire consequences, by the Healthcare Commission.
That situation sits oddly alongside our own experience of frequent inspections, which we welcome as progress checks to better standards, and the covert message that we continue to receive of, "Put up or shut up". The phrase "double standards" inevitably comes to mind in spades.
What about supported living within the community? First, one needs the accommodation, of course, which is no easy task, particularly in affluent areas such as the south-east. In some instances, one may have to overcome antagonism in the local community. It exists—do not let us try to hide it and sweep it under the carpet. That is not because people are intrinsically selfish, but they are very likely to be ignorant of something that they themselves have never experienced. All kinds of ancillary concerns can therefore emerge; for example, a drop in the value of their own properties, the effect that close proximity might have on their children and so on.
Common sense is important in a variety of ways. I remember many years ago the planned closure of a large and much-loved day centre, which took in users from a wide geographical area. That was in response to a perfectly logical shift to more local centres. In accordance with modern thinking, with which in principle I wholly agree, the users were told of the plans well in advance, when the final plan was, in fact, years away from coming to fruition on even the most optimistic estimate. The result was unnecessary fear, uncertainty and grief, not only among users, but also among their families. Surely we should consider the feelings of those who may already have had much to endure in life. I am afraid that occasionally professional workers, because of their expertise and experience, are confident that they know better than users' families and voluntary workers. That leads me to ask the Minister to embrace and encourage the use of voluntary workers in this area and to facilitate the security clearance that we all know is necessary. If that takes too long and is too bureaucratic, it can turn helpers away.
Noble Lords may have noticed that I have not so far referred to finance. I shall merely say to the Minister that it seems to me that social services are the poor relations of the NHS, which is inevitable, when there is so much pressure on council spending. The black hole of over £1 billion, referred to earlier, hardly gives one confidence in the successful financing of grandiose new projects. As so often in government finance, execution follows a long way behind aspirations, yet the need is massive. If one accepts that one in 10 families in the UK has relatives with some sort of learning or physical disability, that points on a conservative estimate to a market of about 4 million or 5 million people. The first step might be the disentangling of NHS and social services finances, as has already been hinted at. Indeed, that has begun in some places, with mental health provision staying with the NHS and learning disability provision going to social services.
That leaves me with one remaining heading: co-operation. A top priority must be the ending of any dysfunction within the provider network, so that a seamless service is available. A recent report by the Picker Institute has highlighted the lack of across-the-board access to information for service users on matters such as the financial benefits available and how to claim them.
Finally—and I commend this to the Minister most strongly—let us embrace wholeheartedly the concept of partnership, be it in the NHS or social services, or within various voluntary organisations. In particular, learning disability partnership boards should be engaged in decision-making, but so often they are bypassed. Let there be no petty kingdoms, of which one hears examples from time to time, but a common resolve to solve problems and create initiatives—in the use, for example, of available land and joint building projects, such as the MCCH project in conjunction with Kent Community Housing Trust, where a 22-bed facility for people with dementia sits alongside a home for 120 elderly people. There is also the home in Hampshire with which I am associated, which, in conjunction with a sympathetic and listening council, is seeking ways in which partnership can become a reality.
The National Health Service is, understandably, seldom out of the headlines. Just for one afternoon, however, can I make a plea that it stands to one side so that its poorer cousin can get a fair hearing? The future reputation of this country depends equally on the sympathetic and imaginative treatment of those not fully able to look after themselves, whose lives can yet be considerably enriched by a sensible, sensitive and well resourced social service.
Baroness Royall of Blaisdon
Forgive me, my Lords, but may I remind the House that time is extremely tight for this debate? I therefore ask noble Lords to keep strictly within their eight minutes. Thank you.
Baroness Howarth of Breckland
My Lords, I, too, congratulate the noble Baroness, Lady Pitkeathley, on leading this debate and I pay tribute to her long and dedicated career in social care. As her deputy chair in the Children and Family Court Advisory and Support Service, I know at first hand of her tireless commitment, particularly to carers and children.
I also pay tribute to the work of the Commission for Social Care Inspection and the role that its board and staff have played in raising standards in social care. As deputy chair of its predecessor, the National Care Standards Commission, I know personally how much had to be done. The average percentage of national minimum standards met in services inspected by the commission had, by 2005-06, risen for the fourth consecutive year and more councils improved their star ratings. Progress has slowed, but we all know that the better it gets, the more difficult it becomes. In addition, performance against national minimum standards is getting better. For example, the overall figure of care homes meeting standards has risen from 58 per cent in 2003 to 79 per cent now. We should not lose sight of these very real achievements, both by those who set the standards and those who work so hard to meet them—the local authorities and the independent and voluntary sectors.
Against that positive background, I want to raise some key issues with the Minister about care services. In an era when we hear much about choice, the report tells us:
"Thresholds for accessing services are high".
For two-thirds of councils, the threshold for care-managed services was set at "substantial" in 2005-06 and a number of councils were expecting to raise their eligibility thresholds in 2006-07. It may be that service is getting better if you can get it, but what are we doing to ensure greater accessibility for all? The options for people who do not meet the criteria set by local councils are limited. As the report says,
"Some people have no option but to do without".
It actually means less choice.
As this rationing process develops, more people will look to fund their own care where they can. Who will ensure their rights to quality and value for money? People expect the state to give them financial as well as physical protection as they grow old, or if they are vulnerable. The noble Baroness, Lady Pitkeathley, talked about the state. For the ordinary person, the provider of the service, whoever they are, represents the state. People expect the services to be civilised—the kind that a really civilised society would provide—but, as has been said, they remain concerned about the gap between policy aims enunciated by the Government and the reality of their experience.
The Minister will be aware of the ongoing debate on the application of the Human Rights Act to private and independent providers of residential care. The courts have ruled that independent and voluntary providers are not covered by the Act—surely an unintended consequence. Quite properly, the Commission for Social Care Inspection adopts a rights-based approach to its work and puts the principles of dignity, respect and privacy into practice in the care homes that they regulate, irrespective of whether the home is in the public, private or voluntary sector. Surely that must be right. Will the Government support the Private Member's Bill in the other place to rectify that, or do they have plans of their own to correct that extraordinary anomaly?
CSCI's report on the state of social care refers to the need for council commissioning to support the whole community, irrespective of whether people pay for their own care or are supported by the council. We know from the report that approximately a third of people using social care are self-funders, but that just over a fifth of councils have identified the need to provide more services for them. People slide very easily between what we refer to as state-delivered services and services delivered by others, which they still see as being the state, as they try to fund themselves.
The most vulnerable—those who meet the criteria for services—also deserve choice. If the choice is between a service that takes you out of bed at 6.30 in the morning and puts you back at 6.30 at night, with a quick delivery of meals on wheels in the middle of the day, and a good residential home with a variety of activities taking place and company, I know which I would choose. What if the choice is between where the disabled person is isolated in one room as against a unit where he has been able to regain his real independence and interest? Both are real examples. Home is different for different users, but the tightening of criteria and the Government's focus on domiciliary care to the detriment of other services—even when they are more appropriate—means reduced choice.
I will briefly raise the issue of the continuing postcode lottery of services. Levels and performance of services in different council areas continue to vary widely. In 2003, as a trustee of John Grooms, a charity providing services for younger disabled people, I carried out a review of what was available. We found then that services for the younger disabled were many and diverse, but that their supply and quality varied according to where people lived and was arbitrarily affected by local authority policies on provision and resources. It seems no better today. A group of staff recently told me that their local authority colleagues avoided comprehensive needs assessments, because the result might be the need to provide a service.
It is clear that commissioners of services face a daunting challenge, one that my noble friend Lord Tenby illustrated by describing social care as the underfunded poor relation. However, with more imagination, more might be achieved. As the commission points out, too many are locked in old traditional ways of delivering services that lock many out from access to what they need. What are the Government doing to encourage greater innovation of services?
At some point in our lives, we will all experience social care, either directly or linked to those we love or know. It is our responsibility to ensure that it is the best that can be provided, whatever our means and level of need. Choice will matter less if the services available are of good quality and accessible. I know that that is what the Commission for Social Care Inspection seeks to deliver, and I wish it well in its task.
Lord Harris of Haringey
My Lords, I, too, am grateful to my noble friend Lady Pitkeathley for obtaining this opportunity to talk about social care services, which the noble Viscount, Lord Tenby, referred to as "the poor relation". I am also enormously flattered to be in a position to follow the noble Baroness, Lady Howarth. I should make it quite clear that, unlike the two redoubtable Baronesses who have experience of social care, I have never been a social care professional or a social worker. However, for a number of years I was chair of the social services committee of a London borough, and I subsequently chaired the social services committee of the Association of Metropolitan Authorities for seven years.
An equivalent period has elapsed since I did so, but it is interesting to see what features now remain of the scene when I was actively involved in social care. The extent to which the individual is much more genuinely at the centre of care decisions than previously is enormously pleasing. This does not mean that this is perfect or that it was all dreadful in the past, but it is now much more accepted that what an individual believes is appropriate for his care should be part of the decision-making process. That has required a considerable change in the attitudes and culture of those who organise social care, as my noble friend Lady Pitkeathley said.
Where there is a partnership with the individual whose care is being organised, it is much more likely that there will be a care package that best suits him. Maybe that is a truism, but in the past paternalism on the part of those organising and delivering social care led them to think that they knew better than the individual concerned. I hope that that is a thing of the past. It is important to recognise that the individual is, by and large, the best judge of the sort of care that he or she wants. Individuals vary; we all have different preferences, styles and things that we value. They should be critical components of building the care package for any individual. I suspect that when an individual is genuinely part of that decision-taking process, the outcomes are better. Someone who is happy, comfortable and content is more likely to have as healthy and fulfilled a life as possible.
Local government now spends almost £20 billion a year on social care. That is a substantial sum of money that perhaps merits rather more attention than it gets in public debate. Some 20 million people rely on local government to commission care on their behalf and many more people organise it themselves. However, the figures mask a disproportionality. The growth of resources for care services for children usually outstrips the growth of care services for adults. Similarly, local government over the past decade has, in practice, faced a squeeze, or limited growth, on services that are not directly part of education. That has meant that, with all the increasing demands on local government outside education, spending the extra 14 per cent allocated to them in real terms over that period—it is obviously a significant growth and should not be ignored—has meant that difficult decisions have had to be taken.
If you compare that with the 90 per cent growth in real expenditure on the National Health Service over the same period—I certainly do not suggest that it did not need 90 per cent; some would argue that it needed considerably more—it is noticeable that social care, the poor relation as the noble Viscount referred to it, has come off nothing like as well.
I was interested to read the remarks recently by the leader of Lambeth Council, Steve Reed, who highlighted the fact that, typically, councils assess older people's need for care services as being in one of four categories: low, moderate, substantial and critical. He points out that already nearly 70 per cent of councils provide care services only to those whose need is categorised as "substantial" or "critical" because they cannot afford to do more. He warns that, if current trends continue, all councils will be providing only this level of service by 2009 and that some already face the painful decision of restricting access to only those in critical need. He says that Lambeth is already consulting on that option, despite an additional £1.9 million funding for the service in the coming financial year. This indicates the nature of the change taking place. We have an ageing population and, quite properly, increased expectations by those who require care and their relatives about the nature and standard of that care, which puts incredible pressure on local authorities.
There has been a substantial increase in the number of people receiving domiciliary care and intensive home care, defined as households receiving more than 10 contact hours and six or more visits a week. In 2005, 98,204 households received intensive home care, an increase of 6 per cent from 2004. I welcome that, because it is usually better for people to be cared for and have services provided in their own home. But that will not always be the case; obviously such care is more complicated to arrange and more expensive.
The direction of travel is important. I declare an interest as a vice-president of the Local Government Association. In a recent paper, the association stated its aspiration:
"We want to create an environment which supports choice and control through the delivery of services that are built around what each person actually wants, not only to meet their health and care needs but also to improve their well-being".
That will require not just the local authority to organise its own services but what the Local Government Association called:
"Integrated commissioning [which] will include all out of hospital care and support—community health services, public health, adult social care, housing and primary care. This will develop to include a wide range of services from across all tiers of local government and local partners which impact on people's health and well-being, such as leisure, recreation, community safety, benefits advice and access to work programmes".
That is a complicated and difficult thing to achieve.
Something that concerns me, and which I hope the Minister will address in his response, is the adequacy of investment in the standard of commissioning and the skills needed by commissioning professionals. I am working with a number of individuals to try to create an institute of commissioning professionals. The idea is to recognise that it is important to raise the standards and support commissioning professionals to develop skills, values, attitudes and performance; to inform national policy and debate; and to set standards and improve them over time. I hope that we will see support for such ideas and the concept of bringing intelligent commissioning—those who understand the service—together with those who understand procurement, in order to put together the information needed to provide the best package and the best quality of service for individuals.
The Earl of Listowel
My Lords, I too am most grateful to the noble Baroness, Lady Pitkeathley, for securing this debate. I follow the noble Lord, Lord Harris of Haringey, in hearing from people who are subject to contracts how much they regret that operational expertise is not more involved in the commissioning process. I second, as strongly as I can, what the noble Baroness, Lady Pitkeathley, said about the Wanless report and the need for sustainable funding for social care services. The thresholds for access to services, which are too high, were emphasised by the Commission for Social Care Inspection report on the state of social care. Next year's report will focus on the number of people who do not get access to services because of the lack of resources. This was also an important message from the joint chief inspector's report on safeguards for children in 2005, which detailed how children and families were not gaining access to support because thresholds were set too high owing to lack of resources.
I intend to speak about the government White Paper, Options for Excellence. Published in October last year, it builds on the social work degree that the Government have introduced and their registration of social workers, and it is their strategy for the development of the social care workforce. It provides at last a professional framework for social workers to operate within. How far have the White Paper's proposals now been costed and what timetable has been developed for its implementation, especially the proposal for newly qualified social work status—that is, additional support for newly qualified social workers? Shakespeare gives an elderly shepherd the words,
"thou met'st with things dying, I with things new-born".
For some years, it has seemed as though social work was dying but now there seems much hope for new life. The Minister may demur—perhaps it is more the case for child and family social work—but in many areas we have seen unacceptably high vacancy and turnover rates, often with disastrous effects on service users.
To achieve that regeneration, the balance between managerialism and the client relationship needs to be redrawn. Currently, some estimates are that an average social worker can spend only 30 per cent of their time with clients. A consultation by the Office of the Children's Rights Director found that eight out of 10 looked-after children highly valued their relationship with their social worker. On the other hand, the bulk of the report described how children felt let down by their social workers. At yesterday's meeting of the associate parliamentary group for children and young people in care, several young people and adults spoke of their disappointment with the care system and on leaving care, especially with support from social workers. I should say that two of those who spoke mentioned the excellence of their social work support. Without the professional framework, social work may not only fail to be helpful; it can cause harm by repeating earlier experience of traumatic loss.
The Victoria Climbié inquiry report spelt out the lack of supervision and the unrealistic case loads of the social workers involved. It stated that Haringey's argument,
"overlooks entirely the additional need for effective supervision—so demonstrably absent in Victoria's case—when social workers carry active case loads of this size".
Police officers also lack the necessary professional development, but following action did not immediately address the workforce issues. The Government's response to the matter, the professional framework for the workforce, has been welcomed, but it has been late.
That brings us to Options for Excellence. That document is vital because it finally provides the outline of the professional framework required to establish and sustain effective relationships with service users. The White Paper proposed protected status for newly qualified social workers, along the lines of those for teachers—reduced case loads and access to a mentor. It proposed a full induction for first line managers new to post. It offered new opportunities for professional development for department leaders and effective case-load management. It also introduced a programme to define the social work role.
I welcome the clarity with which the British Association of Social Workers voiced concern about the White Paper's implementation, particularly the matter of newly qualified social work status. It stated:
"We believe that Newly Qualified Social Work Status should be introduced immediately. The first new graduates entering work have now completed the social work degree. They should not have to wait to receive good supervision and limited workloads—we cannot afford to lose them from the workforce and waste the money already invested in them through the new degree programmes. This is urgent. They need specific support".
The experience of Paul Fallon, director of services at Barnet, illustrates what is possible if the reforms are implemented and funding is found for them. In three years, he has brought his social work vacancy rate down from 33 per cent to less than 3 per cent. Important to that has been the adoption of small social work teams, groups of six practitioners plus a clerk and a trainee, and an extended career structure to keep experienced professionals closer to the front line. He has introduced the role of principal practitioner to supplement that of senior practitioner.
Foster carers have responded especially favourably to the new consistency in the support that they receive from their social workers. Mr Fallon has funded Barnet's programme of recruitment and retention by diverting funds from the employment of temporary staff. Clearly, as has been said, much can be done by improved use of current resources. At the same time, Barnet case loads are still too high because of the shortage of resources. Given the complexity of their cases and the fact that they can only spend 30 per cent of their time with clients, a caseload of 14 is still too great; other London boroughs go as low as seven.
The Minister's letter of 16 February was encouraging:
"Many newly qualified social workers are thrown in at the deep end with difficult cases right from the start of their employment. Where this happens the rate of burn-out can be high. I cannot pre-empt decisions that have yet to be taken in the context of the current spending review process. We hope to have news on implementation before long, and I would expect to keep you informed".
I would be most grateful to hear from the Minister on this. How far have the options been costed and what is the timetable for implementation?
I say again,
Young carers need their social workers. Children in care and care-leavers need their social workers. Vulnerable families need their social workers. Full implementation of Options for Excellence cannot wait. A young woman at yesterday's meeting was going from care, shortly to start a degree in social work. Because of her experience she had much to give. I look forward to the Minister's response and thank the noble Baroness for calling this debate.
Lord Lipsey
My Lords, the noble Baroness, Lady Pitkeathley, demonstrated that her expertise in this field is deep and very wide. Mine is not, I am afraid, being confined to the social care of the elderly—I sat on the 1999 Royal Commission on Long Term Care for the Elderly. As 46 per cent of the social care budget is spent on the elderly, that gives me plenty to talk about this afternoon.
Those who have heard me on this subject before—I am afraid too many noble Lords have—will not be surprised by where I start. Everything that has happened since the Royal Commission reported shows that the minority—namely the noble Lord, Lord Joffe, and myself—were right to reject the majority proposal of free care for all. What has happened since highlights our central argument. There is, in the real world, a choice between more care and free care. The priority must be, as the moving speeches this afternoon underline, more care rather than free care. This has been emphasised by the perfectly disastrous development since we reported: local authority care, as the noble Lord, Lord Harris, and others said, is increasingly concentrated on those with enormous need, with the result that those in considerable need are not getting support to enable them to stay in their own home. That is bad, but how much worse it would be if, out of that same budget, you had to find an enormous sum simply to subsidise the care of those who, admittedly at some sacrifice, could afford to pay for it themselves.
We often hear, as we did from the noble Baroness, Lady Pitkeathley, the present system for funding long-term care described as "unsustainable". Three factors have led to that perception. The first is the introduction of free care in Scotland. I will not go into detail about whether that has been a success, although it is hugely over budget and half the authorities in Scotland say that people have to queue to get it because they do not have the money. There is still no doubt that it has made the English system more difficult to sustain because, for once, English eyes are cast enviously on the high road to Scotland.
Secondly, a series of judicial rulings on the provision of free healthcare have made it extremely difficult for the Department of Health to construct rules about what degree of infirmity constitutes a need for healthcare, to be free at the point of use, and what degree constitutes a need for social care, to be means-tested. It has also proved difficult to construct rules that stop judges in their new-found activism trespassing into what should properly be the realm of Ministers and politics.
Thirdly, and I regret having to say this, there is a really unscrupulous campaign against the present system, mounted by some organisations that should know better. For example, I recently received an advertisement for a book that claimed to provide information about a "national scandal": charges for long-term care. It cited, in order to sell the book, the example of someone allegedly forced to sell their house to pay for care. I was about to write to the Advertising Standards Authority about it. Everybody in this House will know that nobody is forced to sell their house to pay for care. Under the Health and Social Care Act 2001, passed by this House, if someone wants to keep their home the local authority is obliged to lend them the money until they decide to sell or they pass on.
Then I picked up what purported to be a serious contribution to the debate from Help the Aged, entitled Underfunded, Undervalued and Unfit. To my astonishment—for this is an organisation I respect—it, too, stated on page 9 that,
"older … people are forced to sell their homes to pay for care".
When I raised that with Help the Aged, it did not try to defend the veracity of the statement, for it could not. Instead it came up with various reasons why the loan option might not be widely taken up. How does it help the aged to propagate a material untruth about the options available to old people, adding phantom fears to fears that are, alas, only too real? There is room for a great variety of views in this debate, and I respect those who do not share my views, but it is important that all arguments are based on truth and facts not on invention, whatever its propaganda value.
I would cite against the factors making for unsustainability one that should make the present system more sustainable. It is slightly off-piste, this, but there has been a huge rise in the value of people's homes. More importantly, as you get on in life you can now access that wealth a great deal more easily through equity mortgages. It follows that more and more people are able to fund their own care in old age and—this seems to be something people want to do—leave a substantial sum to their children. That is the sort of thing for which people accumulate wealth, and the wealth they are getting in that way should be used for that purpose.
At the bottom of this argument is a fundamental and difficult dilemma. Long-term care is essential. It can be paid for from public money or privately; there is no third option. There is a theoretical case, and the majority of the Royal Commission set it out as well as it could, for increasing the share of public money. That is a matter to be considered in the present Comprehensive Spending Review. However, I am not convinced—the Minister may put me right, but I doubt he will—that there is any prospect whatever that the CSR will come up with the Niagara of cash that would be required fully to fund improved care from the taxpayer. The Government's priorities are education and health. You can argue with that if you like, but it does not leave enormous scope for increased spending in other areas.
Rather than rerun old arguments—I am afraid I have done so a bit today, but I hope I might be forgiven—we need to think more creatively about how we get more private provision and private money in. Developments here have been pretty disappointing. Private insurance for long-term care has not developed very well. There are not enough advisers, a point I owe to the remarkable Denise Platt, who has so informed the debate today. It is surprising that there are no private organisations offering old people holistic advice on where to acquire the balance of things they require to sustain their lives at home, and the Government have some role in encouraging that.
To end on a more healing note than has animated the rest of my remarks, I think that we can all unite on this one thing: we need better care for elderly people. It is not adequate. There is not enough of it, and it is not properly provided. We need it irrespective of whether it is organised, funded and provided publicly or privately. If the Government are not going to do the job—and in my view they cannot—they should say so frankly and do what they can to encourage the private sector to fill the gaps that are inevitably left.
Lord Best
My Lords, in thanking the noble Baroness, Lady Pitkeathley, for bringing forward this debate on social care, I declare my interests as chair of Hanover Housing Association, which provides housing and care for some 25,000 people in England; as president of the Continuing Care Conference, which brings together care providers from the public, private and voluntary sectors; and as president of the Local Government Association.
Today, I will share some thoughts on the "what now" and "where next" for the voluntary sector in care provision, picking up on two contrasting developments in social care that have featured in this debate. On the one hand, there is the Government's important and positive emphasis—as noted by the noble Lord, Lord Harris, among others—on choice for care service users and empowerment of people needing some care to take decisions for themselves. On the other hand, there are cost pressures at a time when increased longevity and greater numbers of people needing care come up against fierce public expenditure constraints on social services budgets.
In relation to consumer choice, the Government underlined their commitment to greater self-determination in last year's White Paper, Our Health, Our Care, Our Say, and are encouraging take-up of direct payments that enable people to do their own thing and arrange their own care—for example, the disabled young man who prioritises visiting the gym rather than having his flat cleaned. The Government are piloting individualised budgets that tailor care packages to suit the individual. All this is great stuff—user empowerment, as pioneered by articulate people with disabilities and championed by the Joseph Rowntree Foundation and others for more than 20 years. However, only 1 per cent of the budget of social services departments goes on direct payments. Individualised budgets are still at a tentative, pilot phase. For those without the money to pay their own way, dependency on a cash-strapped local authority means accepting the standardised care packages that the local authority can negotiate with care providers. Yet we each have preferences and, often, the form of support that an individual wants is not found in a standard care package.
Worming the Cat is the title of one of the Joseph Rowntree Foundation reports, because that is what one elderly person wanted her carer to do; she did not want help with cooking, which, however painstakingly, she wanted to do for herself. One resident in a Hanover extra care scheme told me the other day that her care worker is not allowed to take her to the hairdresser, as this is not part of the specification in the care contract organised by the adult services department. However, having her hair done was very important to her self-esteem and was a chance to meet old friends.
The problem with choice is cost. In this debate, we have heard about the severe pressures faced by social services departments to ration what is available and to go for the economies of scale that are hard to reconcile with user control. Let me bring together questions of choice for users on the one hand and the impact of cost pressures on the other, in the context of voluntary bodies such as the Hanover Housing Association, which is one of the largest providers of retirement housing and extra care. Before becoming chair of this organisation some months ago, I had not appreciated the switch taking place in the care of older people, not just from the public sector but also from the voluntary sector to the rapidly growing and now dominant private sector.
To obtain public funds for care provision today, an organisation must win the competition for a contract. Since most of the cost of supplying care is in care workers' salaries, the winning bidder is likely to be the one with the lowest wage bill. The private companies employing migrant labour, which now means principally those from EU accession countries, are likely to win the contracts.
Many voluntary bodies, including Hanover, find it hard, culturally, to pay the minimum possible wage and we cannot compete successfully with those private operators. Let me be clear: I do not think that Polish, Slovakian or Czech workers are any less clever, hardworking or caring than British care workers. I have met some delightful eastern European carers in recent weeks and I can see that the language difficulties can usually be overcome fairly quickly.
However, Hanover—like, I guess, other care organisations—is not prepared to enter this low-wage contest. We have decided not to tender for care contracts at all. This has led us to reconsider our role. What exactly are we there for? Is it always to be the provider of services to older people? For other organisations, that would mean services to disabled people or those with learning difficulties and so on. Or is the role of a charity such as ours to address that desire of each of us for choice, for the independence that comes from choosing and being empowered to take decisions, not as a provider but as advocate, adviser and ally?
After talking to a large number of our residents, I see a real need for agencies that stand alongside the service user and support that empowerment process. We are working with another charity, Counsel and Care, to take this forward. Older people need advocacy in dealing with care commissioners; they need advice on their entitlement to attendance allowances, on pension credits that can lift them out of poverty, on their entitlements to care, on equity loans—as suggested by the noble Lord, Lord Lipsey—on befriending services that may be available from volunteers within their local communities, and on fitness and well-being. Within this holistic, supportive role—that is, not providing all the services, but seeing that they are provided—the voluntary body as the independent broker can help to increase the miserably low level of take-up of direct payments. The voluntary body is acting as advocate, adviser, ally, enabler and broker.
With fears that the Treasury's Comprehensive Spending Review will not come up with nearly enough extra cash, and given the rapid expansion of care contracts with private sector providers, the future role of the voluntary sector may involve a shift from being provider of services to enabler and empowerer of the individual older person or other service user. If so, perhaps this will not always be a change for the worse.
Baroness Massey of Darwen
My Lords, I am grateful to my noble friend Lady Pitkeathley for introducing this debate. Her knowledge and experience in this field are highly valued, and she covered in her introduction a wide spectrum of issues. As she said, the Government have done a great deal to focus on issues of concern. As this year's CSCI report notes, improvements have been made and, as others have said today, there is a basis for action.
I shall focus on two of my particular concerns. One is care within substance misuse services and the other is grandparents as carers. The CSCI report states in its executive summary:
"People say they want services that help them to realise their potential and make the most of their life chances".
In that context, I shall speak about substance misuse and where clients need to be helped through care to greater health and happiness. I declare an interest as chair of the National Treatment Agency for Substance Misuse. We were established in 2001 as a special health authority charged with doubling the numbers in treatment by 2008 and reducing waiting times. These targets have been met two years early. In addition, staffing levels have improved and user/care involvement in treatment has been well established.
This success reflects what good social care should be about. I shall give examples of some factors for success and perhaps the Minister will comment on them. The first is funding and high-level interest, which provides a focus. Interest in drug treatment from the Prime Minister, the Home Office and the Department of Health has increased funding. Secondly, ring-fenced funding at a local level has protected services. Local involvement through drug action teams, with budgets pooled from national and local funding, has ensured community interest. Other factors include the development and dissemination of models of care guidelines. These clarify the need for commissioners and providers to increase their focus on improving the client journey through a structured care programme, including assessment and co-ordination of care.
Models of Care promotes a well co-ordinated service across all organisations that need to be involved. My organisation, the National Treatment Agency, supports planning with drug action teams at a local level through its regional managers and staff. Absolutely key is the collaboration between all agencies that touch the drug user: health and education agencies, social services, housing and employment agencies and the voluntary sector. Good commissioning is also key, as has been said. We have developed a sound model for social care planning in relation to substance misuse and I believe that it could usefully be taken into account in relation to other aspects of care. We have changed attitudes and structures, a point referred to by my noble friend Lady Pitkeathley.
I want now to look at carers and, in particular, grandparents as carers. Part 2 of the CSCI report states that,
"joint working to deliver comprehensive services for carers",
is essential. However, only 7 per cent of councils mentioned having a dedicated carers partnership board and there is very little cross-department collaboration. Perhaps the Minister can tell me whether that has improved.
With my substance misuse treatment hat on, I come into contact with grandparents who are looking after their grandchildren because their children have died from substance misuse, are in prison, or are incapable of looking after their own children. Between 250,000 and 350,000 children live with parents who are problem drug users. The report, Hidden Harm, of 2003 showed that problem drug use in parents caused harm to children from conception through to adulthood. Alcohol misuse by parents was identified as a factor in over 50 per cent of child protection cases. That is sometimes where grandparents, usually the grandmother, step in and assume a caring role—and they have a difficult time of it. Many surveys conducted with grandparents point to loss of earnings—sometimes from giving up a job to care for grandchildren—difficulty with housing, lack of support, financial hardship, exhaustion and illness.
I have now been involved in two meetings with grandparents, hosted by my noble friend Lord McKenzie of Luton, in the Department for Work and Pensions. My noble friend had been wonderfully supportive. He has met grandparents and action points have been identified. Some are very simple. They include producing a simple leaflet on the rights and entitlement of grandparents. For example, there seems to be enormous confusion about what they can claim financially. We have recommended producing guidance to local authorities, which seem to operate in different ways and with differing calculations of how to reward grandparent care. We recommend contacting the Local Government Association. We recommend collecting good practice. We need to ensure that support for grandparent carers from social workers is equivalent to that given to foster carers. We need to look at possible grants for emergencies. We need to ensure that departments at all levels, national and local, are aware of the problems. We need in future to look at how the Bill on children in care can help children who are looked after by grandparents. That means helping grandparents with a better financial package and a better care package.
It would be unfair to ask the Minister to comment today on all these factors. I just want to make him aware of the issue and to ask whether his department will talk to the department of the noble Lord, Lord McKenzie, and other government departments to try to help this group of carers who give up so much to help children.
I have given an example of how caring works when well organised, well monitored and well structured. I have also given an example of where we need to do better. Social care is an important element of a civilised society. It is a symbol of how a society functions. Getting it as near right as possible has advantages for everyone.
Lord Harrison
My Lords, noble Lords will recall that subterranean army of terracotta soldiers found some years ago in Xian in China. Carers remind me of them because they, too, are subterranean and silent; they, too, have many common features; and they, too, like the statues with their individualised faces, have their own personal stories about caring. That is why I am so pleased that my colleague, my noble friend Lady Pitkeathley, has brought the debate to the Chamber today. I would say to her that it is the second debate today on slavery, because caring can too often be that.
We do not have to look too far to unearth that hidden army. Often, they are in our own immediate families. A personal story comes from one who is very dear to me who for most of her life has spent that lifetime in vigil with a loved diabetic son and a loved husband, who has only recently succumbed to Parkinson's. She speaks for all that silent army of carers when she talks about the dramatic introduction that she had to Parkinson's when her husband first fell ill. She says:
"Of course, being married, one automatically takes on, willingly, caring for one's own spouse, but being in the midst of caring, I couldn't see the wood for the trees. What do official carers offer? What do they do? Where do you get your information from? The GPs and various clinics should be positive and not expect the patients' spouses to do all the asking. Sometimes carers are just plain exhausted and don't have the energy to pick up the phone or write a letter".
In concentrating today on Parkinson's, I hope that I can illustrate some problems experienced by all carers doing the job that we so value. I declare an interest as patron of the Chester and District Parkinson's Disease Society. There are some 120,000 sufferers of Parkinson's throughout the country but some 500,000 are affected as carers. Three-quarters of Parkinson's carers say that they themselves have a health problem—and no wonder when for most of them their charge may have an existence of 14.6 years, which is the average duration of a PD sufferer. That is really quite a considerable chunk out of your life to be looking after someone else.
Parkinson's has the distinction as a disease of fluctuating in nature; it is a complex condition, with clinical circumstances requiring a quick response, and there is a need for specialist advice not only for the sufferer but for the carer. They desperately need the multi-disciplinary teams, such as the Parkinson's disease nurse specialists; the local support workers to give information and advice; district nurses, who were so wonderful when I had a period of illness; social services; and occupational therapists. But consulting such teams cannot always be done quickly by the carer and the sufferer, and we need to do more.
Some of the problems concern information about carers' entitlements to assessments. A study by Carers UK in June 2003 showed that only one in three carers has had such an assessment. Indeed, in June 2006, the Parkinson's Disease Society held a focus group in which none of the carers had had such an assessment. Then there are financial difficulties. Many carers face financial hardship; their net income on average is lower than that of non-carers, but they then bear additional costs, such as higher transport costs or expensive food if a special diet is prescribed, extra heating and specialist equipment. Then there is the lack of access to high-quality respite care, currently funded through the carers grant and paid by central government to local government. I am pleased that the Government increased it by £60 million last year, but there is still an unmet need.
The PDS focus group also referred to the respite care and the fact that sometimes the service providers do not thoroughly understand the disease and therefore do not provide the best care. There is vagueness about the eligibility criteria. Sometimes respite care should be offered, not required or requested by the carer involved, who is often very reluctant to ask for such a thing.
We need to do more to help the two out of five PD carers who receive no additional help in caring for this challenging condition. Of course, the role of the Parkinson's disease nurse specialist is crucial not only for the sufferer but for the carer, because good advice means so much. In 2005, a Parkinson's Disease Society survey, appropriately entitled Just Invisible, highlighted the problem of the level of care appearing to diminish as the condition advanced. That begins to install in the sufferer and the carer a feeling of abandonment and hopelessness.
So carers should have a holistic assessment not just about the immediate carer's needs but beyond that and then the right to receive the benefits that derive from such an assessment. Often the assessment is made and then the help is not provided. Financial difficulties need to be addressed and the pittance carers are allowed, £45.70, needs to be raised to the other earnings replacement benefits equivalent with a corresponding increase in the carer premium of means-tested benefits. All that could help the Government because, for instance, if the extra £100 million was spent on keeping people within their own homes it could mean a saving of £200 million per year that would otherwise be spent on hospitalising.
I have so many other things to say, but I see that my time is drawing to a close. However, I would mention what the noble Baroness, Lady Pitkeathley, said about carers' breaks. I recommend a very good programme that Diabetes UK has installed and I know that members of my own family have benefited from children's support holidays and from adult support weekends where spreading the information to the carers of those who are immediately around a member of the family is so vital and important. I would have liked to have asked about children in schools who often have to look after a parent at home. I am in ignorance about that but I would like to invite the Minister to reply to some of the points that I have made this afternoon.
Allusion has been made to the conclusion of 10 wonderful years by our Prime Minister. I have therefore written this little ditty:
"With tender loving care
I say a warm goodbye to Tony Blair
And strongly hope from our Mr Brown
A quick and handsome payment down
For all our faithful carers; that silent army
Who need a little more help and some extra loving TLC".
Baroness Barker
My Lords, like the noble Baroness, Lady Pitkeathley, I declare an interest as someone who works professionally in social care. I congratulate her on her excellent timing, because it seems to me that it is a good day to talk about retirement and issues associated with it. I am not going to go into verse, but I am going to start with Tony Blair. In 1997 he said:
"I don't want to live in a country where the only way pensioners can get long term care is by selling their home and where they struggle for survival, scrimping and saving, cold, alone and waiting for death".
Ten years on, as we approach CSR7, that is a good benchmark from which to view the progress that has taken place in the past 10 years and to think forward about what needs to be done in future.
This is a timely debate, coming as it does in the week when the BMA has proposed a constitution for the NHS that would include a statement of what it terms core services that would be provided. Over the past 10 years, one question that has never properly been answered is where the role of the NHS and its responsibility for older people ends and where the role of social care begins. The Government have ducked and dived around the central question of continuing care. It will surprise none of your Lordships to learn that I take a distinctly different view from the noble Lord, Lord Lipsey, and I take a different view of the situation in Scotland. I commend to noble Lords, as I have done previously, a report on care from Stirling University. It explains why costs have increased in Scotland but also points to the immense benefits, particularly to carers, of being able to continue work and to be economically active, because they know that there is going to be a basic entitlement to social and personal care.
As we move towards CSR7, the question of where family responsibility for social care ends and the role of the state begins becomes ever more urgent. People aged 65 and over constitute some 16 per cent of the population, but account for 43 per cent of NHS expenditure and they occupy 65 per cent of acute beds. In 2004-05, older people accounted for 58 per cent—£6.38 billion—of social services expenditure, not including the £1.7 billion of which the noble Viscount, Lord Tenby, spoke. In addition, older people received 71 per cent of all social care packages.
In April, Sir Derek Wanless, author of the King's Fund report on the future of social care for older people, noted that one year on from his report little has changed other than there being wider agreement that the current system is in crisis. Budget increases are welcome but have not kept pace with growing need. The people who have missed out are those with moderate needs and modest means, as other noble Lords have said. The Joseph Rowntree Foundation produced a report in April on older people's views on their experience of available resources in later life. It is important research, because many respondents to that survey had a high level of responsibility in saving towards the costs that they thought would occur in retirement, but many found it difficult to plan for the biggest determinate of costs in later life: ill-health. They knew neither what their needs would be nor what social care they could or should expect. That survey highlights a factor that is often overlooked. While there is agreement that people should be encouraged to save for their retirement, both for income and for their care, there is no way of knowing what level of state health and social care they can expect, making it extremely difficult to plan prudently.
Julia Unwin, director of the Joseph Rowntree Foundation, in an article in April, argued for a clear system of social care entitlements, citing countries such as Japan, Germany and—I should say to the noble Lord, Lord Lipsey—Scotland, where there are basic entitlements for personal care at home and flat-rate contributions to homecare fees. She stated:
"Helping someone to carry out the basic functions of everyday living is not cheap, and it is not a cost that a private individual can really budget for. Private insurance on reasonable terms is not available because insurers know too little about the longevity and health of older people several decades ahead to be able to offer products on reasonable terms".
The noble Lord, Lord Lipsey, conceded that point.
The noble Lord also talked about equity release. He is not the only person who has seized on the idea of equity release as an answer to how we get more money into the social care system. Equity release is attractive but it is not without its difficulties. It is an option that might work for some people at a time of rising house prices, but what happens if property values fall? Is it not wrong to conflate two issues, healthcare and housing, each of which has a degree of risk attached, into a giant lottery, thereby compounding the difficulties for individuals? The consequences of that on the housing market are, as yet, unknown. Even Kate Barker, in her report on housing, recognised that there were issues regarding older people and their occupation of housing, but she did not analyse them fully. Yes, it is right to enable older people to use equity release for such things as repairs and adaptations to enable them to live independently, but the funding of care for an extended and indeterminate period cannot be sustained solely or even largely by capital release.
A further issue to which the Government need to give urgent attention was raised by Sir Derek Wanless in his report and by Dame Denise Platt in her report on the status of social care. I refer to the development of a robust evidence base for social care. Sir Derek questioned whether the current configuration of social care services delivers the desired outcomes. Dame Denise pointed out that while the Department of Health contributes £10 million to research into social care, that compares with the £650 million spent on health research. Even though there is the research programme Modernising Adult Social Care, research is dispersed around a number of different organisations and academic institutions.
What is clear—and I say this very strongly as somebody who works in the field—is that there is a thirst among social care professionals for an evidence base to what they do. They see that as the biggest single contribution that could be made towards designing a system which meets the needs of older people and their carers. At a time when the NHS, via departments such as the Care Services Improvement Partnership and Care Services Efficient Delivery, is bringing back a huge evidence-based change and reorganisation of health services for older people, there is no equivalent programme for social care. When it comes to the point when the commissioners have met the procurement officers and push has come to shove, low-level preventive social care services continually lose out against medical services, which may be redesigned in such a way as to give immediate wins to the NHS.
I agree on one point with the noble Lord, Lord Lipsey. That is something I do not say every day but today I really mean it. We know in the voluntary sector that people have a deep mistrust of the financial services industry. They have a reason to; they have watched their pensions disappear. The need for reliable independent advice on funding care options and funding income and care in retirement continues to grow. There is a growing body of evidence that local authority social services departments are refusing to carry out assessments for continuing care for people whom they expect to be self-funders. By ignoring their obligation set out in Section 47 of the National Health Service and Community Care Act 1990, social services, hard-pressed though they are, are contributing to what is potentially a two-tier system of information and care. I do not know in future where somebody who has neither large assets to release, nor an outstanding knowledge of what is available to them in terms of statutory entitlement, is going to go. I do not want to live in a country where the social care that a person receives depends on their ability to play the property market and to gamble on their own health and well-being, and where what happens in the whole of social care is really a gamble. There is a need for leadership in this matter—today of all days we are thinking about leadership. The Government need to lead a debate about social care, basic entitlements, access to information and advocacy, and then lay out options upon which this Parliament may decide.
My Lords, of all of us in this Chamber, there are few, if any, who can provide a more authoritative view of the state of social care than the noble Baroness, Lady Pitkeathley, and I add my own thanks to her for introducing this debate so clearly and so well. As with almost any topic under the remit of the Department of Health there is cause for praise and cause for disappointment. However on this occasion, rather than launch into a criticism of the Government, I would rather pick up a few of the themes of this debate and explore some of the extremely problematic issues of policy with which Ministers of whatever Government will have to grapple for some years to come.
It is the modern way to talk about challenges rather than problems. If we regard the future provision of social care as a challenge, then at the root of that challenge, as has been said, are the demographics. Over the next 20 years we will be looking at no less than a 40 per cent increase in the number of people aged 65 and older. I have heard some people say that this trend does not really affect things one way or the other. People may be living longer but they are living healthier and more active lives. Unfortunately that is not right. We are going to see not only more elderly people but more people living with disability and chronic illness. Wanless reported that the number of older people suffering from some sort of disability is growing nearly 10 per cent faster than the number of those without a disability. If those statistics are converted into a graph reflecting the demand for social care, we see that demand rising by about 50 per cent between now and 2026. At the same time, we know that the unit costs of social care services typically rise at a rate higher than the ordinary RPI. If those things are put together—I obtained these figures from Professor Julien Forder of the University of Kent—it means that the funding requirement for social care will double in real terms over the next 20 years.
The reality of this situation has to be faced. Someone may ask whether, as a society, we can afford it. The answer is that we have to, but we will have to make some adjustments along the way. The noble Lord, Lord Lipsey, pointed to some long-term options, but some of the short-term adjustments are confronting us at the moment. The strain on budgets at local authority level is, as we have heard, already causing a number of social services departments to ration adult social care to individuals with the highest levels of need. That is not good. Low-level need counts as well, and it counts a great deal. The quality of paid-for care may be going up, but the number of people receiving that care in their own homes is falling. That falling trend is exactly contrary to the one that all of us here want to see, including, I am sure, the Government. The whole thrust of Our Health, Our Care, Our Say, which I for one strongly support, was to promote a shift from treating patients in acute settings to looking after them in the community, forestalling health problems, and making it possible for health and social services to work more closely together. Those were all good concepts, but none of us meant by them that we should put more and more of the strain for delivering care on to families and unpaid carers. We are more than 12 months down the track and the visible progress in implementing the White Paper is a little disappointing.
How far are we getting with joint working between health and social services? One positive step taken recently was the relaxation of the rules for the commissioning of low-level social care services by GPs. Another helpful change is that the areas covered by PCTs now more closely reflect local authority boundaries. But the NHS reorganisation and upheaval that brought that into effect last year did nothing to move the process of integration along. In many areas, there is still a "them and us" feeling between the NHS and local government. The shortage of money in PCTs, as well as in local government, has made these joint arrangements difficult to embed properly. By next year, we are supposed to be seeing joint health and social care networks springing up: teams of people drawn from both sectors who can support those individuals with more complex needs. We are led to understand that pilot projects are not far away, but we need to see them in action quite soon if progress is not to fall behind the plan.
When CSCI reported at the beginning of this year, it pointed to a growing gap between government policy and the reality of what service users on the ground experience. One problem area is that of commissioning, where many local authorities are not thinking out of the traditional box of commissioning residential care and are not putting enough emphasis on allowing those whose needs are being served to exercise choice, control and independence over their lives. Many authorities do not carry out a proper assessment of needs, and that applies particularly in the case of people with more complex health and care problems. One cannot make blanket criticisms in a field such as this but, in many local authorities, there is no doubt that the mindset has to change away from, "We're prepared to offer you this", to, "How best can we help you to live the life that makes the most of your potential?".
Nowhere perhaps is this mindset more evident than in the provision of information—another subject that noble Lords have touched on. A lot of very revealing work has been done in this area recently by the Picker Institute. When people need help, they want to find out what is available, but it is very difficult for the average person to do that. GP practices are not generally good at pointing people in the right direction, and there is very little co-ordination between the NHS and local government in providing information that is relevant. The result is what the Patients Association has described as a maze, which people are left to navigate themselves through as best they can.
Once again, all this points to an attitude of mind that needs changing. I do not know whether the Minister saw the lead article in this week's Local Government Chronicle, reporting the comments of Paul Snell, the chief inspector of social care, who has made the point that it is not good enough for councils to focus solely on those people whose care they fund or procure. In some parts of the country as many as 80 per cent of people in receipt of care use their own money to buy it, and because of tightening budgets in local government those numbers are rising. So for those individuals and those who are fortunate enough to be in receipt of direct payments, it is incumbent on councils to act as honest brokers to help people to make informed and impartial choices and to enable money to be spent to best effect. Other than in a few places like West Sussex, that simply is not happening.
Here we are not talking about an absence of policy, but poor or unimaginative delivery. This is also about transparency and honesty. The other day, I was very struck by the Secretary of State's remarks on Sky News, when she said that PCTs were "absolutely entitled" to restrict access to treatment for smokers and people who are overweight. This is not the moment to have a debate about that issue—we may agree or disagree—but it highlights that patients need to understand their rights. There is a widespread expectation among the public that the state can and will provide. People need to be aware of precisely what the state can and cannot provide and under what circumstances. It is not right that as publicly funded care is progressively rationed, people should be unaware that the bar is slowly being raised; nor is it fair that in different parts of the country the basis on which needs are assessed should differ. There are very good systems for assessing needs on a basis that would result in comparability and fairness around the country, but they are not used.
It was interesting to hear the Chancellor of the Exchequer say at the last Labour Party conference that personal care for the frail and old was,
"one of the greatest failures of social policy".
As this is a long-term issue for government, it implies the need for a broad consensus on state funding and what citizens should be entitled to expect from which arm of the state. It implies a joint recognition that we cannot continue overburdening unpaid carers, and that we shall need more trained people over the next 20 years to deliver the care that we all agree is necessary. Progress is being made, but not nearly enough.
The noble Baroness, Lady Pitkeathley, has articulated not a set of problems, but a set of challenges which I hope the Government and all concerned with the delivery of social care will rapidly take up.
The Minister of State, Department of Health
(Lord Hunt of Kings Heath)
My Lords, we have to finish the debate at 4.46 pm, and I shall attempt to respond to the main points raised in this splendid debate. I congratulate my noble friend not only on her initiative in securing the debate but on her tour de force of some of the key issues that we as a society face generally and the contribution that social care has to make.
It is interesting that, in facing up to some very big challenges for the future, there has been a greater sense of confidence about social care and its achievements in this debate than I have observed in many previous ones. It is important that we celebrate the achievements of the past few years. That will be a great confidence booster when dealing with some of these very difficult matters in the future. I agree with the noble Earl, Lord Howe, on demography, and the fact that we as a society have to face up to some very difficult decisions and issues. I also detect a consensus emerging on the need for a well informed debate which does not believe that there is one simple answer to the issues that have been discussed today.
A number of noble Lords mentioned the important CSCI report on social care which showed that services are improving. It is important to remember that, although it then referred to what it described as shortsighted commissioning decisions by local authorities and issues surrounding eligibility, to which a number of noble Lords have referred.
Let me say to the noble Viscount, Lord Tenby, that I do not underestimate those resources issues. However, although the NHS has had a considerable increase in resources, which I believe was justified and which has benefited many older people, the contribution to local authorities has increased by 39 per cent in real terms since 1997. The Commission for Social Care Inspection has reported on improved social care services for adults for the fourth successive year.
I hear what my noble friend Lord Harris says about the priorities that local authorities have set. However, in 2007-08, authorities will benefit from government grants of about £1.6 billion for specific initiatives in adult social services. There are many examples of significant investments in that area as well.
I understand that there is considerable interest in the current discussions on the Comprehensive Spending Review. I will reflect over the next few weeks whether it would be advisable for me to send the ditty of my noble friend Lord Harrison to the Chancellor of the Exchequer.
I cannot say anything more about the CSR than has already been stated. However, the 2006 Pre-Budget Report faces up to a lot of the long-term issues that have been raised, particularly the number of older people and the implications for public services. It mentions the Wanless review for the King's Fund and the report of the Joseph Rowntree Foundation, which the noble Baroness, Lady Barker, mentioned. It says that in assessing proposals as part of our long-term vision for older people in the current CSR, the Government will consider whether they are affordable, whether they are consistent with what is described as progressive universalism and whether they promote the independence, dignity and well-being which so many noble Lords have mentioned. My department is in continuing discussions with the Treasury about the CSR settlement.
I do not underestimate the concerns that noble Lords have about eligibility criteria and the suggestion that local authorities are raising them, as the social care inspectorate has said, although it is a fact that the number of people receiving social care is rising rather than falling. I echo the comments of the noble Earl, Lord Howe, about the risk of neglecting what he called low-level need. Not dealing with those needs means storing up trouble in the future. The message to local authorities has to be that dealing only with those with the highest need is not a good use of their resources. They need to place emphasis on preventive services, helping people with lower needs to avoid admission to hospital or residential care.
My noble friend Lord Lipsey returned us to a debate on free personal care that goes back many years. I disagree with the noble Baroness, Lady Barker—I think that experience has been borne out and that my noble friend was right when he took his courageous view on the royal commission at the time. I was interested in the comments of the noble Baroness's colleague, Sandra Gidley, that were reported as arising from the Liberal Democrat conference when she called her party's policy of free personal care "dishonest" because people thought that their accommodation costs would also be paid for—which is certainly not the case.
Looking at the experience in Scotland, I am not sure that I altogether recognise the rosy picture that the noble Baroness, Lady Barker, painted from the research she quoted. In fact, a number of local authorities in Scotland have to pay money back to clients who have been wrongly charged in relation to preparing meals for the elderly, and there are waiting lists in some councils for assessing people's personal care needs. We were told that free personal care would suddenly eradicate all of these problems, but that idea has not been shown to be true in practice. We know that there are simply no easy answers when it comes to funding.
We all want personal services to be offered to people in this category. The noble Lord, Lord Best, and my noble friend Lord Harris talked graphically about that and about the importance of direct payments and individualised budgets. Although that has huge potential, I also understand the concerns expressed about what was described as a slow uptake and the issue of it being only 1 per cent of the budget. We clearly need to do more and the Government recognise that. We are doing all we can to spread best practice around local authorities. However, I have no doubt that that is the way we will have to go if we are to achieve ownership of the care provided to so many people. We have to continue to encourage local authorities to understand why it is so important to offer much greater independence of action by individuals rather than simply to expect those individuals to be passive recipients of the care which the local authorities deem they ought to provide.
The noble Lord, Lord Best, made some interesting comments about the voluntary sector's role as enabler and empowerer rather than as one of necessarily providing services. As the noble Baroness suggested, individual budgets and direct payments could have a very important role. My noble friend has championed the role of carers for many years. She also mentioned the current strategy review. I will ensure that the important remarks of my noble friend Lord Harrison are fed into the review. I particularly take his point on the need for public authorities and GPs to be proactive in providing information to carers, rather than expecting carers to struggle through a system to find out what help is available to them. That applies as much to child carers as to adult carers.
I also noted the comments of my noble friends Lord Harrison and Lady Pitkeathley on emergency respite care, which I know is an issue of concern. My department plans to issue guidance to local authorities in summer 2007 to help them recognise the need for more effort. Likewise, I can tell my noble friend Lady Massey that I have taken note of her comments on grandparents and about my department meeting the Department for Work and Pensions. I shall certainly ensure that that happens. As she will know, we have made provision in the Pensions Bill to help grandparents if they are primary carers. However, I accept that more needs to be done.
The noble Viscount, Lord Tenby, made some interesting comments about learning disability services, which I fully understood. I also understand that there are real issues about information for users and their families. It is important that the partnership boards which he mentioned are involved in helping on decisions rather than feeling that they are being ignored. I very much agree with him on that. He also made some very interesting remarks about commissioning. Indeed, a number of noble Lords spoke about the need to enhance the commissioning process, not just in social services but in the health service. It is the same issue. I was very interested in the comments of my noble friend Lord Harris on the development of an institute of commissioning professionals. It sounds like an excellent idea. Dame Denise Platt's report is very important in that regard, and I pay tribute to her work. Her report stresses the issue of leadership and how it can be enhanced. Commissioning skills have to be seen in that context. We want to take that forward.
My noble friend Lady Massey referred to her experience. I pay tribute to the National Treatment Agency for the work that it has done in meeting targets early. As my noble friend said, the keys were funding, high-level interest, ring-fenced money, models of care, guidelines, collaboration and commissioning. I agree that there are many elements. One could look at all adult social care services and other social care services and say that many attributes could be taken on board. However, I object on the issue of ring-fencing. Ring-fencing is justified when a new service is started or there is a specific area of concern, but I do not think that it can be used in the whole range of adult social services. We must let local authorities have discretion in this area.
The noble Earl, Lord Listowel, referred to a number of important workforce issues. First, I pay tribute to the General Social Care Council for its work, which has been enormously important not only to public safety and public assurance but in raising the standing of the profession as a whole. There is the very exciting prospect of eventually extending regulation to all workers in the front line in social care. I have always felt very committed to that.
The noble Earl referred to the protection of newly qualified social workers and to Options for Excellence—which is very important in dealing with the issue that he raised. On money, I refer him to my comments about the current CSR discussions. However, I recognise the importance of ensuring that we take forward the Options for Excellence ideas. He is right about the vacancy rate: it is still too high in many local authority areas. I was very interested in the good practice that he quoted. I am sure that there is much that we can do to encourage local authorities to meet those issues.
Noble Lords raised a number of fundamental issues about the future and I wish to conclude by commenting on those. My noble friend Lady Pitkeathley discussed the role of the state, which my noble friend Lord Lipsey again suggested is a fundamental question that we need to tackle head on. As noble Lords will know, my honourable friend Ivan Lewis, the Minister with responsibility for care services, has raised the question of a new settlement. The question is essentially this: what should be the respective responsibilities of family, state and individual in the new social care world? What role is there for the voluntary sector? What is the balance between family carer versus care workers? There is no doubt that, as the noble Earl, Lord Howe, suggested, we have to think outside the box. We need a cultural shift to respond to the inevitable demographic changes that we see. My honourable friend has made it absolutely clear that, alongside the new guidance on continuing care, we seek to achieve a new consensus for this new settlement which defines the respective responsibilities of the state, the citizen and the family in personal and social care. I am confident that we are in a good position to debate that challenge maturely.
Despite all the adverse publicity that we have seen in social care over the past few years, there has been a huge advance—in the infrastructure and the social care council, in workforce issues, the change in structure at local level, the development of the degree course, and the underpinning of training and development more generally. We should also acknowledge the tremendous work of social workers and other members of the workforce in rising to these challenges. That is a good foundation on which to take a mature debate forward. I do not pretend that any of the answers are going to be easy but I am encouraged by, and very grateful to my noble friend for, the tone of this debate. It suggests that we can have a reasoned discussion and, one hopes, a consensus on the way forward.
My Lords, this has been a thoughtful and well informed debate. There is only enough time remaining for me very quickly to thank all noble Lords who participated, contributing their knowledge, experience and common sense in such large measure. I also thank the Minister for his undoubtedly wise, considered and far-ranging response. I think we can guarantee that, with other events taking place outside this Chamber, we shall not be on the front pages tomorrow—but let us never forget that what we have been debating today is of the utmost importance in the lives of ordinary people in our country as this century progresses. We owe it to them to ensure that they remain on our front pages at least. I beg leave to withdraw the Motion for Papers.
Motion for Papers, by leave, withdrawn.