§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Kenneth Carlisle.]10.16 pm
§ Mrs. Gwyneth Dunwoody (Crewe and Nantwich)
It is not pleasant to be frightened and alone. It is even less pleasant when one is old, frightened and alone. In my constituency many people are unfortunately in that situation. The last census informed us that my population was becoming elderly, that young people were being forced to go elsewhere to find jobs, and that some of the difficulties they would face would be associated with long life and failing health.
It is frightening to approach the situation that we are rapidly approaching in my constituency, with many elderly people being admitted to hospital and being told, "You now have a choice. You need fairly long-term care but it is clear that we cannot provide that within the hospital service." The old people are told, "We suggest that you go into the private sector and seek to find some way of supporting yourself in one of the very pleasant private nursing homes that have grown up since the Government gave very positive encouragement to many people to look on geriatric care as a suitable field for private expansion."
As a result of the pressure on the Health Service from an elderly and growing population requiring help, the NHS has almost become a system that decants units into suitable storage depots. That is not a suitable or acceptable way of looking at the provision of health care. I get letters almost every day from people who say:It seems there is an almost, Impossible task facing me. Due to the health cuts I have to take a decision on which I have no option. [1. To nurse my very sick husband at home. He is paralysed in both legs and cannot talk or even do anything for himself, after a brain operation. He is doubly incontinent and needs turning 4 times each night. I am told I have the other choice of private care which is going to cost at least £185 per week and, possibly more, as time goes on leaving me with about £20 to live on after I have bought clothes, etc, for my husband—as the funding for this is to be made from his pension, DHSS and private pension.That unfortunate woman is herself not very well. Her letter goes on to describe how both she and her husband served in the forces during the war and how they find it unacceptable that, at this point in their lives, this is the solution that they are asked to accept.
Another of my constituents is in her seventies and has a 38-year-old, severely mentally handicapped daughter whom she has to dress and care for. She has now been told that she must take her mother home to live with her, or alternatively place her in private care. Her mother, who is normally very spry, is blind in one eye and nearly blind in the other. She has a fractured hip but she was kept in hospital for only two days. She subsequently had to be re-admitted and was then sent to another hospital, where she was told that she must move to a private unit.
Is all that so cruel? The Department of Health and Social Security will say that it assesses every situation and does everything that it can to make the individual comfortable. However, the other side of the equation has been put to me by increasing numbers of those who, taken by the Government's attitude towards the expansion of geriatric care, have themselves set up homes for geriatrics.
They inform me that the DHSS has now fixed a cut-off point beyond which it will not pay for those in geriatric 301 care. One SRN told me of a man suffering from multiple sclerosis who had been in her care for four years. The fees she charged had now reached the level where neither he nor his family could find a way of meeting them, and the DHSS was not prepared to meet them either. The SRN running that home asked me, "What am I expected to do?" She was told that what was important was that she should decide for herself. When she asked if the suggestion was that she should put a man suffering from multiple sclerosis out on to the street, she was told, "If that is the only alternative, that is what you must do."
In another case, a general practitioner was so deeply incensed that he wrote to me after one of his patients died.
He said:Whilst he was in hospital in a 'holiday relief' bed, [his] condition deteriorated, and at the end of the fortnight he was therefore unfit to be discharged. [His wife] is herself ill and in any case would not have been able to take him home to look after him. I think the family are relieved, in view of [his] mental state, at what has happened, and I would like to thank you for your efforts on his behalf.But the chairman of the health authority had sent a letter saying:I can only presume that [the doctor] has confirmed this is not a case where the patient, for acute reasons, should stay in hospital, but could be looked after at home.In his letter, that general practitioner went on to explain in psychiatric terms why he did not share that view, and why he had made clear from the beginning of that patient's treatment the fact that he required constant hospital care, which he could not receive in a private home.
The reality of geriatric care in my constituency is straightforward. Over the past two years, 36 geriatric beds have been closed—18 in October 1986 and 18 in March 1988. There were 3,139 geriatric admissions in 1986–87 and 3,104 in 1987–88. The continuing pattern of care shows that over the past two years the average length of stay was 23.3 days in 1986–87 and 30.6 days in 1987–88.
There is now a demand that the local geriatricians and psychogeriatricians should themselves find a way of dealing with the question of organising geriatric care in my constituency. They are told that the easiest way of doing that is to create a trust. When they produced a plan that gave them at least some control over the standards of care in private homes, they were told by the chairman of the regional health authority, Sir Donald Wilson, "That is unfortunate—take it back. It does not rely sufficiently on the private sector."
Let me say one thing very simply to the Minister. If the Government persist in a policy that deliberately cuts down the numbers of geriatric and psychogeriatric beds in the National Health Service—if they deliberately seek to expand care in the private sector—they must face up to their responsibility in some other way. First, the Department can no longer say to people, "You must be cared for in private homes, but we shall limit the amount that we pay for your stay." They must know that that places on working-class and even middle-class families a burden that many find unacceptable, and with which many are unable to deal. There is no point in saying to someone who may himself be unemployed or low paid and in need of a sufficient boost in his income to achieve a decent standard of living that he must support his aged parent—or, in some cases, both aged parents—in private homes, at a cost that they know that he cannot meet.
302 Few people in my constituency can meet a cost of £200 a week if they are to undertake their proper responsibilities. Yet the Department is deliberately not accepting changed plans for geriatric care that would enable such people to be dealt with in the NHS, and at the same time is throwing out any attempt by the geriatricians to ensure that private homes attain a proper standard of care.
That is a plain, simple and entirely unacceptable policy. In effect, it says to many old people, not only in my constituency—unfortunately this is happening throughout the length and breadth of the United Kingdom—"We are sorry, but you have lived too long. Our form of Christianity says that if you can obtain charity, well done, but if you cannot the state will neither provide you with proper care in the NHS nor support you within the private system over a certain point." That is now happening every day.
If the Minister has come here tonight with a plain statement that my constituency is to have increased geriatric care, I can only welcome that statement with open arms. But if he has come to reel off a lot of statistics without pointing out that the day-to-day reality for my constituents is an entirely unacceptable decision with which they are unable to deal, I must tell him that, along with his colleagues in the Conservative party, he bears a heavy burden. They are effectively saying that a nation that can afford with no difficulty to hand back considerable sums to those who already have means intends to treat its old—particularly its sick old—in a way close to barbarism.
I find that a sad commentary on a democratic country. I find, above all, that my constituents now see the stark reality of Conservative health policy, which is: "To them that have shall be given; to them that have not, there will be no health care in any form."
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mr. Michael Portillo)
I congratulate the hon. Member for Crewe and Nantwich (Mrs. Dunwoody) on obtaining this Adjournment debate, and on speaking at a fairly reasonable hour. I join her in saying that this subject is important. She has broadened her remarks to cover the welfare of the elderly, not merely the issues immediately brought to mind by the title of the debate.
However, there is a certain inconsistency in some of what she has said. She seemed to attack the encouragement that she said that the Government had given to the expansion of the private sector. At the same time she was attacking the limits paid under income support as being too low.
Since 1980, first through supplementary benefit and now through income support, it has been very much easier for fees for nursing homes and residential care homes to be met. Of course that has brought about an increase in the number of people in residential care homes or nursing homes who are claiming income support to cover their fees. There has been an enormous increase in the number of claimants who are not well-off, as the hon. Lady seemed to imply. By definition, they are poorly off. For those people a need that could not be met before has been met through supplementary benefit and income support. It has 303 given those people choice. They can choose the place where they go to live with the taxpayer picking up the burden. Perhaps the hon. Lady should bear that in mind.
First, I shall deal with some of the issues that are particular to the hon. Lady's constituency and to her health authority. I understand that the Crewe district authority has been considering discharging elderly patients from hospital into the community when they no longer require the level of medical and nursing care normally provided in hospitals. These proposals are still at an early stage. Crewe DHA has been examining a number of options. some of which would involve the NHS building nursing home facilities on NHS land. Thereafter the property would be leased to a private operator. Also under consideration are a number of other options involving use of private or company trusts or use of the voluntary sector. Those options are being examined within the context of national policy, and no decisions have been taken. Crewe DHA is due to meet next on 17 June when this matter will be given further consideration.
§ Mrs. Dunwoody
I should not like to accuse the Minister's Department of misleading him, because I am sure that that is what it has been told. The reality is that it was suggested that a private home should be built on an NHS site. That plan was set up in such a way that geriatricians would be able to control the level of care. That plan has been turned down by the regional health authority which said that there is not sufficient private involvement. If it meant by that that the geriatricians should have no say in the standards of care, it is better that the Minister understands that and makes it public.
§ Mr. Portillo
I heard the hon. Lady say that during her speech and I raised an eyebrow at the time. I shall tell her what I understand the situation to be.
The proposals made by the DHA are very complex and need to be considered with care. The recent Public Accounts Committee report on community care readily acknowledged that patients should not be tranferred into the community until appropriate services are in place. There are legal problems where health authorities have set up trusts or joint arrangements with voluntary bodies or housing associations to house patients discharged from long-stay hospitals. These problems arise from the fact that health authorities are not allowed to charge, and must provide the care free. Legal problems arise where there are intimate connections between health authorities and privately provided care and living facilities.
Last autumn we asked health authorities to hold back on proposals for any new schemes on those lines where they were at the planning stage while we gathered information on the extent of such schemes, clarified the legal position and considered the long-term expenditure implications of any switch in services from a cash-limited Health Service budget to a demand-led social security budget. We are now giving urgent consideration to the way forward. Obviously Sir Roy Griffiths' report will be an important consideration.
In my opening remarks I referred to the extent to which the provision of support has risen, first through supplementary benefit and now through income support. When people cannot afford fees in private or voluntary homes they can get help from income support, and the spending on that has increased considerably from £10 million in 1979 to well over £500 million today.
304 The hon. Lady is looking impatient because she said that she did not want to hear any statistics, but the statistics are about a very large number of people with almost no resources of their own who are now being helped by the taxpayer to live and to be cared for in residential care and nursing homes, and that is a very important factor.
§ Mrs. Dunwoody
Will the Minister please answer the point? In my constituency—he can come and visit it any time he likes—people are told that there are no NHS beds and that they must go into private care. But they cannot afford to pay the sum, even with income support or anything else with a fancy name for handing out charity. That is happening day after day, and talking about billions of pounds does not change that for anyone.
§ Mr. Portillo
That is not true. Talking about billions of pounds changes the position for many more than the 100,000 people who are receiving their care in that way. The situation has arisen under this Government because before 1980 these fees were not available on supplementary benefit. It is nonsense for the hon. Lady to talk as though the help was insignificant.
I am not arguing that the social security arrangements are perfect, but the hon. Lady will recognise that some sort of limit needs to exist. She seemed to accept that point when she said that she disapproved of the expansion of the private sector. Where income support pays the fees of people in private homes, whether residential care or nursing homes, she presumably wishes to see a decent standard of care, that the charges are reasonable and that the amounts that the DHSS is willing to pay are suitable to reasonable, average charges throughout the country, and so they are. We base the amounts that we allow on research into the costs and charges that various homes make.
We introduced those national limits in 1985 because we wanted a coherent approach. There are now national limits for a range of categories of residential care homes and, similarly, nursing homes. Many of these limits have risen sharply in recent years. For example, in residential care homes the limit for elderly people is £130 and for those who are very dependent £155. Those figures represent increases of 18 per cent. and 41 per cent. over the 1985 limits, well in excess of inflation over the period. Again, people are being provided for in that way.
We are always willing to listen to the views of hon. Members and the public on this, but we keep these limits under careful review. That has been demonstrated by the fact that several limits were raised again in April 1988. Health and local authorities have the power and duty to meet high care needs, and they are often best placed to judge these. The question that arises is whether people are suitably placed. Although the national limits are tailored to care categories, they cannot respond to the infinite variations of individual needs. That matter is discussed in the PAC report published last week.
§ Mrs. Dunwoody
Will the Minister please listen to what he is saying? Will he tell me why there are insufficient beds in the NHS, and why the Government have encouraged the expansion of private care and now refuse to pay for it? The Government must either provide care under the NHS where it belongs or justify how they treat people in the private sector. They cannot have it both ways.
§ Mr. Portillo
I would perhaps listen to myself more carefully if the hon. Lady was not making so much noise in my speech. She pointed to the plans of the Crewe DHA to discharge patients into new set-ups that it is planning. I have already addressed that issue in saying that it raises complex issues which need to be considered, and for the moment we have said that health authorities should sit on such plans until we have been able to resolve those issues.
At the same time there is this large expansion in the private and voluntary care sector, about which the hon. Lady seems to be confused. On the one hand she is denouncing it as a bad thing and on the other saying that the limits seem to be set too low. Those two attitudes cannot be consistent. We believe that people are on the whole appropriately placed under the present system, but that is something on which we do considerable research. Recent research that was done by the social policy research unit seemed to show that more than 90 per cent. of the people studied needed residential care at the time of admission to homes and two years later. A minority of those in the sample were admitted to homes directly from the community, and were found to have lesser needs at the outset, although there was no difference between them and the rest of the sample by the time of the survey. Those are not conclusive results, but again I believe that they show that the care packages that are available on the whole suit the needs of people.
§ Ms. Marjorie Mowlam (Redcar)
If the Minister is going to talk about the SPRU report and the Public Accounts Committee report on community care that was issued last week, would it not give a fuller picture if he also talked about the PAC report, which said that there is not enough community care, that 800,000 people have been let out into the community, and there are not the facilities to cater for them, as my hon. Friend says?
§ Mr. Portillo
The hon. Member for Redcar (Ms. Mowlam) will forgive me if I do not respond to the PAC report, because that would be improper, apart from anything else.
§ Mr. Portillo
No, I have mentioned the PAC report on two occasions and I have quoted from it, but I have certainly not attempted to respond to it.
The hon. Member for Redcar and her hon. Friend the Member for Crewe and Nantwich cannot be in any doubt that the Government are serious about community care because we have devoted much time and effort to studying the subject. The hon. Ladies need to show a little more patience.
We have recently received the Griffiths report. These are complex issues. I do not think that the hon. Member for Crewe and Nantwich did justice to the complexity of the issues which concern the appropriate level of care for people in the community, the efficiency with which the taxpayer can deliver that care, and the question whether it is best provided to persons in the home, in the voluntary sector, in residential care, in a nursing home or in geriatric beds in the National Health Service.
§ Mr. Portillo
The hon. Member for Crewe and Nantwich has not referred to geriatric care in the National Health Service, but she will be perfectly clear about it. That option is in general the most expensive, not least because many of those who are cared for within the NHS are most dependent and require the greatest amount of care. That is a very important factor, but none the less it does not remove the great importance of ensuring that taxpayers' money, whether it is spent via the social security system, through social services or through the NHS, is spent efficiently so that we provide the appropriate level of care for people in whatever context.
§ Mr. Portillo
In short, I believe that the present arrangement for benefits for those in homes are a good deal better than they have been in the past, particularly given the reforms that were made in 1980. I am open to any suggestions for further improvement, and I am grateful to the hon. Lady for the characteristic way in which she has made a number of suggestions to us this evening.
§ Question put and agreed to.
§ Adjourned accordingly at eighteen minutes to Eleven o'clock.