§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Chapman.]
§ Mr. Speaker
Two right hon. Members and many hon. Members have indicated their wish to participate in the debate. Therefore, I propose to put a limit of 10 minutes on speeches between 7 and 9 o'clock. If hon. Members who are called before that time also try to stay within that limit, it may be possible, in fairness to all hon. Members, to take that limit off later in the debate.
§ 4.1 pm
§ The Minister of State, Department of Health (Mr. David Mellor)
I am encouraged by the announcement that you have just made, Mr. Speaker, which shows that there is to be a full participation in this debate by a wide range of hon. Members, because that is precisely what was in our minds when we tabled this subject for a debate on the first day of the spillover session. As the House will be aware, my right hon. and learned Friend the Secretary of State for Health, in his statement in July, made clear the Government's broad acceptance of the principles set out in Roy Griffiths' report, but said that further work would be done in the subsequent months leading to a White Paper, which it is intended should be published towards the end of the spillover period, early in November.
It is of the essence of these arrangements that the fullest account should be taken of the views of all groups and interests. That is what we have been seeking to do during the recess, with organisations representing the disabled and the providers of care, with local authority representatives, with the Association of Directors of Social Services, and so on. Today represents an opportunity to have the most important consultation of all, because the Government will hear what the House thinks about an issue that is of fundamental importance to all of us, and of which all of us, as Members of Parliament, are only too well aware because of our pastoral work within our constituencies.
Community care is of the most direct relevance to the interests of significant numbers of our constituents and, whatever our other differences, we should be capable of discussing it objectively and of recognising the enormous benefits that will flow from our endeavours to move these policies forward. By community care, we mean policies that enable people to live as full a life as possible, in whatever setting best suits their needs. That may be in their own home, sheltered housing, a group home, a hostel or a residential home.
An increasing number of vulnerable people live in our community and they will require assessment under these new arrangements for community care. Therefore, our aspiration to provide individually tailored care will command support across the political spectrum and will be recognised as a necessity. Obviously, the real test is not that we accept that this is an important topic or that we accept that something needs to be done, but that we are able to create a framework that will enable us to turn these high aspirations into reality. That was the practical task with which Roy Griffiths was asked to deal in his report, and on which we have been engaged for some months now. I hope that the House will turn its attention to that practical task for the next few hours.
§ Dame Elaine Kellett-Bowman (Lancaster)
My hon. Friend has referred to a suitable setting. Is he aware that in Lancashire the full cost of a local authority home place is £190, whereas these arrangements allow for only £140 in a private home? Is it not possible to raise that level so that people can make a choice and may have a chance to keep these excellent private community homes going?
§ Mr. Mellor
It is of significance to know the proper level of support for those who are in long-term residential care and the proper level of charging that should be made for that support. One of our aspirations is to have a range of different providers, whether from the private, voluntary or local government sectors. Such a range would establish a framework within which it should be possible for good care to be offered at a sensible cost to the public purse.
It is obvious that long-term residential care will be an expensive option, and we cannot afford to neglect the necessity to obtain value for money. We have discovered —this was one of the primary reasons for wanting to reopen this area—that there has been a massive movement of resources into long-term residential care, and this has had implications for the development of other forms of care.
Over the decade there has been a movement in the cost of private residential care from £10 million to nearly £1 billion for this financial year. With a movement of such significance, we have to ask ourselves whether it is necessary, whether value for money is obtained and, if it is not, whether enhancing domiciliary care might be a better option for some of those who, as a result of the perverse incentives which Roy Griffiths has identified, had to go into long-term residential care. I know that my right hon. Friend the Minister of State with responsibilities for social security and the disabled is only too well aware that one of the essential matters that the Government have always to keep under review is the adequacy of the financal provision that is made to meet needs.
§ Mr. Mellor
I am troubled because, if I continue to give way, especially so early in my speech, I shall detain the House and prevent others from participating in the debate. I shall give way to my hon. Friend but I hope that the House will understand that I shall not be able always to give way to others.
§ Mr. Mellor
It is an interesting question, but my response will not give my hon. Friend any satisfaction. Tax relief is a matter for my right hon. Friend the Chancellor of the Exchequer.
I was saying by way of introduction that, while we all can agree on the need for an effective framework for community care, it is not a policy that can be easily implemented successfully. We have increased sharply the resources and the manpower that are devoted to community care over the past 10 years. As I shall demonstrate, these have been years of achievement in community care. As a central starting point and as an 34 evidential base on which the debate can proceed, I shall explain what the achievements have been. It is equally clear, however, that, notwithstanding the achievements, we must recognise that progress in developing adequate services has not been as even or as rapid as we would like; hence the need for further effort.
Over the past 10 years there has been unprecedented expansion. For example, during the financial year 1978–88, the cost, as best as we can estimate it, of core community care services, not including administration or joint finance, was £3,444 million as against £1,169 million in 1979–80. In eight years we have witnessed an increase of 68 per cent. in expenditure of core community care services in real terms.
Back in 1979, about 55 per cent. of local authority gross expenditure was on residential care for elderly people, younger disabled people, mentally handicapped children and adults and mentally ill people, with 45 per cent. on domiciliary services. By 1987–88, local authority gross expenditure was more evenly balanced, with slightly over 50 per cent. on residential care and just under 50 per cent. on community-based services, especially on home helps, day-care centres, meal services and adult training centres.
That is a sign of movement in the direction of domiciliary services that I am sure we would all like to see enhanced as a result of our acceptance of the new framework that Roy Griffiths proposes. Most of us who deal with these matters in practical ways at our advice centres week in and week out are aware that most people would rather stay in their own homes for as long as possible if proper support can be provided, and go into long-term residential care only as a last resort.
We are in the middle of a two-decade span, when the number of the old elderly in our society—that is, those over the age of 85—will double, and it is quite clear that there will be an enhanced, not a diminished, need for long-term residential placements. We must be aware of the impact of demographics on provision, because not only do we aspire to do better for those in need of community care now, but we must recognise that, year on year, as we progress through the 1990s, there will be more people in that category. That poses a challenge not only in making resources available, but in ensuring that they are used to the maximum benefit to provide the best possible care. There is manifestly no room for waste at such a key time.
During this decade there has been a sharp increase in the number of places at day centres—up by 16 per cent.; an increase in home help staff of almost 30 per cent.; an increase in the number of meals served by meals-on-wheels and lunchtime clubs of about 14 per cent.; and a significant growth in a whole range of other personal social service provision. I am confident, looking ahead to the next decade, that there will be a similar increase in that provision; and some even envisage an enhanced increase.
In the presence of my hon. Friend the Minister for Social Security, I should also point out that the same period has witnessed a striking growth in social security payments to people in need. I have already singled out the increase in independent sector residential and nursing home support, which has risen a hundredfold, from £10 million to £1 billion in May this year. I must repeat that, when committing such large sums of public money, it is our duty to ensure that it is spent in the best and most appropriate way to provide care for the clients that best meets their needs. It is in that spirit that we asked Roy Griffiths to undertake his analysis. It is in that spirit that. I believe he delivered one of the most cogent and 35 worthwhile reports in recent times on this or any related topic. It is in that positive spirit that we have accepted his analysis and are inviting the House to debate and discuss it.
§ Mr. Tony Banks (Newham, North-West)
The Minister is making an interesting speech. He mentioned the increase in home help staff and in the number of meals served by meals-on-wheels, but he did not fully acknowledge that those are provided by the social service departments of local authorities. Many local authorities, especially Newham, then find themselves penalised for overspending. Is the Minister prepared to reconsider social service departments' budgets and the provisions for those budgets in central Government funding, so that there may be a continued growth rather than the restrictions now being faced by certain authorities?
§ Mr. Mellor
I am anxious to make as much common ground with the hon. Gentleman as possible, and I welcome his remarks. We should be failing in our duty if we turned this debate into a partisan matter. I know that he is not anxious to do so, and neither am I—nor, I hope, will any other hon. Gentleman. It is in recognition of the contribution that local authorities have made and can make that, after the most careful consideration, we have decided to follow the analysis of Roy Griffiths and give local authorities the leading role in arranging the provision of good quality community care. We recognise that a great deal has been achieved in that sector, although we are also aware that there have been some conspicuous failures.
That new role will obviously require an increase in resources. The year-on-year discussions about local authority expenditure have led to an increase of 39 per cent. in real terms in expenditure on personal social services during this decade. There is also the question of the transfer of resources from the Department of Social Security to local authorities to boost their domiciliary care arrangements.
There will obviously be room for debate—the hon. Gentleman has his view and I have mine—about whether a local authority seeking to make good quality social service provision would fall foul of the Government's arrangements. I come from a borough that has an excellent social services department and has never been threatened with rate capping or any of the other problems. I suspect that that is an issue on which we shall not agree, but one thing on which we are agreed is that it is at the heart of the achievement of good quality community care that local authorities should make good provision. That is the inescapable conclusion to which we have come, and it is in that spirit that we are moving ahead with our proposals.
§ Mr. John Bowis (Battersea)
Will my hon. Friend acknowledge that, where appropriate, we must also transfer best practice from the health authority to the local authority? For example, in domiciliary care there are cases where home helps and social workers are available only during the week, and district nurses and so on take over at the weekend. I hope that my hon. Friend will monitor the changeover carefully to ensure that full care is given to such people throughout the week.
§ Mr. Mellor
Given that there is a continuing role for the NHS community services, it is of the essence that there 36 should be a better and much more effective liaison or interface—I try to avoid that dreadful word, but it is probably the best in the circumstances—between local authority social services departments and the NHS. There will plainly be people who require medical and social care and it is necessary for the two services to interlock. If we are honest, most of us will say that the provision of home help services in our localities is not necessarily the greatest ornament in the local authority's shop window. It is a service which needs to be developed. Even in the best local authorities it leaves something to be desired. It is one of those services that we wish to see developed in our aspiration for better and more comprehensive domiciliary care for those in need.
§ Mr. Mellor
With respect to my hon. Friend, I must push on; otherwise, there is a danger that I shall detain the House for longer than I would wish.
§ Mr. Lord
No, I shall not. I am grateful to my hon. and learned Friend for giving way on the point of Government funding to local authorities. Those responsible for the matter in Suffolk are anxious that the correct amount of money should go to pay for the changes for which it is designed. I believe that it is called ring fencing. My county is anxious that that money should not be part of some general grant that is then used for all sorts of different purposes. Will my hon. Friend assure the House today that such money will be specifically earmarked?
§ Mr. Mellor
My hon. Friend is vindicated in his decision to press me to give way. He has put his finger on one of the key issues, which we are still in the process of discussing. That is as it should be, when such new arrangements do not come into force until April 1991 and when tomorrow I shall be meeting the Association of Metropolitan Authorities and we are consulting widely outside as well as discussing the arrangements within Government.
The first point that needs to be made is that we did not accept Roy Griffiths's advice on the financing arrangements, largely because, having just changed the financing arrangements between central Government and local government, it did not seem opportune to change them yet again for social services spending. It is right that hon. Members on both sides of the House should speak up for local authorities and, since one of the principal burdens of complaint in the past decade has been an excessive determination of such issues by Whitehall, I should have thought that many would welcome the fact that we are accepting that local authorities should have sufficient discretion over the allocation of resources between the different services that they have to provide without too many of those decisions being pre-empted by Whitehall.
That is the argument in so far as it relates to the totality of Government support for local authorities. My hon. Friend the Member for Suffolk, Central (Mr. Lord) may have been referring to the funding that is transferred from the Department of Social Security to local authorities.
37 There is an argument that, whatever the arrangements that relate to the general transfer of funds from national to local Government—that specifically Griffiths-related transfer from the DSS to local authorities—they should be ring-fenced. The Government have reached no conclusion on that argument. It is my genuine intention and that of my colleagues ranged here in extraordinary numbers to listen with care to what the House has to say. It is well worth advancing a case for ring-fencing that part of the transfer. However, it will be wrong for me to seek now to predict how that argument will shape up.
§ Mr. Mellor
With great respect to my hon. Friend, I really must get on. I am between the devil and the deep blue sea. No doubt the flashing lights will exterminate me at the end of my speech if I go on for too long.[Interruption.] I am sure that that is an outcome devoutly to be wished by Opposition Members.
I hope that we can take the opportunity of exploring together these important avenues, some of which have already been raised in previous discussions. I hope that, as well as dealing with the broad thrust of the proposals, those who have expertise in dealing with some of the especially vulnerable groups will not hesitate to bring that to bear. My hon. Friend the Parliamentary Under-Secretary has taken a particular interest in the development of our policies on mental health. He will want to say a good deal about that when he winds up the debate. I shall not say too much about that now so as not to duplicate what he will be saying.
The overriding aim of our proposals is to make sense of the existing over-complicated and multi-faceted system for providing health and social care in the community. In particular, we want to promote independence and choice for the individual who needs community care. In the end, those people are the most important and their needs must lie at the heart of our proposals.
We are looking for a new partnership which, if it is to be effective, must be not only between central and local government but with the private sector, the voluntary sector and the National Health Service. If it is established in a spirit of constructive common sense and a businesslike responsibility, it will enable better and more appropriate care to be delivered to more people.
That brings me to the central pillar of our proposals. As I have already said, local authorities will be responsible for co-ordinating the appropriate care packages for those who need them. Our acceptance of Roy Griffiths's analysis is full-hearted on that point. We spent a long time thoroughly considering all the options and decided that this was the most practical way forward.
We want it to work out, and that is why the White Paper will have running through it a conscious awareness, 21 years after Lord Seebohm's famous report, that the Seebohm concept of the social services department remains highly relevant to our needs today. Lord Seebohm described an integrated social services department asenabling the greatest possible number of individuals to act reciprocally, giving and receiving services for the well-being of the whole community".We believe that the key components of community care must be services which respond flexibly and sensitively to individual needs, particularly those of the most highly dependent people, and which allow for real consumer 38 choice. The Government have set the framework for those services with those objectives in mind. There are three objectives and I shall set them out.
Our first and foremost aim is to ensure that, wherever possible, domiciliary, day care and respite services are used to enable people to continue to live in their own homes for as long as possible. Existing funding structures have worked against that in the past; but the unified social care budget that we propose, to be managed by local authorities, will provide a new incentive to give priority to those services for people at home, and to direct them towards those in greatest need of support. As I have said, many people will need long-stay accommodation, and we want them to have it. I am convinced that better domiciliary care will meet a real demand.
Secondly, we want to ensure that service providers make support for carers a high priority. We all recognise that carers make an enormous contribution, but we do not always do enough—indeed, sometimes we do not do anything—to help them. Pious acknowledgement of the role of carers is not enough; we must develop practical ways of helping them, and I believe that the provision of respite care schemes must be a priority. Policy for carers is one of the most crucial aspects that we want to develop, and I look forward to receiving further advice from the House this afternoon.
Thirdly, we want to ensure that service delivery is based on a proper assessment of need. Social services departments will be familiar with the process, but the new financial arrangements will require the task to be undertaken in a different context. That will involve taking account of all the individuals' circumstances, including their health, and the several different ways of meeting needs within the broad objectives of community care policy.
The basic aim is an individual assessment of need designed to offer the best possible outcome within the resources available. Clearly, the amount of time and effort required to make the assessment will vary considerably from case to case, as will the need to consult other agencies; but we want to ensure that when consultation is needed it takes place, particularly when residential care is being considered. An input will plainly be necessary from the National Health Service as well as from local health authorities.
Although in some instances collective consideration will be necessary, it is vital for us to recognise that in many cases not collective but individual responsibility will be essential. We neither need nor can afford a case conference on every decision. We shall want to develop with the social services departments good practice in case management, with the aim of ensuring that named individuals are responsible for individual cases. That is the basis of the exercise of responsibility within a properly disciplined framework in social services departments. I hope that those will be seen as common-sense concepts with which we can all agree.
Another key part of our proposals is the continued development of the independent sector, supplementing rather than replacing—I stress that—local and health authorities' provision, and therefore increasing the available range of options and widening consumer choice.
§ Mr. Mellor
I will give way in a moment.
A steadily increasing number of authorities are already moving to become "enablers", and we wish that trend to continue. At a recent social services conference in Coventry, I was encouraged to note the number of authorities across the political spectrum that recognised that that was a proper role for them to be asked to fulfil. It makes a great deal of sense to look at what the independent sector can offer, in terms of both quality and cost-effectiveness.
§ Mrs. Gwyneth Dunwoody (Crewe and Nantwich)
Is the Minister aware that his Government's policy of deliberately moving people out into the private sector, and then limiting the amount that they could receive in social security, is causing a real problem for many of my constituents? Having found themselves in private homes, they can no longer afford to stay there, and will soon be put in the intolerable position of having virtually nowhere to go. How does the Minister assess that idealised picture of a mix of private and public health care—which is not being provided under his command?
§ Mr. Mellor
I think that the hon. Lady is being less than fair. I have already pointed out that there has been a hundredfold increase in the provision of resources to enable people to enter long-term residential care. The number who have availed themselves of that opportunity has been far greater proportionately than the increase in the number of elderly people over the past decade.
I have acknowledged—and I am happy to repeat—that it is of the essence to look at the two variables. The first is what is right and proper to be charged by way of fees in these circumstances. One of the advantages of a mixed market is that there is competitive pressure to offer value for money. The second is the need to look at the amount of resources devoted to each individual.
My right hon. Friend the Minister of State for Social Security, who is present today, has said, notwithstanding the many other matters on his plate, that he appreciates that it is of the essence to keep under review the adequacy of these provisions. But I am a long way from being persuaded that the Dickensian picture that the hon. Lady paints is anything like an adequate or fair description of what is happening now.
§ Mr. Mellor
I have an imploring trio, but I think the hon. Member for Birkenhead (Mr. Field) is the most irresistible
§ Mr. Field
The point that my hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody) made is vital. Many of our constituents, after a lifetime of contributing to the NHS, expected to be given a free service when they needed it. They now find, when they are put in what the Minister described as residential care, that they are in difficulty. In the first instance they may have found the situation satisfactory because the fees were covered in full. Increasingly, however, many of them are finding that the DHSS is not meeting nursing home fees in full. Many families are, fortunately, able to make additional 40 contributions to ensure that the fees are paid, but gradually an increasing number are finding that they are unable to do so.
The result is that, whereas many of our older constituents expected to be cared for free in hospitals, they are finding now that they are cared for initially free in residential care but are then faced with bills of £10, £20, £30 and even £40 a week. What does the Minister say to those constituents and families who cannot make up the difference by topping up the fees, who previously enjoyed a free service but who are now expected to make contributions?
§ Mr. Mellor
The hon. Gentleman, whose authority and good will on these issues I recognise, paints a less than fair picture. I cannot believe that he wanted to make one point in the way in which I heard it—the idea that those in residential care should have been better placed in hospital.
§ Mr. Mellor
I am glad that the hon. Gentleman was not implying that. It is of the essence of sensible provision under whatever Government may be in power that we do not use hospitals as places for the long-term care of those who do not require medical as against social care.
§ Mr. Mellor
Some saw that as a clear advantage. In other situations, it meant that people who could reasonably have made some contribution towards their residential care did not do so. We must accept that we shall increasingly be living in a society in which, while it is true that many will require full protection—and they are getting it, because I have it on the authority of the Minister of State that the majority of people are receiving full cover in this connection—some will not be receiving full cover because they and their families can make up the difference without it being unreasonable for them to do so.
I know that the hon. Member for Birkenhead wants to be fair, and he will appreciate that while in any of these policy areas one can never have all gain and that there will always be problems, my right hon. Friend has acknowledged the need to keep these issues under review. It has been a major benefit this decade that there has become available good quality residential care for the elderly provided by the private sector largely financed by the public sector. No amount of quibbling at the margin can deny that that has been a major achievement of the Government.
§ Ms. Walley
In relation to fairness and placing people in the independent sector, perhaps the Minister will address a problem that was represented to me at my surgery on Friday. An elderly pensioner couple with a sister in a private residential home told me that she was in receipt of £10 a week less than was needed for her stay there. The elderly pensioner couple are having to find that £10 every week out of their pension of £74 to make up the shortfall between what is available from public funds to keep their sister in that home and what is being charged by the independent sector.
I assure the Minister that that is not an isolated case. People throughout the country are facing similar situations. We cannot rely on the independent sector when 41 there are not sufficient funds available to cover that sector's charges. What answer does the Minister have for our constituents who are facing such problems?
§ Mr. Mellor
I appreciate the concern felt by the hon. Lady. I have already said that it is of the essence to assess the reasonableness of the fees charged and the reasonableness, in individual circumstances, of the amount of public assistance given. The hon. Lady will not expect me to give a substantive answer because, although I obviously know something about these matters, they are not my primary departmental responsibility and, secondly, it is difficult for me to comment on an individual case. I suggest that she writes about the facts of the case to my right hon. Friend the Minister so that the matter can be looked at.
Plainly, there are some problem cases that we must examine. I have already acknowledged that, and I do not mind doing so, but if we are to have a balanced and sensible debate, it would be helpful if all Opposition Members acknowledged that the reason that we are in this position is an unprecedented expansion in the availability of an area of care that was never available before the Government came into office.
In this mixed economy of care, it is clear that ensuring quality will be vital. Quality is at the heart of our concern. No agency has a monopoly of virtue on quality, but we will be looking to local authorities to ensure that the care provided is not simply the cheapest, the most convenient to supply or just a ratification of the way things have always been done, but the package that best meets the needs of the individual client.
To define good quality is not easy, but I hope that local authorities will begin by listening to their clients. Recently I was particularly glad to read an article in The Guardian by Tessa Jowell—a name rightly respected in this area—who made the point most graphically. She concluded a piece about local authority provision, which had food for thought for all of us and not just local authorities, by saying:Local authority provision is a badly directed mish-mash whose ineffectiveness frustrates or dispirits the provider and often demeans the beneficiary. The solution in local authorities is to listen to the customer.I hope that that kind of straight talking will persuade local authorities to see the need for change and improvement not as a threat, or something to bridle at defensively, but as a shared endeavour which central and local government should work on together.
§ Mr. Tom Clarke (Monklands, West)
It is appropriate for the Minister to quote Tessa Jowell as she was a well-known supporter of the Disabled Persons (Services, Consultation and Representation) Act 1986. The Minister will note that I waited 37 minutes into his speech in order to hear what the Government plan to say to local authorities—and he has an opportunity to do just that, when he meets the Association of Metropolitan Authorities tomorrow. Where do the Government stand on this Act, or are we to assume that the off-the-cuff comment of the Secretary of State on 12 July now represents the Government's definitive position?
§ Mr. Mellor
I was asked this question at Coventry and I understand why, but all I can give is the same answer. I have no further announcements to make of further 42 progress in implementing other parts of that Act, but I have plenty of other plans and schemes and everything must fit in to a sensible order of priorities.
Service specifications and monitoring have a vital role in local authorities' own services. Contrary to what some have said, we are not stopping local authorities providing their own old people's homes and so on. What is clear, however, is that local authorities will need to prove better than they have ever been able to do that they are properly monitoring the standards within their own homes as well as having an arm's-length agency capable of dealing fairly with residential homes that lie within their areas. In the years to come, their ability to be fair will be one of the key tests of whether we were right to charge local authorities with those responsibilities under Griffiths.
I should like to commend those local authorities that are already developing quality assurance work within their social services departments. It is not enough that social services departments should believe in what they are doing: they should be capable of demonstrating that what they are doing is of good quality. That is essential.
Turning briefly to planning and monitoring, while quality will be an essential element in the new planning and monitoring system, there are other issues that we need to grasp. Accountability will be a central plank of an effective, high-quality public service, and we shall be looking to satisfy ourselves that authorities have plans which are in line with national policy objectives. We shall be taking new powers to call for reports from authorities where we have reason to think they may be needed. We shall want the social services inspectorate—which is well respected by local authorities of all political colours—to have access to plans and to offer advice on them. We have no desire to establish an over-bureaucratic or heavy-handed system, but it is important that future community care arrangements are subject to that additional form of public accountability.
Let me say a word or two about resources. I have already made it clear, and I am happy to do so again, that the Government have an important role in ensuring that local authorities have the financial resources they need to tackle these new tasks of assessing need, arranging care packages and buying residential and nursing home places. Our proposals are aimed at making sure the best possible use is made of all available resources, whatever their source. They represent a challenge to local authorities in terms of developing their role as enablers encouraging quality control, giving value for money, improving community involvement and enhancing consumer choice.
We have not under-estimated these demands, and recognise that local authorities will need the means to meet their new responsibilities. That is why we shall be transferring to them the money that the Government would otherwise have provided to finance care through social security payments to people in residential and nursing homes. Decisions on the amounts to be transferred, which will allow for projected growth in the numbers of people needing support, will be taken in next year's public expenditure survey. I am well aware of the importance of those discussions proceeding well. That is why we are having intensive discussions with local authority associations and others in trying to ensure that we reach some balanced judgment as to what that figure should be.
§ Mr. Campbell-Savours
Can the Minister explain what is happening in Brighton, as in many ways that is at the beginning of the route we are on? We understand that in Brighton a health authority has in effect handed over to a housing association responsibility for the care of 16 to 20 people with learning difficulties. The housing association has told the people who currently look after those people that they cannot have jobs if they seek to remain in the same union. Clearly, the housing association has done that because it considers that there are economies to be made and money to be saved if the people working for the housing association who take over that care are not members of the trade union they belong to in the Health Service. Is that the community care arrangement one wants for people with learning difficulties, whereby one hires people without skills, who have not been involved in that care in the Health Service from outside in the market, simply to save on wages and conditions? Is that what we are to expect?
§ Mr. Mellor
The hon. Gentleman has not made the best possible use of the time he took for his intervention. Obviously, he cannot expect me to comment on a case about which I know nothing. My principal curiosity is why the hon. Gentleman who represents Workington should be so fascinated by what happens in Brighton, which, so far as I am aware, is extremely capably represented by two of my hon. Friends who probably get on perfectly well without him on that aspect.
Let me say a word or two about training. We recognise that there is a significant training agenda here for local authorities, who must now be starting to consider how to meet the training needs of their staff and to plan new training programmes. At last month's social services conference in Coventry, I was glad to announce the continuation in 1990–91, at present levels, of the training support of an additional central grant of £2 million next year to support post-qualifying training in management which will be at the heart of all this. Authorities should be able to take advantage of these in preparing their training plans for the new community care arrangements.
Obviously, however, the partnership goes wider than between Government and local authorities during the implementation period. It stretches out to embrace all those involved in community care—health and social services, independent and statutory sectors, providers and consumers, advisers and assessors, care managers and carers—and it will persist as working together in a real sense after the new mechanisms are in place. Our ability to devise systems whereby those various parts of the system can work together will be a test of whether we have succeeded.
I am to be involved in this area of activity at a time when there is a real chance of making a decisive move forward towards better community care. There is, I realise, a wealth of difference between stating policy and putting it into practice. Nevertheless, I believe firmly that, given strong management and a businesslike approach, there is much that can be achieved. We can get better at meeting the needs of the public to whom we are all of us accountable. The focus should be on the needs of the individual, whether a child with a mental handicap, and elderly person who, despite disabilities, wants to remain at home, or a person with mental illness who needs help facing the problems of living with dignity with his disease.
44 I conclude with another passage from Tessa Jowell's article:It takes time, patience and a commitment to change, rather than a lot of money, to translate the vast range of individual experiences into service changes that are recognisable to the people who use them.I add to that that of course money will be needed. I gladly concede that, but people need also to find the time, the patience, the commitment to change and the effective organisation and management of these services. If that is absent, no amount of money will give us the community care that we all want to see.
Those people who are cared for and those who do the caring deserve a better deal from community care. That is the spirit in which we have announced our proposals. I hold firm to my belief that central Government, local authorities and all the other major players in the community care world will be better able under these arrangements to forge the new partnership needed to give that better deal to the increasing number of people who need it.
§ Mr. Robin Cook (Livingston)
This is our third debate on community care in the past six months. It is the first such debate in Government time, and it was widely expected on both sides of the Chamber when the debate was announced in July that this would be the occasion when the House would debate the White Paper we were promised on 12 July in the Secretary of State's holding statement.
In reply to a question from my hon. Friend the Member for Monklands, West (Mr. Clarke) the Secretary of State said, on the timing of the White Paper:It will probably be in the recess."—[Official Report, 12 July 1989, vol. 156, c. 998.]I believed him. I certainly believed him when I discovered that we would be debating this matter on the first day back after the recess because I could not believe that anyone would be so foolish as to expose himself to a debate on this issue unless he was confident that the White Paper would be published in advance. I now know not to believe him next time.
Like the rest of the House, I tuned in to the Secretary of State's address to the Conservative party conference. I was flattered to note that the Secretary of State found time to make two references to me, but they were two more than the references he made to the Government's plans on community care which have fallen back down to the depths of his mind. It is perplexing that the delay is not just a matter of three months since the holding statement in July. It is now a delay of 19 months since the Griffiths report was published. The Government have taken close on two years to get themselves together to publish their response to a report which was written in just over one year. When one considers that laid-back timetable——
§ The Secretary of State for Health (Mr. Kenneth Clarke)
That is what the hon. Gentleman was going on about last time.
§ Mr. Cook
The Secretary of State says that this is what I went on about last time, but if the case against the Government's delay was strong in June, how much stronger it is when we meet again in October.
It is perfectly clear what is getting priority under the Secretary of State at Richmond house—his plans to 45 convert the NHS to market medicine. That means focusing on conditions that can be cured quickly and therefore can be priced and delivered on price. That means marginalis-ing infirmities, disabilities that cannot be cured, that require long-term, low-technology care and nursing, that are expensive without ending, and cannot be made a commercial proposition.
One consequence of this further, unanticipated, delay —about which I think we are entitled to press Ministers, particularly the Secretary of State, since he is with us today —is the problem of the vanishing interval available for consultation on the White Paper when it is published. I grant that this is not a ministerial team noted for lending a patient ear to consultation. They have not paid a blind bit of notice of the storm that the last White Paper produced, but there it is—for form's sake, presumably they intend to have some sort of consultation when they produce the White Paper.
We understand that, if there is to be legislation arising from the White Paper. it will be included in the Government's Bill on the National Health Service proposals which, although unloved, unpopular and consistently rejected by four to one by public opinion, they intend to whip through the House.
I keep reading in the press that that Bill will be in Committee before Christmas. That is using the universal law of the guilty—if it is to be done, it is best that it is done quickly. Where does that leave the proposals for community care?
§ Mr. Mellor
The hon. Gentleman's debating points seem always to move further and further away from any anchorage in reality. He has chosen to make complaints about consultation and delay. Would he care to tell us which group, whose interests he claims to represent today, has briefed him to say that there has been inadequate consultation? He knows that, as I have already said, there has been the closest consultation with all local authority associations and the Association of Directors of Social Services. If it is taking a week or two longer to complete the White Paper, it is because of the thorough examination that is now going on.
Is the hon. Gentleman just making debating points or will he settle down and debate the topic seriously?
§ Mr. Cook
Since the hon. and learned Gentleman asks me, I am happy to say what groups I consulted when preparing this speech. They are the Spastics Society, MIND, Mencap, Age Concern and the Association of Metropolitan Authorities, all of whom remain quite mystified as to the financial arrangements that will flow from the holding statement last July and are anxious to obtain the White Paper.
§ Mr. Cook
I shall give way again, but I want to ask one question. One of those organisations told me that it has heard a rumour that, because of the narrow interval that will now exist between publication of the White Paper in late November and publication of the National Health Service Bill in early December, the Minister intends to put necessary clauses arising from the White Paper on community care before the Committee that considers that Bill. That would be only too typical of the contempt with which the Government have treated parliamentary procedure.
46 Since the hon. and learned Gentleman is so anxious to intervene, I shall ask a specific question. Will he give us assurances that the House will have those clauses on Second Reading of the Bill so that it may be afforded the courtesy of debating them on Second Reading?
§ Mr. Mellor
The hon. Gentleman—[HON. MEMBERS: "Answer!"] The hon. Gentleman wants to wriggle off a hook of his own making by posing another question. He mentioned four organisations, one of which I am meeting tomorrow. He made the accusation about lack of consultation. Will he tell us which of the four organisations complained to him about lack of consultation by the Government during the preparation of the White Paper on community care?
The hon. Gentleman can wriggle and jiggle. That was the point he was making and it is a bad point, as he well knows.
§ Mr. Cook
I can answer that point fairly and squarely. All of them said they did not have the July statement and that they needed clarification.
The Minister cannot escape the fact that the Government produced a statement in July and that all the organisations in this field remain ignorant of its meaning.
The Minister said that I produced another question. I have asked only one question of the Minister so far, and it is one that he has singularly failed to address.
I am grateful for the Minister's intervention—interventions at the Dispatch Box usually are enlightening. He has not ruled out the possibility of these clauses being produced in Committee. That is typical of how the Government proceed once a Bill is before the House. No doubt they will already have guillotined it. Nothing illustrates more clearly the low priority that the Government attach to community care for the disabled, the elderly and the mentally handicapped than their reducing clauses relating to them to a Committee point.
I shall now consider what we know about the White Paper, which comes from an essay, "Plan for a White Paper", published by my hon. Friend the Member for Peckham (Ms. Harman), which is more enlightening about the likely contents of the White Paper than was the Minister's speech.
As the Minister knows, concern about the draft synopsis for his White Paper focused on the passage about non-residential services. In that passage, the draft says:Local Authorities: To encourage the further development of mixed economy of care, to encourage diversification of private providers' entry into domiciliary care market.I have asked only one question so far and I think I am entitled to a second. What does that mean? I am sure that it does not mean a greater partnership with voluntary agencies because there is already a flourishing partnership between local authorities and voluntary agencies. Most lunch clubs are funded by local authorities but administered by voluntary groups. The only thing that holds up expansion plans is lack of local authority resources. Nor can it mean that commercial companies will be allowed to enter the market to sell services to the consumer, because commercial companies can do that already and they have not shown the slightest interest in entering what is an unprofitable market. What I presume it means is that local authorities will be forced to hand over chunks of their provision to the commercial sector. That brings me to my second question. Does this bode putting home helps out to competitive tender at some future date?
§ Mr. Andrew Rowe (Mid-Kent)
I cannot believe that it has escaped the hon. Gentleman's attention that, during the past decade, and in the past 40 years, there has been an enormous growth in the number of people who have disposable incomes and who have had them for most of their working lives. They are accustomed to making choices in the market place about the kind of care that they want. It would be entirely in keeping with that choice that there should be a considerable growth of a mixed economy in the provision of care, as there already has been in the provision of residential care.
§ Mr. Cook
The hon. Gentleman says that many people with an income are obliged to buy in the private sector what they cannot obtain from the public sector. Since the hon. Gentleman's constituency is in Kent I shall describe a situation that faces some of his constituents. His local authority is in the bottom 20 for provision of home helps to people over 75, and it provides the lowest number of meals per person to those over 75.
§ Mr. Cook
No, I shall not give way again.
It is hardly surprising in those circumstances, when there is dire, desperate and inadequate public sector provision, that so many constituents are forced to turn to the private sector.
That brings me to the Minister's observations about the increase in the provision of home helps and of domiciliary services. There has undoubtedly been an increase. There are also dramatic variations in provision across the country that ought to be of interest to the Minister. The top 20 social services authorities provide more than 40 hours of home help service per person over 75. Virtually all of them are Labour authorities.
I agree that none of those authorities would be complacent about provision. Every one would accept that there is a case for further provision and that they are not meeting needs in their area, but at least they are in the top 20. They all provide more than double the number of hours of home help service that are provided by authorities in the bottom 20, all of whom provide less than 20 hours per person to those over 75. I am proud to say that none of those local authorities in the bottom 20 are in majority Labour control.
The issue is not the Minister's barren ideological obsession with whether services are contracted out or are with a private provider but whether the services are being provided at all. My hon. Friend the Member for Newham, South (Mr. Spearing) mentioned the inadequacy of home help provision in Newham, where the number of hours of home help provided per person over 75 is 38. The neighbouring borough to Newham is Conservative-controlled Redbridge, where the average number of hours of home help per person over 75 is 16—less than half that of the neighbouring borough.
Are there so few old people in Barnet that it can get by by providing one fifth the number of hours of home help provided in Greenwich? Are old people in East Sussex so wealthy that East Sussex can get by with a quarter of the services provided in Cleveland? There is the same variation in the provision of meals for people over 75 in Kent. Can Kent get by with one tenth of the provision of meals per person over 75 as is provided in Lewisham, which is only half an hour's drive away? The variations that those figures reveal have nothing to do with variations in need, 48 but everything to do with the political priorities of the people in charge. Throughout the country, Labour authorities are committed to meeting those needs, but the services that they provide may be put at risk by the political dogma foreshadowed in the White Paper.
The Government's worrying double standards on residential homes were revealed in the Secretary of State's statement in July and confirmed by the Minister's speech. The Secretary of State takes pride in saying that he has delivered on 80 per cent. of Griffiths's recommendations. Typically, the two major departures from Griffiths relate to money. The first is arrangements for people in residential care. The Government's proposals are not the same as Griffiths's, despite the Minister's congratulations on a cogent and worthwhile report.
Griffiths recommended that there should be a level playing field between the public and private sectors, which is what one would expect from an author committed to a free market in which people can exercise choice. Instead, Ministers are offering a rigged market in which one choice is off limits. One will receive social security support only if one chooses private provision. One will be lucky to receive local authority provision because, inevitably, Labour and Conservative-controlled authorities will be obliged to steer people towards the sector that enables them to maximise revenue and protect their fixed budgets. On this playing field, the public sector will be playing up hill.
I note in the synopsis of the White Paper a delphic line that reads:Explanation of the rationale for this.I look forward to reading that. I do not know how Ministers propose to wrap it up, which may be a cause of the delay. We are already aware of one reason for the delay —to force local authorities out of direct provision. If anyone doubts that, he should consider what is happening in local authorities where the Conservatives already have their hands on that direct provision. In Bradford, they are selling old folks' homes, not necessarily to be used as such once they are sold. Since the publication of the Secretary of State's statement in July, the authority in Wirral has divested itself of all old folks' homes.
In those circumstances, what happens to the rights of the users of those homes? What about the choice of residents who live in them? What guarantee do they have that they will be allowed to continue to exercise their choice to stay in a local authority home?
The truth is that there is a mixed market in residential care, and that no one in the public sector is arguing against it. Indeed, precious few people in the private sector are arguing against it. The only voice urging retreat by public sector provision is that of Ministers. That dogma matches the prejudice with which Ministers are currently booting local authority representatives off the health authorities at the very time when community care requires greater co-operation between the two.
§ Mr. Peter Thurnham (Bolton, North-East)
The hon. Gentleman said that only Ministers were calling for more provision by the private sector.
§ Mr. Thurnham
That certainly was the drift of the hon. Gentleman's remarks. I should like to draw his attention to remarks that the Royal College of Nursing made in its report. It said: 49Inspectors are setting standards for the private sector which are not adhered to in the public sector, especially in residential care homes.Perhaps the hon. Gentleman will take that on board.
§ Mr. Cook
The hon. Gentleman should be on this side of the Chamber. The Government propose to leave registration inspection in the hands of local authorities. The Labour party proposes that registration inspection should be carried out by a national agency and not left with local authorities, but that is a debate that the hon. Gentleman can have with his hon. Friends and not Labour Members.
Local authorities are being invited to make long-term dispositions about residential care homes on the basis of the rigged market that will be introduced in 1991. The next Government will remove the absurd discrimination against the public sector. We shall restore to local authorities the right to compete fairly and the ability to be direct providers of residential care.
That brings me to the Secretary of State's second major departure from Griffiths. Griffiths recommended a specific community care grant to meet half the total expenditure of local authorities on community care. No specific grant was included in the Secretary of State's statement to the House. I was astonished when the Minister said that the Government had not yet made up their mind about that. It is perfectly clear from the Secretary of State's statement on 12 July that he had made up his mind. I asked a specific question about this issue, to which the Secretary of State replied:As to money and resources, we are following Sir Roy Griffiths's recommendation to transfer resources and the care element of social security to local authority budgets … We have not followed Sir Roy's recommendation for a specific grant."—[Official Report, 12 July 1989; Vol. 156, c. 982.]If the Minister is saying that the Secretary of State is having second thoughts, that is most welcome, but I should like to tempt the Secretary of State in his second thoughts to go beyond the specific minor element to which he referred—the transfer of the present social security provision to those in residential care. If that is the only commitment to money being diverted to local authorities and a specific grant, I warn hon. Members that we are not talking about large sums. We are talking not about the £1 billion that is currently given to those in residential care who are on social security, but about only the care element of funds that the Department of Social Security would otherwise pay out on persons admitted for the first time to residential care after April 1991.
The increase last year in DSS expenditure on residential care was less than £200 million. The Minister has not told us how much of that is the care element, but if we assume that it is about one third, we are talking about a transfer from DSS funds to local authorities of less than £100 million—perhaps £750,000 for every social services authority in England and Wales. We are not talking about sufficient grants to meet 50 per cent. of their community care expenditure. Local authorities are worried that they will not be receiving enough even to carry out the function of substituting for the DSS and maintaining people in residential care.
It is not enough for the Minister to dismiss the intervention of my hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody) as Dickensian. The point that she made about the under-funding of those who are currently on social security in residential care is well 50 documented. A study carried out in Oxford identified almost one third of those residents having a shortfall in excess of £30 a week. A firm of accountants, on behalf of the British Medical Association, is studying that picture.
There is no mystery about it—the gap dates from 1985, when the Department of Health and Social Security changed the rules, no longer met the full fee of the homes and residential care and annually uprated only a flat charge, which in every year since 1985 has gone up by less than the rate of inflation. Tens of thousands of elderly people are driven frantic with worry because of a shortfall between what they receive in benefit and what is required to keep the roof over their heads. The nightmare for local authorities is that, if and when they get this new money transferred from the DSS, it will entirely vanish on topping up the shortfall that already occurs on existing provision, never mind fresh provision.
That brings me to the key question. If the Under-Secretary of State wishes to choose a question to which to reply from the multiple choice questions, this is the one that I would most prefer him to tackle. A new duty has been placed on local authorities to sponsor elderly and disabled persons who are admitted to residential care. Along with that, there is the duty to assess whether they are appropriately admitted to residential care. In this new system, if the local authority carries out the assessment and decides that residential care is appropriate, will it then be obliged to find a place and will it be guaranteed the resources to meet the cost of that place, or will applicants be told, "Yes, you are entitled to residential care and you pass the assessment for residential care but, sorry, we have hit our cash limits and we cannot afford to place you in residential care"?
The worrying feature is that we are moving from a system in which cash from the DSS is awarded to the individual on individual entitlement to a system that will be based on a fixed budget and will therefore be cash-limited. It is difficult not to conclude that the elaborate rhetoric of a new direction in community care conceals the fact that the Treasury has now got what it has long been looking for—a device to cap the bounding social security expenditure on residential care. The device will consist of sitting back and letting local authorities take the strain or, as Chris Heginbotham of the King's Fund expressed it rather bluntly, but tellingly, there is a real danger that local authorities will be "politically stuffed".
That brings me to the critical question of why there is no specific grant for the transfer of resources. As we understand it, the transfer of resources will be buried in the revenue support grant, where they will be so small that even the Secretary of State will require his best pair of ornithologist's binoculars to spot it. Certainly no one else will be capable of seeing what is going on, and that, of course, is what local authorities suspect is the intention behind not ring-fencing this transfer of resources.
The Minister asked about the voluntary organisations that I consulted. Every one of them pleaded for the transfer of resources to be ring-fenced so that it could be separately identified. The Minister keeps referring to the importance of the private sector. The joint care committee, which represents the commercial sector, is terrified about what will happen if the transfer is not ring-fenced, because it is worried that local authorities will not have the resources to meet the claims of the claimants currently in their homes.
51 I raised the matter with the Secretary of State in July. In responding to my intervention, he said that the separate specific grant proposed by Griffiths was intended as a control menchanism—the implication was that local authorities should be pleased that he was not imposing this control mechanism on them. Possibly the most remarkable voice in support of a specific separate grant is that of local authorities. They are willing to accept the deal of a specific grant for specific services. That is a control mechanism that they are confident they can meet. They want it also because it will be a control mechanism on the Secretary of State as well. A specific grant would make it clear to everyone how much he was putting into community care and who was responsible if it was not enough. the person dodging the control mechanism is the Secretary of State; it is not the local authorities.
The Minister's comment on the carers of those in need of care was welcome and generous. However, the House should recognise that the bulk of care in the community is met by informal carers, by which—let us be blunt about it —we mean the nearest female relative, time after time. It is impossible not to salute the dedication and sacrifice of those carers. The Minister of State went to the AMA conference the day after I did, and no doubt found as I did that every delegate to that conference had been deeply moved at the plenary session when a number of carers had been specifically selected by Tessa Jowell to talk about their experiences and needs. They included one woman for whom that was the first hour in two years in which she had been out of the house and away from the person for whom she was caring.
The Minister is right to say that we cannot be pious in deriving a warm glow of satisfaction from contemplating the devotion of those carers, but the response of the House in contemplating that dedication and devotion should be shame—shame that we provide so little help to them, that we do not provide any training for them and that we provide little respite care and minimal relief for them.
There are undoubtedly a number of pertinent questions that can be asked about the Government's intentions. One set relates to how the Government intend meeting the need of those carers for an income of their own. I am glad that the Minister for Social Security is with us, because the way in which this Parliament has treated the benefit rights of carers is a disgrace. If the carer lives with somebody who claims social security, it is almost certain that, by definition, that person was one of those getting higher social security levels, based on allowances and extra payments for heating, diet and other needs, all of which were abolished in April 1988. Therefore it is likely that such a carer now finds himself or herself stuck in a household on transitional protection, with a frozen income for the past three years. If the carer was on social security in April 1988, she would have found herself in April 1988 in the only group on long-term supplementary benefit which got no premium on transfer to transitional protection, and therefore she would have lost the equivalent of £5 a week.
I was deeply moved a couple of months ago when I read an article by a woman who gave up work four years ago to nurse her terminally ill sister. She explained how she got out of the house only twice a week. At the end of those four years of constant nursing and after her sister died, she 52 applied for unemployment benefit because her invalid care allowance had expired. When she applied for benefit, she was told that she did not qualify because, as a result of the Social Security Act 1988, credits for ICA no longer counted towards unemployment benefit.
§ Mr. Frank Field
Does my hon. Friend agree that the position is even worse, because no carers get credits for unemployment benefit? Therefore, when the person for whom they care dies and they claim benefit they are told that they do not qualify for any national insurance benefit. The Government say how important it is to support the carers, but does my hon. Friend agree from experience of his surgeries that about six months after the person for whom they have cared has died, many carers often have a breakdown, such is the pressure on them? If the Government were serious about supporting carers in their move back into work, the very least they could do today would be to announce that all carers would qualify for benefit when they cease to be carers.
§ Mr. Cook
I agree absolutely with my hon. Friend. All the medical surveys that have been carried out show that not only those who are in need of care are infirm or disabled, but the people who care for them are less healthy than the rest of the population.
I stress that however much we improve the service to carers and whatever solution we find to the serious problem they face in obtaining independent income, it would be an immense mistake for any hon. Member to imagine that we shall be able to palm off the growing number of those in need of care on to a growing number of carers. Most people over the age of 85 have children —if that is the right term—who are now in their early sixties and who are on the verge of needing domiciliary support. There are not enough younger relatives to go round. Already, 29 per cent. of single women between the age of 45 and 64 provide full-time care for disabled relatives. In the real world that percentage cannot be increased. Other Ministers, especially the Secretary of State for Employment, have other plans for these women and want them to step into the breach caused by the declining numbers of school leavers.
The harsh reality is that individual solutions in private families cannot match the growing need for care in the community. It will take collective provision by public agencies for the community. That will not be achieved by a Government who persist in regarding local authorities as whipping boys and every increase in public expenditure as a defeat and who, when faced with a social need, see only a market opportunity. Those are the real reasons why Ministers are having such difficulty writing the White Paper after 18 months and why all the signs are that when the White Paper appears it will not match the challenge that we face. They are part of the reason why the public outside this place are increasingly impatient to be rid of the Government.
§ Sir Geoffrey Pattie (Chertsey and Walton)
I followed closely what the hon. Member for Livingston (Mr. Cook) was saying and I had some sympathy with his point about carers, because I am most concerned in case there is any belief in Government circles that the voluntary sector can in some way, in totality, take over the responsibilities which have hitherto been the purview of the state.
In 1971 my wife was involved in establishing an emergency social health scheme in the Brixton area of south London. After it had been going a few years and a partnership had been developed with the local authority, it had five full-time paid employees, who were paid for largely by the local authority. There were also about 80 volunteers. Without the five full-time employees, it would have been impossible to keep the 80 volunteers in the field. I would be happy to be reassured, but I am concerned that there is a belief that the 80 could be extended and the five full-time employees could be taken away so that the entire scheme—which is replicated throughout the country—could be run on a completely voluntary basis. Quite frankly, it cannot.
We seek reassurance from the Government that they will look at the importance of funding some paid employees in local schemes to act as false multipliers to make it possible for the considerable amount of voluntary good will which exists to be utilised. They must not regard volunteers as a substitute for paid effort.
I know that many people want to speak in the debate, so I shall be brief; but there are some points that require further elucidation and clarification from the Government. It would be extremely helpful if, when replying to the debate, the Minister could tell us when the Government intend to transfer the management and staff of long-stay mentally handicapped hospitals to social services departments. There is a considerable gap on this subject and we should like to hear about it.
There is also much concern about what the care packages will consist of. There is a problem between what constitutes a care cost and what a housing cost. In my own part of the country, one of the specialities of the North West Surrey health district is respite care breaks. There is a great deal of demand from individuals and carers for such respite care. In order not to disadvantage the individuals, they would need to be able to pay not only for their respite care, which is a care cost, but for the rent on their homes, plus rates, heating and water, which are housing costs. They should also pay something towards the hotel charges incurred by the providers of respite care, which is a housing cost. Therefore, the formula for calculating care costs must include provision for the housing element; otherwise, there would simply not be enough to pay for the service.
Mr. Chris Heginbotham, who has been mentioned in this debate, has spoken in favour of the desirability of setting up various forms of trusts to help to administer housing needs in areas where there is a considerable degree of pressure. In my part of north-west Surrey we must have sufficient capital, revenue reserves and resources provided otherwise we shall be in great difficulty when following through some of the excellent initiatives that we have. There is much that is good in what the Government have been proposing; now we want further clarification on some of the points that I have raised.
§ Mr. Jack Ashley (Stoke-on-Trent, South)
I shall try to deal in a few moments with a few of the points made by the right hon. Member for Chertsey and Walton (Sir G. Pattie), but shall begin by saying that the Minister of State is a pretty dab hand at putting a gloss on the policies he presents—that is, when he gets round to doing so. I was disappointed that he took so long to get round to community care. The Government have had the Griffiths report for a long time, as my hon. Friend the Member for Livingston (Mr. Cook) has constantly mentioned.
Today, the Minister of State is making friendly overtures to those people who need community care, but I was not that impressed by the substance of his speech. Community care is one of the greatest social problems of our age, affecting old and disabled people. I would have thought that the Government would have given the subject a much higher priority and dealt with it more quickly.
Despite the vagueness of the new proposals mentioned by the Secretary of State in April and filled out a hit today by the Minister, they show that a new financial burden may be added to those shouldered by people who receive community care. Many people are fearful that, if local authority care is to be privatised, it may mean that the Government will replace free provision with means-tested care. That is a point of great importance to disabled and old people, because the consequences would be devastating.
If that fear were justified, it would mean that thousands of elderly and disabled people would gradually lose their savings, and nothing could be more important to them than that. They might even have to sell off their houses as their resources melted away in payment for essential care services. I hope that the Under-Secretary will be able to give a categorical assurance that the Government will not privatise community care. I would welcome that. If he cannot, I shall take that, too, as a statement of Government policy. If the Government privatise community care and charge for it, that will be scandalous; it will be the equivalent of selling it like cigarettes or detergents.
The Minister of State expressed good will to people who receive community care. I shall tell him where Government policy is wrong. The fundamental shortcom-ing of the Government's new policy is its assumption that the acknowledged inadequacies of community care can be remedied by shuffling responsibilities, not by increasing resources. The truth is that we need new polices and new money, yet we do not seem to be getting them. Indeed, the level of finance may even be reduced. It may leak away because of the Department's refusal to make specific allocations.
On 12 July, the Secretary of State said that he had not gone down the specific grant route but would use the inspectorate route. Today we heard the Minister of State say what the inspectorate would do. He has been led up the garden path if he thinks that it is a substitute for specific grants. He said that the inspectorate would "offer advice". What is the point of that? Intransigent local authorities which are not prepared to allocate funds for community care will not be impressed in the least by advice from any quarter.
We must have specific allocations by the Government for realistic and genuine community care.
55 One of the problems facing Ministers is that specific grants would enable people to identify the true cause of poor services—the Government's inadequate funding. Without specific grants, blame can be diverted to local authorities, which may well be why the Minister has rejected such grants.
Local authorities are under great pressure to divert funds to badly needed housing or to repairing decaying school buildings. That could be tempting to some impecunious local authorities—and to some mean ones. It would devastate old people if the cash were diverted in that way.
Few things are more insulting to disabled people than being patronised or refused consultation, or denied someone to represent them. I know that these things can be and sometimes are done on an ad hoc basis, but disabled people want such consultations as a statutory right. That is very important. Improved community care for disabled people will develop only from consultation with them and their representatives when that is a statutory right, and I hope that the Minister will be able to say today that the Government will implement sections 1, 2, 3, and 7 of the Disabled Persons (Services Consultation and Representation) Act 1986. If he does not, that will show that, despite having quoted Tessa Jowell's view of caring in the community, the Minister is not prepared to go as far as disabled people want him to.
The mentally handicapped and mentally ill are of special concern because of the appalling way in which many of them have been shunted into an unprepared and often indifferent community. Hon. Members on both sides have made that point strongly. An eloquent Conservative Member demanded recently improvements. These matters concern all hon. Members, and I do not believe that the policies spelled out by the Minister will deal with them substantially. I hope that the Under-Secretary will be able to enlighten us more about what the Government intend to do to keep these people off the streets, out of the prisons and out of the cemeteries.
The Minister of State spoke at some length about carers and I was glad to hear him say that they should have top priority. Many of them bear enormous and unfair burdens. Carers are more overworked, worn out and exploited than workers in any sweatshop in the east end ever were. They are the martyred millions; 6 million of them have had their lives pushed out of kilter because of their affection for relatives. The Minister said that they had been given £1 million more, but they have saved billions of pounds by the care which they have devoted to people in need. It is not possible to solve their problems with £1 million or even more—they need much more cash and they must be given the money. It is imperative that they get it. They must be recognised, consulted and supported. They need respite care, specifically allocated financial support and involvement in the creation of new care packages for their dependent relatives. When the Government provide those, we shall be on our way to proper community care for Britain's disabled people.
§ Sir David Price (Eastleigh)
Unlike the hon. Member for Livingston (Mr. Cook) I welcome the fact that we are having this debate before the White Paper, because we 56 heard from the Deputy Prime Minister in Blackpool that the Government have become a listening Government, and I shall take them at their word. In the interests of brevity I intend briefly to put to the Government some of the issues that I hope will feature in the White Paper. Inevitably I shall cover some ground which has already been covered by others.
I want to take up a point mentioned by the right hon. Member for Stoke-on-Trent, South (Mr. Ashley)—the recognition that some people need permanent asylum: I use the word in the proper technical sense. The House will recall that the Social Services Select Committee produced a report in the session 1984–85 which dealt with the mentally ill and the mentally handicapped. We were concerned about the speed with which profoundly mentally handicapped people were being turned out of long-stay institutions without adequate provision. In theory, there were plans for their care but in practice they were not being carried out.
I remind the House of what we said at the time:While the disabilities of long-stay patients may well be heightened by institutional care, the simple facts are that there is little prospect of major change for the better for many mentally disabled people … The concept of asylum has nothing inherently to do with large or isolated institutions. Asylum can be provided in a physical and psychological sense in the middle of a normal residential community: traditionally indeed, in the midst of a busy church. We must face the fact that some people need asylum.I repeat our conclusion that some people need asylum.
We also need to take into account the demographic facts upon which my hon. and learned Friend the Minister touched. We must recognise, as the Royal College of Nursing has said, that among those over 75 the rate of various forms of dementia requiring 24-hour nursing care is currently running at between 21 and 22 per cent. The college says that there is no reason to suppose that that percentage will drop. In real terms, by simply extrapolating demographic trends, we see that by the end of the century we must make provision for between 80,000 and 100,000 more dependent people with dementia. We are talking about nursing care. It is not fair to ask ordinary care attenders or social workers to cope with that. That is my first point—the need for asylum.
Secondly, there is a need to quantify the number of clients with whom this public policy is trying to cope. I remind the House of the wise words of a famous Scottish physicist, the late Lord Kelvin, who said:When you can measure what you are speaking of, and express it in numbers, you know that of which you are discussing. But when you cannot measure it, and express it in numbers, your knowledge is of a very meagre and unsatisfactory kind.It is time that we made the message a little less meagre and less unsatisfactory. I hope that the White Paper will attempt to quantify it.
The task has been made infinitely easier by the reports of the Office of Population Censuses and Surveys on the number of disabled people in our midst. Extrapolation of the demographic trends and percentages such as those that I have quoted from the Royal College of Nursing on the elderly can give us a reasonable estimate of the number of people with whom we shall have to cope. I can tell the House that there are far more such people out there needing support than are recognised in official statistics.
My third point follows from that. It is that we must have better resourcing of care in the community. We all agree that if we are to make public policy more effective, 57 it must be properly resourced. That means that it must be more generously and more effectively resourced. That is the message of Griffiths, of the Audit Commission and of every organisation in the health care business that submitted evidence to us. No mention has yet been made in this debate of the telling report from the Audit Commission. In the simple language of the King's Fund Institute:More and better-used resources will be required.Does my hon. and learned Friend the Minister and the Treasury agree?
If the local authorities are to be the vehicle for these more and better-used resources, it is imperative that the contributions of central Government should be in the form of specific grants and should be ring-fenced. I think that every hon. Member who has spoken in the debate has made that plea, and I should like to reinforce it. Whatever earlier hesitations he had, I trust that the Minister, having listened to the debate, will accept that argument in his White Paper. It should appeal to the Treasury and certainly to the Audit Commission.
My next point is about the need for an inspectorate. The proposal for local authorities to make arrangements for independent care facilities to be inspected by them is welcome. Nevertheless, some major organisations have argued for national standards covering both the private and public sectors. Here central Government must play their part as the procurers and enforcers of standards. The social services inspectorate will have powers to monitor community care plans, but unless it is given wider powers its recommendations can be ignored by local authorities —as they currently are.
I plead with the Minister to beef up the social services inspectorate. If he is worried about that being a revolutionary advent, I remind him that under the first Elizabethan poor law, which, as the House will recall, was administered by the parishes, the Privy Council had a duty to monitor the effectiveness of the parishes in implementing care in the community as it was conceived in those days. Therefore, there is good precedent behind my argument.
Finally, may I return to the old theme with which I have burdened the House in the past and which I have noticed other hon. Members have taken up—the importance of private carers? In so doing I declare a personal interest. Far more dependent people are being cared for at home than are being cared for in all the hospitals, institutions and rest homes whether statutory, charitable or private in the kingdom. Therefore, the first priority of any more active policy for care in the community must be to improve the lot of private carers. In his July statement, the Minister praised that concept and my hon. and learned Friend the Minister of State did the same today.
Are the Government and the House aware that two thirds of live-in carers receive no help at all from any service? Some of them may be caring 24 hours a day for very dependent relatives and may be working round the clock with no support. Caring for the doubly incontinent is no gentle pastime and looking after a dotty old relative is demanding and exhausting. That fact alone puts into perspective the role of the carer in our society. From its own experience, the House will know that carers come in all shapes and sizes and that they cover the entire age spectrum. Many elderly people are themselves carers. That fact must be emphasised and, given the demographic forecast, the number will increase.
58 While the personal circumstances in each case may vary greatly, the common factor is that most carers have consciously chosen, or accepted, the role of looking after their dependent relatives because they love them. For I hat reason they do not want to hand over the job to anyone else. However, caring for someone who is heavily dependent is continuous, tiring, stressful and restrictive. It can impose serious strains upon other relationships in a family.
We should think of the effect on other children in the same family that comes from looking after a severely mentally handicapped child. There is no 40-hour week in the caring game. Outside help at key times on both a regular and a one-off basis can make the difference between a total breakdown and a successful and loving partnership between the carer and the cared for.
I hope that we can all agree that carers need more backup, regular support and emergency assurances. They especially need sound professional support if they are to fulfil their mission as carers and still have any hope of even a modicum of a personal life of their own. I invite the Minister to spell out in his White Paper how the community can support the carers more effectively. That is essential if we are to make a success of any improved national policy for care in the community. I and I suspect other hon. Members will judge the validity of the White Paper by the extent to which the Minister succeeds in doing just that.
§ Mr. Ronnie Fearn (Southport)
Although I welcome once again the opportunity to debate this subject, I thought that this important issue was to come before us quite soon and that during the recess we would see the White Paper. However, that was not to be. Like everyone else, I naturally assumed that, as the Government had scheduled community care as the business for today, the purpose would be to discuss some concrete proposals. From what the Minister said, I understand that the White Paper is now expected in early November. If that is so, I doubt whether what is said in the debate will have time to make a great deal of difference to the content of the White Paper.
The matter is extremely urgent, as previous debates have shown. The lack of care in individual cases in some areas and in certain sections of the community service has led to an intolerable level of neglect. Social services departments are presently working at crisis level. I say that from experience of my own authority of Sefton. They are responding with short-term solutions. Many long-term strategies are abandoned because of the shortages of funds and grave doubts about what the future holds.
I know that community care is a complex issue that requires thorough investigation, and I should be a little happier about the delay if I thought that it was due to Ministers conducting an in-depth study to ascertain what the true needs of the community are, in terms of care for the elderly, the handicapped, the disabled and the mentally ill, and then devising plans as to how best the needs can be met. However, I fear that the delay has more to do with the conflict in policy and ideology between the Prime Minister and her many advisers and to the narrow terms of reference within which the proposals for community care are now to be drawn up.
59 I am referring to the fanaticism with which some members of the Government approach any service that is remotely connected with the welfare state and the need that they see to reduce public spending while increasing support for the private sector. Such thinking is often coupled with the view that local government can be tolerated only if it has its hands tied firmly behind its back.
It is clear that the recommendation by Roy Griffiths that local government should act as the lead agency for community care services was accepted only reluctantly by the Government. We must now ensure that local authorities receive the resources that they need to fulfil this role, not only financially but in terms of manpower and training. I was pleased to hear the Minister say that there would be a full commitment to training. We must take care that local government does not become the Government's whipping boy. I take that view not because, I am soft on local government—far from it—but because, if that were to happen, many people in need of community services would not receive them.
We all know that a policy of care in the community is not a cheap option, but we do not know what will be the true cost of that policy. There is no adequate means to assess the many different forms of care, and I hope that some investigations are carried out to rectify this. What is certain is that the present level of resources is not enough. Too many people are out in the cold and too many have been allowed to slip through the net. I fear for the future. We have little knowledge about the allocation of funds to local government except the few hints given to us by the Secretary of State in his statement on 12 July, which in effect amounted to a cash-limited system.
We were also told that funds would not be earmarked. This will make it difficult to identify the amount allocated for community care services at national and local level. This raises a number of issues that I hope that the Minister will address. Given that there is already a great shortage in the amount of money required, will he guarantee extra resources to meet the demands not only of providing for the numbers who need support but of ensuring the type of support that is needed? The requirements and costs of care for the elderly, the handicapped, the disabled, and the mentally ill are different, and I hope that the proposals will allow for assessments of funding for the needs of each client group.
It is expensive to provide constant 24-hour care for those suffering from senile dementia, the numbers of which increase every day. This point has been mentioned already, but it needs to be mentioned again. When local authorities are forced to make choices between services, such a community care group will be neglected. The poorer authorities, where often those in the most need live, will be the hardest hit in any cash-limiting exercise.
The Government's attempt to put pressure on local authorities to use the independent sector by refusing to fund people in local authority homes will have devastating consequences. The provision of private and voluntary homes varies considerably across the country. It is not viable for the voluntary or private sectors to set up all those homes in some inner-city, rural or suburban areas. Some people will be cared for in local government homes out of necessity and others out of choice. Neither should be discriminated against.
60 We support the provision of personal care packages, which would involve a pluralist approach to community care. My party has long called for the Government to act as an enabler—I was pleased to hear the Minister say this as well—rather than a universal provider. We are adamant that some public provision must remain as an option in community care services. It is intolerable that, even in the present circumstances, local authorities are being forced to sell off their residential homes to ensure that there are adequate standards of care. In the interests of choice and as a means of last resort, the individual client and carer must be given access to public provision.
The public sector has not generally provided care for the more vulnerable members of society, and the voluntary sector should not be expected to take too many contracted-out services. If it does, it is inevitable that its services will change in character and the community will lose the benefits of the flexibility, innovation and new initiatives that many voluntary organisations now provide.
There is not and cannot be any obligation on the independent sector to make provision for any form of community care, and if it closes down its operations in an area without public provision, it will be difficult and expensive for the local authority to restart its residential care provision. Once again, the more vulnerable and the disadvantaged will suffer the most.
I said earlier that community care is a complex issue. Unless one has experience of it or is advised by those with some experience on the ground, one will never grasp all its complications and implications. I have much to learn, but the Secretary of State has even more. After his statement on 12 July, I asked him about housing within community care and whether he would direct that local authorities would receive more finance for this purpose. While I accept that the solution does not entirely lie with the Department of Health, the Secretary of State's reply—but I honestly do not think that housing finance is remotely related to what I am talking about today"—[Official Report. 12 July 1989; Vol. 156, c. 984.]—leaves me with little hope of a co-ordinated community care policy from the Government.
Does the Secretary of State not know that many community care projects involve housing and capital finance? These include the provision of housing for those with special needs to live independently, ordinary housing for handicapped people to be trained for independent living, sheltered accommodation for the elderly, hostel provision for the more vulnerable and special units to provide short-term respite care for the carers. I could go on, but I hope that I have made my point and that the White Paper offers some proposals for ensuring some provision for capital finance for community care projects.
I shall look with interest at the proposals in the White Paper that lay out the respective responsibilities of the health authorities, family practitioner committees and local government. For instance, will it make clear who is responsible for a patient who is discharged from hospital with certain needs but who is assessed by the local authority in a way that does not meet those needs? Who will provide the care? Will it be the health authority, the local authority or the general practitioner? Above all, who will make the decision? This is critical to the whole matter. Will there be a single point of access for clients and carers or will they, as they do now, have to negotiate a mammoth maze before reaching their objective?
61 Will the White Paper spell out how the Government's proposals relate to those contained in the White Paper "Working for Patients"? Will self-governing trusts have responsibility for ensuring that adequate community care provision is available for discharging those in need, such as the elderly after an acute illness? Who will be responsible for community units that opt out? Will it be the Secretary of State, the health authority or local government?
What guarantee will there be that health authorities will provide the medical services such as geriatric care, including geriatric psychiatry, that any care in the community requires? Will they retain enough funds to provide community services, or will those funds be drained off by the acute sectors, the hospitals?
The dividing line between medical care and social care is not always apparent or easy to define. It is important that an atmosphere of co-operation and co-ordination exists between all agencies so that the client and carer do not find themselves stuck in no man's land, which often happens now. One of the important measures to assist in that direction will be to ensure that each agency has sufficient funds to prevent the practice of dumping.
It is important also to ensure that all sectors are involved and represented at strategic planning level and in the plans for the everyday operation. Without clear-cut lines of responsibility between the agencies and without safeguards for the consumer, there could be catastrophe. Changes to the National Health Service taking place at the same time as community care services will create chaos. I only hope that both services come through them in a recognisable form.
It will be virtually impossible to plan for the future, as there will be so many unpredictables. One essential step is to extend the statutory duty of local government to include all community care client groups. The proposals that are set out in the White Paper, which we hope will create a system that is based on individual selection and packages of care, must include national guidelines and standards of care, with the mechanisms to monitor them, so that we can ensure a degree of equity and access to services along with quality of services.
The client and the carer should have easy access to information that sets out their rights and their entitlements, including the right to be consulted and involved in the decisions that affect them. They have a right to advocacy and to a simple procedure for complaints.
On 12 July, the Secretary of State said:The great bulk of community care will continue, as now, to be provided by family, friends and neighbours."—[Official Report, 12 July 1989; Vol. 156, c. 976.]I hope that the right hon. and learned Gentleman has taken on board some of the comments and concerns that have been expressed by the Carers Association. I have the honour of holding office within it in the branch that is local to me. Demographic trends show clearly that the elderly population is increasing rapidly while the proportion of those who are available to care for the elderly is declining.
Another factor is the trend of Government Departments to pursue polices that are designed to attract women into the work force. I hope that the White Paper will contain a package of care for informal carers that takes into account their loss of earnings and career opportunities as well as the need for a wide range of support services, including short and long-term respite care.
62 I call upon the Government to show their good faith by implementing in full the Disabled Persons (Services, Consultation and Representation) Act 1986, which among other things provides for local authorities to take the needs of the carer into account when making assessments. If the Government were to provide the resources to enable local government to carry out its duties under the 1986 Act, I would have rather more confidence in assurances that adequate resources will be provided for whatever the White Paper may contain.
If the Government were to accept the premise that care in the community is not a cheap option and commit themselves to providing sufficient funds, they might find an improvement in the popularity of the Conservative party among the electorate. A MORI poll, which was published in Reader's Digest under the heading "Britain, a Caring Society", shows that on average people are prepared to add £2.28 to their individual tax bill to support disadvantaged groups. In the order of priority it was those groups in need of community care that appeared at the top of the list.
Community care should not be left to charity. It is one of the rights that is part of being born into a privileged and civilised society.
§ 6.5 pm
§ Mr. David Atkinson (Bournemouth, East)
I welcome the Government's response to the Griffiths report as, I believe, do all the organisations which are involved in the caring services, even including, perhaps, the British Medical Association.
My right hon. and learned Friend the Secretary of State is right to reaffirm the principle of community care and to seek to build on what has been achieved already which has been considerable during the past 10 years. There has been a 40 per cent. increase in resources in both health and social services for community care. That it is no mean achievement and the Government deserve full credit for bringing it about. The increase in benefits for supporting people in private residential homes increased from £10 million a year in 1979 to no less than £878 million last year. That is remarkable.
It is vital that the rate of increase be maintained, for three good reasons. First, we must ensure that the Griffiths recommendations are properly implemented by the new community care authorities. Secondly, we must be able to cope with the increasing number of elderly people, about which we are increasingly being warned. We are told that the problem will hit the country generally, but we in my constituency have more experience than most of accommodating an elderly population, and I think that we do so quite successfully. Thirdly, I believe that there is a serious underestimate of the numbers of the mentally ill who are in need of care. Their numbers will increase in the years to come as a result of the breakdown of family life and of marriage. The trends are upwards. There are also the consequences of an inability to cope with the technological changes that are taking place, which will undoubtedly continue in future. All of us have met such people in our surgeries and have done our best to help them.
In passing the buck of community care to social service authorities we must ensure that they will have enough bucks to do the job. The Dorset authority is concerned because neither it nor the Government have undertaken 63 any accurate quantification of demand and cost. The authority feels that there will be a shortfall and it looks to the White Paper for reassurance. It is concerned especially, as I am, that social security payments to people in the community for board and lodging have not kept pace with the increase in the cost of living.
From the representations that I continue to receive from members of Dorset Association for Sheltered Homes, who I believe undertake one of the most valuable and underrated forms of community care in offering hostel and sheltered lodging for the mentally ill and those who would otherwise be homeless, it would appear that current payments no longer meet the cost of living, especially as the maximum rate for hostels has been pegged since 1986. I do not see how such establishments can be expected to survive much longer on that basis. I must warn my hon. Friend the Under-Secretary that unless the private and voluntary sectors that are involved in community care are financially viable, far from filling the greatly enhanced role that is expected of them, as recommended by the Griffiths report, they will contract and the recommendations set out in the report will not succeed.
It is right, however, that the social service authorities should be the new community care authoritie s. Having chaired a social services area committee, I believe that county councillors, who are in close partnership with their officers and with local carers, are in a unique position to identify local needs and to initiate new ideas. Why cannot those who represent areas that are covered by neighbourhood watch schemes ascertain what can be done to extend the security aspects of the schemes to include care?
A widespread complaint that I receive from carers is that there is insufficient information about the care services that are available. Perhaps county councillors can ensure that sufficient information is available.
The new community care authorities will have some extremely challenging decisions to make, not least the future of local residential homes. As my right hon. and learned Friend the Secretary of State has emphasised, and as my hon. and learned Friend the Minister said when he opened the debate, the authorities will have new roles as enablers and funders of care, for which they will have a budget, rather than being mere providers of social and residential care.
This policy, however, must be phased over years. The sudden announcement of a proposed closure of a residential home without any immediate apparent alternative would not encourage public support for community care. It would have a devastating effect on the residents in the home, who had expected to live out their remaining years in what had become for them their one and only home with their fellow residents and the staff, who had become to them their family. There is such a case in my constituency with the recommended closure of the Henley Court home. The residents—my constituents—are understandably concerned and confused about what will happen to them, but no one in authority can yet tell them what their future will be. Elderly people, for whom the local authority has undertaken to care, cannot be treated in that way.
The same principle should apply to the proposed closure of a residential home as that which the 64 Government rightly insist should apply to the closure of mental hospitals—that is, that a clear plan for suitable alternative provision for the residents must accompany any plan for closure. All the residents should be kept together if that is possible, and if it is their wish. My hon. Friend the Member for Bournemouth, West (Mr. Butterfill), whose constituency also faces the closure of the Labourne House home, has asked to be associated with the concerns that I have expressed.
As social service authorities become the enablers of care, there will be a wider interest in residential and nursing care opportunities outside their own areas, but I question whether there is an adequate centralised source of information available. I commend to my hon. Friend the Minister the Elderly Accommodation Council, a charity for which I act as honorary adviser, without an interest. It has computerised information on most of the residential and nursing homes and sheltered housing throughout the country and provides a unique placement service for carers.
There remains considerable scope in the private sector for better inspection and monitoring of residential and nursing homes, notwithstanding the improvements that the Government have introduced during recent years, and which both the Griffiths and Wagner reports recommend-ed. I fear that frail, elderly and confused people may be regarded as a soft touch by unscrupulous and insensitive carers, who provide services devoid of any quality and imagination. They must be snuffed out.
I wish to confine my remaining remarks to the care of the mentally ill, in which I take a personal interest as parliamentary consultant to the National Schizophrenia Fellowship. As many hon. Members are aware, that organisation is composed of the relatives and friends of sufferers. They are the real community carers, who work without pay, support, training or holidays, and often for a lifetime. In many ways, they are more expert than the experts in dealing with schizophrenia because they must live with what is happening on the ground. They did much to campaign for the Griffiths review, and they are delighted with the concept of the comprehensive care package as outlined by my hon. Friend the Minister in his statement on 13 July. However, they remain concerned at the rising percentage of readmissions, which suggests a lack of social support for those who have stayed in hospital for less than six months. Of the 26,000 people diagnosed as suffering from schizophrenia in 1986, 24,000 left hospital after a stay of less than six months. As most of those are not covered by section 117 of the Mental Health Act 1983, many experience squalor, misery and neglect, which in turn leads to crime and suicide.
My private Member's Bill dealing with schizophrenia after-care was especially directed at those people. It is still before the House, and it seeks to disapply the after-care of schizophrenics from current legislation concerned with the mentally ill, and to provide a package of measures exclusively for those people, so that following discharge they do not slip through the net of community care. I urge my hon. and learned Friend the Minister to ensure that his individually tailored care programmes for those discharged will include all that my Bill proposes.
§ Mr. Frank Field (Birkenhead)
I think that this is the first time that I have followed a speech of the hon. Member for Bournemouth, East (Mr. Atkinson). I was somewhat confused when listening to him because he suggested that out of the proposals would come a community care authority. My criticism is that while that name may be used, in reality there will be no such body emerging from the proposals that the Government put before the House prior to the Summer recess.
Like the hon. Member for Eastleigh (Sir D. Price), I am pleased that the matter is being debated prior to the publication of the White Paper because the Government might listen to what we say today. The hon. Gentleman was right to remind the House that the Government are now a thinking and listening Government, but my old gran used to say that the proof of the pudding was in the eating. We shall await the White Paper to determine whether there has been any change in substance.
The hon. Member for Eastleigh made a powerful and important speech. He probably knows more about this topic than any other hon. Member in the Chamber. He said that it was unlikely that there would be a community care authority—not for the reasons that I shall give, but because most care takes place in the family, unnoticed unrecorded and unaided. I hope that the new caring, thinking Government will, before they produce the White Paper, dwell on that point and come up with some concrete proposals which, although they will not cost a great deal of money, will mean a great deal to those who care for others in the community.
It is an interesting point that when Ministers come to the Dispatch Box they talk about the wonderful "job" that carers do; they do not talk about an "activity" or a "pastime". Most of us understand the meaning of "job". It is work and employment. Yet for all the reasons given by my hon. Friend the Member for Livingston (Mr. Cook), the Government treat it as far from a job. When carers cease their caring activities they are not eligible for any benefits in their own rights, yet the provision of benefit is important to them. They face real difficulty re-entering the labour market, so I hope that the White Paper will cover training schemes for some of the younger carers who wish to re-enter the labour market when those for whom they care have died. They should also be eligible for unemployment benefit. Those would be two small but important reforms, which should be announced in the White Paper if we are really serious about changing the status of carers.
I am facing the difficulty faced by all my hon. Friends when we have to follow the opening speeches of my hon. Friend the Member for Livingston. Indeed, while sitting here today I thought of a reason why I should not vote for him in the shadow Cabinet elections—although I assure him that I will not follow that through. There is real difficulty following him because, on the terms of the motion before us, he has actually completed the debate. Perhaps we should be big enough to say that the debate is over, that we await the Government's response, and all go home. I do not intend to cover the ground covered by my hon. Friend, but shall take the debate a step further.
The Government say that their proposals are the Griffiths proposals, but, as my hon. Friend clearly said, they are not. I therefore fear that there will be the opposite in community care to that which the Government say they 66 want from their health proposals, which is money following the patients. If the Government go down the road announced by the Secretary of State, the opposite will be the case and a major opportunity will be lost. It is one reason why I disagree with the hon. Member for Bournemouth, East. If there were to be a community care agency, the Government would be radical and brave and bring together all the functions of the different statutory authorities, whether the local authority, the family practitioner committee, social services, education or housing, and put them into one health and community care authority.
Indeed, we could go one stage further—as the hon. Member for Eastleigh has done in private conversation, which I am sure he will not mind me putting on the record —and that would be to put such a body in charge of the whole budget. The reason that the manager, or whatever he will be called, will not be able to deliver on the care package referred to by the hon. Member for Bournemouth, East is that he will have to deal with all those different authorities.
We know perfectly well who will win. I want reforms that will deliver to the consumer. It is political consumerism that will dominate the next decade and the decade after that. Unfortunately, the Government's proposals are backward looking, backing the producer and those with vested interests. Many hon. Members with constituents with an interest in receiving a necessary package of care will find that their needs take second place to those of the producer.
§ Mr. Morgan
I want to confirm what my hon. Friend has said about the package of care that should be produced by the combined resources of the health authority and the local social services department. It was drawn to my attention last night that in Cardiff, following the withdrawal of the community evening nursing service, there has already, pre-Griffiths, been a deterioration. One elderly person, a stroke victim, has had his community evening nursing service withdrawn. Therefore, he has to be put to bed by the afternoon nursing service at 4 pm arid does not get up until 19 hours later. He is mildly incontinent and, since the withdrawal of the community evening service, he has developed pressure sores which a re turning into septicaemia. He will probably have to spend the rest of his life in hospital, costing the state a great deal more. That appears to be care in the community, Tory vintage 1989. That is not good enough.
§ Mr. Field
No, it is not. If the Government were serious about delivering the community care that the consumers —the people in need of care and the carers—need, the package that we are discussing today would be very different.
Let me make three suggestions to the Government. If they wanted to modify their proposals now and make sure that the money follows the patient rather than vice versa, those three suggestions would find a prominent place in the White Paper.
First, as we know that our constituents would lose out against the producers of the different services, it is crucial that each year part of the budget of those statutory authorities becomes footloose so that workers in hospitals can fulfil part of their contract working in the community.
67 No amount of saying that community nursing is needed will deliver community nursing if people are trapped, via their contracts, into working in hospitals.
Secondly, while many people in need of care and those caring for them will be grateful not to have choices and to have delivered what the social services deliver to them, many others—a growing proportion—want a crucial say in the care that they get. If the Government do not want to turn the world upside down, they should be saying that part of the budget—an increasing part of the budget, if that is what consumers want—should be given to those who need care, or who care, in the form of vouchers. In that way they will be able to have more home helps or more community nurses and rather less institutional care. I fear that the institutions have vested interests and that they will deliver packages suitable to them, which may or may not be suitable to their constituents.
Thirdly, the Government should look carefully at one of their reforms about which they have forgotten and build up the side of community care which gives money to our constituents who need care and who are caring. If I were to ask hon. Members whether they knew what the independent living fund was, most would have only a vague recollection of having discussed it at some time. I shall give way to any hon. Members who can tell me how many of their constituents draw help from the independent living fund. None of my constituents do, but I hope to put that right shortly. Yet that Government initiative allows those who need to buy in care to do so, whether it costs as little as £2 a week or as much as hundreds upon hundreds of pounds a week.
If we were serious about a consumer-led community care policy, the Government would remove that benefit from the Official Secrets Act. Will the Minister give an undertaking tonight that some forms will be printed about that benefit and that they will be made available in post offices, citizens' advice bureaux, social security offices and general practitioners' waiting rooms? Hon. Members might even be given a few as well. The Minister should then say that that will be the development of the future rather than the forgotten benefit that the Government announced because they were so embarrassed about what they were doing to disabled people in the change to income support in 1968. That should become the flagship of the future development of community care. Rather than being covered by the Official Secrets Act, that benefit should play an increasing part. Many of our constituents would benefit enormously from receiving such a benefit.
Let me give one example of what that benefit meant to a family in Wigan where the mother, because of her age, is finding it increasingly difficult to remember what is going on. Her daughters sleep with her during the week, but, because of the independent living fund, they are relieved of that responsibility at the weekend. Neighbours are paid —not a fantastic amount—to look after that lady, a resident in their road. The mother has dignity because she is paying for that care rather than putting on her neighbours. That makes a great difference to her and to her daughters and it makes a great difference to her neighbours and to the hospital services which would otherwise have to look after that lady across the river in Wigan.
68 I understand why the Government have made the change from an open-gate system whereby anybody who is eligible for income support can pick up income support and go into residential care. However, until my hon. Friend the Member for Livingston spoke, I did not understand just how clever the Government would be in ensuring that the total budget does not go to the community.
For all its faults, the old system had one wonderful advantage, which was apparent to me from my surgeries, as I am sure it was to Conservative Members. In the absence of an adequate inspection system, daughters carried out inspections. I say daughters, because we are mostly dealing with old ladies being cared for by their daughters. Women live much longer than men. As my hon. Friend the Member for Livingston said, for all sorts of reasons it is women who have taken the lead role.
Because the money follows the old ladies, as soon as a daughter finds that a home is inferior, she works like billy-o to find another. Entry to that home was open because its owner knew that the money was coming from social security with the mother. However, I fear that, even if all the money goes to the social services departments, they will offer a list from which to select a home. We would then have the problem that residents of council accommodation experience when they want to move and the authorities ask what is wrong with where they are living since all sorts of other people are living there and why should they be so fussy about it. Once the bureaucrats take hold, the freedom to choose is lost.
I hope that I have effectively put across two points. We have a thinking, listening Government. The hon. Member for Eastleigh suggested that we cut the cant about worrying about the carer and start delivering something. The first easy move would be to ensure that when a carer ceases his work of caring he should have a full national insurance record for a pension and unemployment pay.
Secondly, younger carers will have difficulty returning to the labour market. Let us make sure that we have training schemes to help them to do so. Many of them have missed 25 years of their career fulfilling their caring functions.
Thirdly, as I said in an intervention in the speech of my hon. Friend the Member for Livingston, I am struck by the number of carers who, six months after the death of the person for whom they cared, have a breakdown. It is at that point that the strain breaks through. We should be thinking not only about preventing such breakdowns but about providing adequate support if we fail to do so.
Despite all the Government's talk about making the consumer the sovereign body, I fear that in the hotch-potch of proposals which they call the Griffiths proposals, the consumer will be in the back seat rather than in the driving seat.
I advanced three proposals: first, that new contracts be issued to allow flexible staffing among the different bodies providing care; secondly, that vouchers be introduced to enable people to choose the statutory body from which they wished to buy their care; and, thirdly, that the Government put behind them their secrecy about the independent living fund and proclaim that, above all their other proposals, as the flagship for community care in the future.
§ Mr. Nicholas Winterton (Macclesfield)
The hon. Member for Birkenhead (Mr. Field) has done the House a great service with his contribution. The hon. Gentleman chairs the Select Committee on Social Services with considerable knowledge, compassion and commitment, and I believe that my hon. Friend the Under-Secretary of State is now on an upward learning curve for the purposes of his inquiries into the independent living fund. Perhaps, however, the hon. Gentleman was a little unfair to my hon. Friend in that that aspect is not really his responsibility, but that of my hon. Friend the Minister for Social Security.
Let me endorse the articulate message in the hon. Gentleman's plea about provision for carers. There is too much cant in this place about the importance of carers, and all too infrequently do we do anything about them. As my hon. Friend the Member for Eastleigh (Sir D. Price) said, without carers tens of thousands of people would have to be found places in residential accommodation or hospitals. Carers are therefore of paramount importance, and the White Paper on the Griffiths report should clearly devote much more thought to provision for them.
I thank my hon. Friend the Under-Secretary for visiting my constituency during the recess, thereby honouring a commitment that he made in the House in July. When he came to Macclesfield in September, he paid quite a lengthy visit to the Parkside hospital for the mentally ill, and also visited the young persons' unit in Macclesfield, which caters for young people with emotional and behavioural disorders. I know that he was immensely impressed not only with the facilities at Parkside hospital and the level of care provided by its staff, but with the tremendous work undertaken by Dr. Peter Wells at the young persons' unit, which is probably more successful than any comparable unit in the country. I hope that my hon. Friend will ensure —as far as his responsibilities enable him to do—that the environment and level of care at Parkside hospital are not reduced when parts of the hospital are sold off for development, and that Dr. Wells's team can continue to provide fantastic rehabilitation, care and treatment for young people.
I also endorse what has been said by almost every speaker: that although we may be disappointed that there is not yet a White Paper on Griffiths, the Government are genuinely listening to the debate and will take on board the extremely good points that so many hon. Members have made. Those who have spoken so far are immensely knowledgeable: far from voicing instinctive views on issues about which they, in isolation, hold fervent beliefs, they have advanced informed proposals based on a knowledge resulting from lengthy involvement in community care.
How right my hon. Friend the Member for Eastleigh was to quote Lord Kelvin, who said that anyone who spoke of such matters should have the facts at his fingertips. Let me pick up the point made so articulately by my hon. Friend the Member for Bournemouth, East (Mr. Atkinson), who does a great deal of work for the National Schizophrenia Fellowship—with which I, too, work closely. He mentioned the 1986 figures relating to the admission of schizophrenics to mental hospitals in England, which totalled over 25,000. That figure is not plucked from the clouds; it matches the figures for 1984 and 1985, and thus presents a typical picture.
70 My hon. Friend did not, however, mention what. I consider a particularly important figure. In 1986, 90 per cent. of schizophrenics admitted to mental hospitals were being readmitted after having a relapse. I mention that because it is clear to me that long-stay psychiatric hospitals are needed—in the right environment, of course, and rehabilitated and brought up to date. It would be a tragedy for us to allow such wonderful sites, some lying within communities, to be destroyed. My hon. Friend the Minister has seen Parkside hospital in my constituency: it has a superb environment of peace and tranquillity, and it is vital that that facility—as well as the building itself, and the superb staff who go with it—should continue in being.
I warmly welcome much of the Griffiths report; I think it important, however, to put down a number of priority markers. In respect of assessment, I consider it vital to draw up a national scale of need so that even standards may be ensured throughout the country. That has been suggested by many organizations—not only those in the public sector, but private-sector bodies such as the National Care Homes Association. I welcome the Government's determination to achieve better standards. Surely, however, what is needed is a national registration and inspection system—independent of any one sector and covering all residential homes—so that the independent private sector is not monitored only by the public sector, and the public sector does not in turn neglect its own house, which would be very dangerous.
As for resources and funding, it is essential—as the hon. Member for Livingston (Mr. Cook) said—that the care element of cost should be ring-fenced to prevent diversion of money for other purposes. If the Government are serious about Griffiths, they must ensure that that is done; otherwise people will suspect—rightly or wrongly—that they are trying to get away with making the change on the cheap. That would be a tragedy.
As my hon. Friend the Member for Eastleigh said, the Social Services Select Committee carried out an in-depth inquiry into community care for the mentally ill and mentally handicapped, the report of which was published in the 1984–85 Session. The Committee concluded that, far from requiring less money, community care would inevitably require much more. Those involved in community care would have total trust in the steps proposed by the Government if they admitted that fact and were prepared to provide specific grants.
There must be comprehensive and continuous monitoring of the performance of local authority social service departments, and local authorities would be happy for that to happen. The only way to ensure the delivery of the community care we need is to achieve proper standards throughout the country through an effective permanent body answerable to the Secretary of State, and I support those who recommend the establishment of a national community care agency or other body. Local authorities and the independent private sector would like to see such a body set up.
I have been committed for many years to the area of provision for the mentally ill. The Minister recognises that the mentally ill represent a special problem and I am aware of the representations that he has received from, among others, SANE and the National Schizophrenia Fellowship. Those representations have led him to take a close interest in what is happening to the mentally ill.
I am pleased that the Government have issued instructions to the effect that no patient shall be discharged 71 from a psychiatric hospital unless there is proper care and accommodation at an alternative site or within the community. I am pleased that the Minister stressed the importance of the fact that no mental hospital, such as Parkside, shall be closed until there is adequate provision, accommodation and care elsewhere in the community for the patients of that hospital.
Having taken an active interest in matters relating to the mentally ill for 10 or more years, my sincere view is that there is and always will be a need for long-stay hospital care, particularly for the more acute patients suffering from schizophrenia. I hope that when any application is made to the Department by a health authority for the closure of a hospital for development or other purposes —remembering how valuable such sites are and how badly many regional and district health authorities require the money—the Minister will consider the request carefully to ensure that the standard of care and extent of provision for the mentally ill is in no way eroded by the closure. Indeed, he should feel sure that the standard of care and provision of accommodation for the mentally ill will be enhanced by such a closure and the money that might result from the development of the site.
I hope that the Minister, who now has a considerable understanding of the difficulties facing the mentally ill, will have taken on board the points that I and others have made and will ensure that when the White Paper is published, the mentally ill are, and will continue to be, a priority.
§ Mrs. Gwyneth Dunwoody (Crewe and Nantwich)
A frightening aspect of the Government's attitude towards health policy is their ability to take what is basically an important idea—such as care in the community—and turn it into something different, like an organist who takes the song of a nightingale and turns it into the sound of a cash register.
It is clear from the debate that hon. Members on both sides fear what is really behind the Government's attitude towards care in the community. Indeed, already in the constituencies we can see some of the practical effects of the changes that have occurred. The hon. Member for Macclesfield (Mr. Winterton) spoke of mental health care. He and I, with the hon. Member for Congleton (Mrs. Winterton), have a common interest in a large hospital at Cranwich, where we see in microcosm many difficulties that I foresee arising from the attitude to Griffiths that is being taken by the Government.
Cranwich hospital is a large Victorian establishment spread over many acres. A great deal of money had to be spent on it, and despite some valiant efforts to update it, much remained to be done. The agreement among the patients and their families towards changes that would result in many of the patients going out into the community, and otherwise being cared for in changed circumstances, was obtained on the undertaking that, within the grounds of that enormous Victorian hospital, special village accommodation would be built.
During the time I have been in the constituency, a different picture has emerged. There have been constant moves towards developing the acreage for housing and pressure to move the patients out of the existing buildings 72 and into the community, in some cases irrespective of the quality of care that they would receive. There has been no agreement to develop the plans for building a village for the patients requiring to remain within the mental health care services.
That is the reality of the situation, and when we consider the steps that the Government propose, we are frightened about what will happen next. Having listened carefully to the Minister's remarks, I heard not one clear undertaking that he is prepared to go in for the necessary training, to provide the money that is needed and to find ways to seek suitable management facilities for the changes that he is proposing. There is no clear evidence that local authorities will be able to provide the increasing sums that will have to be made available to make those changes work. The difficulties that are now emerging in my constituency and elsewhere will lead to continuing problems.
There have been cases of purpose-built old people's homes run by county authorities closing because the authorities can no longer support them and provide the level of care that is necessary. Those authorities have been forced, despite tremendous local opposition, to close homes. I have in mind an elderly persons' home on a site which only one political party tried to retain on that site. The only alternative to what the local authority proposed was the suggestion that the home be put into a private trust.
Let us consider what happens when NHS or social service facilities are hived off into private trusts, and I speak with authority on this issue because what I have described has happened more than once. In the first instance, people are happy to give a commitment to retain a facility that they appreciate is essential. They then spend great effort and time trying to raise the necessary money. Within a short while, however, it becomes clear to them that the constant raising of cash to support such voluntary organisations makes it impossible for the facility to continue on a professional basis, as was the case when the state supported it.
I foresee, at a time when a determined attempt is taking place at what I can only call the balkanisation of the NHS, nothing but total chaos ahead, especially if the Government's proposals go ahead in parallel with hospitals being allowed to opt out and GPs having constantly to worry about the extent of their budgets and the facilities they can provide.
Who will police adequately the standards of care of the elderly in the community? Elderly folk in my constituency are already being told that there is no NHS facility available for them and that they will have to go into the private sector. When they are offered the list of homes to which they can go, they immediately find a discrepancy between the money available from social security and the fees that have to be paid in the private sector. Some people can absorb that difference, but many people cannot, and it represents an increasing difficulty.
What does one say to a state registered nurse, herself desperately trying to keep a private unit viable, when she says, "I have an elderly gentleman, who is doubly incontinent and who has had a stroke. He has been with me for three years, but I cannot get an increase from the state for his support and he has no living relatives or any assets to find the difference between my fees and the amount of money paid for his care"? If the Minister can give me the answer I shall be comforted. I assure him that 73 that example demonstrates that the onus of care for an elderly person has been moved from the state and from those who should decide on the right level of care to the management of a private home, which is then faced with almost insuperable difficulties. In the future that problem will become more and more common. Those nursing homes will be forced to ask whether they should evict those who have been in their care and then worry about whether they will be picked up from the street outside or whether they should continue on a declining path until they reach the point when they can no longer produce viable profits to meet the economic demands necessary to keep those homes going.
This is the Government who insisted on the explosion of private health care and it is they who are closing down the local authority alternatives. For purely dogmatic reasons, they are making it impossible for many elderly people who want to remain within the state system to find a suitable place.
Time and again today the case has been made for real support for the carer. There is little reality in the glossy phrases used to praise those carers. We know that they find no joy in their situation even though they dearly love their relatives. When they are utterly exhausted they find it impossible to see that justice will be done to them under the existing system.
During my time in the House my grandmother, who was 98 and nearing the end of her life, was nursed at home. To give her 24-hour cover took five adults and three of them had medical or paramedical qualifications. I assure the Minister that few people in my constituency could offer that degree of cover. To say to a women of 5ft 1 in that for all but one hour a day she must nurse an 18 stone, 6ft 1 in man who has suffered a massive stroke is to condemn that woman to an insufferable life. Such care diminishes the quality of the carer's existence and frequently leads to a deterioration in the health and future life of that carer.
The paper before us gives no clear future plan for how health care will be delivered to the elderly or, especially, to the mentally ill. It is a glossy representation of an empty policy. If the Minister is sincere he will say not just that the Government are prepared to commit resources to meet the changes that they are suggesting, but that they are prepared to give training and to decide who will do the assessments and how they will be carried out. Above all, in the interim, the Government should make it clear that they will give sufficient resources to local authorities so that there is an alternative to private care. In that way, those who do not want to go out to the private sector can remain within local authority care in the places that they know and where they are and will be happy.
I can tell the House what happens when one decants, to use the fashionable phrase, a number of elderly people from a home where they have lived for a long time. They save one a lot of bother; most of them die. That is not my answer to health care, and nor should it be the Minister's.
§ Mr. John Marshall (Hendon, South)
In the summer when I spoke in the debate on community care, I did so for precisely three minutes. I cannot promise to be equally brief tonight, but I am conscious of Mr. Speaker's advice that we should speak for no more than 10 minutes.
Since the summer I have spoken to a number of people who have been the victims of the community care policies 74 followed until now. I refer to the relatives and parents of schizophrenics who suffer twice over—they suffer the agony of the illness of their sons, daughters or relatives and they also suffer a sense of dissatisfaction at the hopelessness of the treatment offered to their relatives.
Common characteristics have been apparent in the cases that have been brought to my attention. The first is the acute difficulty that relatives encounter in having their sons or daughters sectioned. In one case, the parents told me that their son had been in and out of a mental hospital six times, but he had been sectioned only once. Another set of parents told me that their daughter had been in and out of mental hospitals for 10 years, but never once had she been sectioned. In another case a father walked into my surgery in an extremely distressed state. His son had walked out of Napsbury hospital, gone to the local building society, taken out all his money and travelled to Marseilles. The father had been asked to go to collect him or to ensure that he could be brought home.
There is no doubt that until the 1950s we were far too willing to force people to go into mental hospitals. I believe, however, that we have moved from one extreme to the other and that now it is too difficult for someone to be detained compulsorily. When someone deals with an individual suffering from a physical illness he knows that that person will agree to accept a course of treatment. We must accept, however, that in mental illness the course of medication may be unpleasant and that the victim may be unwilling to suffer it until the end of the course. When such people move into the community for care they are often unwilling to continue with their medication. Frequently that medication is unpleasant, frequently the patient feels cured and, frequently, there is inadequate supervision.
Many patients discharged from mental hospitals are not registered with general practitioners. Who will supervise them? There is an inadequate supply of community psychiatric nurses and as a result many such patients go unsupervised. The parent of a schizophrenic wrote to me saying, "Brian never turned up for treatment and no one ensured that he did.". No one took any action to ensure that that individual who needed treatment undertook it. As a result of such neglect, a number of those who have been let out and who have been recommended for care in the community turn to violence.
In one case I was told that Dr. X struck off the individual because of his bad behaviour and that no other practice was willing to accept him. That man has no solicitor either. The solicitor refused to act for him because of his impossible behaviour. The man has no home. The hostel that the probation officer found for him has banned him because of his aggressive and impossible behaviour. It is ironic that some of those who sleep rough are people who have been sent into the community for care, but they end up with no doctor, no solicitor and no home. As a result, a number of such individuals turn to crime.
It was written of one of my constituents:He returned to live in Barnet. Since then he has been arrested by the local police a few times. They have called the crisis team who do nothing. Next morning Hendon Magistrates Court do nothing.It is a supreme irony that we are closing mental hospitals, which are expert at treating the mentally ill, and we are building additional prisons where some of the mentally ill who have been sent into the community for care in the community will end up. Many of those who are sent to receive so-called care in the community indulge in 75 anti-social behaviour. I remember a deputation coming to one of my surgeries and asking for help. They lived in a block of council flats where one of their neighbours was a discharged patient receiving care in the community. He played his hi-fi system for 16 hours a day starting at 8 o'clock at night. That was not care in the community for him and he was causing many problems for his neighbours.
It was written of another of my constituents:His neighbours live in fear of his verbal abuse, loud music played day and night and at times violent behaviour.All that is a denial of care in the community. It is good neither for the victims nor their neighbours and relatives.
Of course, these stories cover only a minority of schizophrenics. Many will recover, but I am referring to the hard core who will always be vulnerable. For them a mental hospital is a genuine asylum; a refuge for them, their relatives and the rest of society. We must accept a greater role for compulsory care. There must be a greater willingness to issue a section notice. For those who are going into the community, a community treatment order would ensure that the treatment that they were meant to receive was undertaken. Surely it is nonsense that people should be encouraged to go into the community to receive treatment and then not receive adequate treatment with no one to check up and find out what is going wrong. Only if that happens will the individual have a chance of recovering. Everyone who leaves a mental hospital must be registered with a general practitioner before entering the community. What hope has he if he goes into the community without being registered with a GP?
Finally, Dr. Tannoch was surely right to say that there should be a computerised list of all those who have been released into the community so that people can check up every six months that they are receiving the care and attention they deserve. Every six months we all receive a notice from our dentist requesting the pleasure of our company. We do not always reply saying we would like the pleasure of his. If a dentist can check up on us, there is no reason why we cannot check that those who are meant to receive care in the community are receiving it.
It is clear that the quality of care in the community could and should be improved. There is inadequate supervision and support, and too few psychiatric nurses, day centres and occupational therapists. As mental hospitals close, they generate substantial capital receipts. If a business man was relocating production in a new factory, he would not wait until the existing factory was closed before he built a new one. The National Health Service financial rules which tell a health authority that it can invest the money only when the facility has been closed are wrong. I see no reason why health autorities should not be allowed to borrow on the strength that an asset is about to close and invest that money so that it can provide new and adequate facilities as soon as the hospital closes.
We must also look at the rest of the world. In Japan they compulsorily detain 250,000 patients. Italy passed a law saying that no one could be compulsorily detained, so instead they renamed them "hospital guests" and the effect is the same. We should not indulge in either extreme. We must recognise, first, that for some people there will be a constant need for long-term treatment in hospital; and, secondly, that care in the community cannot be care on the cheap, but must be seen as more effective care. It has not 76 always been seen as that, and it has not always been that, but that must be our goal. We must also remember that to have decent care in the community we need to have a strong economy, and I believe that this Government are more likely to provide it.
§ Mr. Deputy Speaker (Sir Paul Dean)
Order. I remind the House that the 10-minute limit on speeches is now in operation.
§ 7.5 pm
§ Mr. Gerald Bermingham (St. Helens, South)
When I read the letter dated 12 February 1988 from Sir Roy Griffiths to the then Secretary of State, paragraph 18 was of particular interest to me because in my constituency there is a very large mental hospital called Rainhill, which has existed for many years. When I first became a Member of Parliament, there were more than 1,000 patients. At present there are fewer than 500 patients there, which means that in the past six years at least 500 patients have been discharged into the community.
Paragraph 18 of the letter reads:Dominant in discusssions and visits was the question of the closure of the large mental hospitals.One sometimes gets the impression that some of these large mental hospitals are not being closed simply because they are large mental hosptials. I may be overtly suspicious by nature, but the fact that Rainhill is surrounded by some 200-plus acres of prime building land, may have something to do with the view taken by Rainhill hospital by those who run our health authorities. However, I do not have much time for health authorities whose prime object in life appears to be to dispose of large assets without providing alternative facilities in advance of the closure of the hospitals said to be out-of-date, as the hon. Member for Hendon, South (Mr. Marshall) rightly said.
Nor do I have much time for the assurances of Ministers, if my own experience at St. Helens is anything to go by. In St. Helens we are a bit short of beds for the elderly. I think that we have about 0.5 out of 10 instead of the 10 out of 10 needed to meet our requirements. A delegation of the community health council, councillors from all political parties and myself went to see the Minister with our all-party all-body agreement complain-ing about the closure of geriatric wards at Whiston hospital and the closure of other wards at another hospital so that those beds could pass into the private sector, with no replacement in the public sector. Several months later, as I had half expected, we heard that the Minister was not coming to our aid.
In my constituency, not only is a large mental hospital being run down but we face the reduction of public sector geriatric beds. We have also seen the steady development of the private sector and one understands that the private sector is developing in that area, as my hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody) said only a few moments ago and as I know from my own surgery last Saturday. An elderly couple came to see me saying, "Our brother-in-law is in an old people's home in the private sector. The fees are so much and the trouble is that the money that we get from the social security does not meet the fees. We are about to retire, and the shortfall that we have now carried for many months and years is £25 a week. We cannot afford £25 a week. We have run out of savings. He has terminal cancer and is dying. The doctors say, 'Don't move him,' so what shall we do?
77 What should we do? We are talking about human beings. The letter written on 12 February 1988 says that dominant in our thinking must be the need to protect people being released from long-stay hospitals. Paragraph 6.37 states:Those services must include the nomination of a care manager for each long stay patient discharged.When I go and talk to nurses and staff at Rainhill hospital—who have done a magnificent job over the years —and I ask where those patients have gone, they tell me to try the streets of Birkenhead and Liverpool, and a trip to the church there and to the old people's homes in Colwyn Bay. They are people who lived in that hospital for 30 years. Many of them have now gone to meet their maker. They have died because, as my hon. Friend the Member for Crewe and Nantwich said, everything they ever had was taken away from them. After 30 years in a mental hospital, it was their home, where they had their friends and their social life.
The hospital is not perfect. It is not wonderful. Conditions are sometimes not very good. Nevertheless, we take that all away from somebody aged 60 or 70 and tip them back into the community, but which community? The one whence they first came? It may well be that she got pregnant in 1928 and the easiest thing in the world was to put her into a mental hospital because that is what we did in those days. The Minister talks about care in the community. We tip them out. It is a death sentence. By all means let us have care in the community, but let us not mess about. Let us do it properly
As hon. Members on both sides of the House have said time and time again, care in the community costs. Let us have proper mental hospitals. As a practising lawyer, I declare an interest. I am fed up with going into prisons to see people who should be in mental hospitals. We are a modern society, but what do we do with people who are least able to defend themselves? It is not their fault that they are mentally sick, or mentally handicapped at birth, but it is our responsibility.
The hon. Member for Eastleigh (Sir D. Price) is quite right to refer back to the old Privy Council rules. Two hundred years ago we talked about village care, because the village and the community cared for the weakest among them.
When Griffiths comes to be enacted, we must be prepared to ring-fence and allocate the necessary money because local authorities such as mine, which has a large number of patients who are yet to be discharged, and which has nowhere else for them to go need it. Such patients have to stay in St. Helens. It is the only place they know. They were not born there, but we have a duty to them. We have to be given the facilities to build homes and to maintain them at standards people need.
As has been said, we need long-term hospitals. There is a desperate need for them because some patients need long-term treatment or they cannot be cured. In and out does not do them any good. The handicapped need care and support at all levels.
We must not pursue cheap and easy solutions. We have to invest in the future and build a structure that we can be proud of rather than the one we have at the moment, which we can only be ashamed of.
§ Mr. James Couchman (Gillingham)
As I am Parliamentary Private Secretary to my right hon. Friend the Secretary of State for Social Security, I shall obviously not comment about benefits or money during my speech on this important subject.
As I am a former chairman of a health authority and a social services committee, I have long been involved with care in the community. I have been worried by the ambivalence of responsibility of the Health Service and social services departments, particularly in relation to the mentally ill and the mentally handicapped.
Like my hon. Friends the Members for Eastleigh (Sir D. Price) and for Macclesfield (Mr. Winterton), I was a member of the Select Committee which, in 1983 and 1984, considered care in the community in an in-depth study which ranged from here to San Francisco. During our deliberations and investigations we saw the worst and the best of care for the mentally ill and mentally handicapped.
In America, we saw the ghastly St. Elizabeth's hospital outside Washington, and an extremely old-fashioned place in Nebraska where the mentally handicapped were cared for. We saw soup kitchens in San Francisco and the hostels where people who had been de-institutionalised were decanted, in that wealthy city.
One of the best programmes that we saw during the year was for mentally handicapped people in Nebraska. There was a most progressive scheme for the mentally handicapped within a factory which gives them real work to do, and makes one-to-one care in residential homes available. That was available and being made good use of, and people with severe handicaps were able to have a worthwhile quality of life in the community.
During our deliberations, my hon. Friend the Member for Macclesfield obviously came to certain conclusions which he has expressed in the House on a number of occasions. It is clear that he would prefer to keep long-stay hospitals—the old asylums. In many respects, I sympathise with his worry about people being decanted into the community for whom the community can never be a real place to live. Among the mentally handicapped it is quite clear that the autistic represent a special problem. It is most unlikely that they will ever easily be able to live in the community, and I speak with knowledge on this, as I have an autistic brother-in-law.
I welcome my hon. Friend's statement on 12 July—particularly his assurances with regard to the closures of long-stay hospitals. He said that they will not be closed and that patients will not be discharged into the community until proper and appropriate social and medical provision has been made. That is most important. If we have learnt nothing else over the past 20 years, since the de-institutionalisation and decanting of schizophrenics at the onset of neuroleptic drug treatment, we must have learnt that these people must be cared for properly in the community.
Closure of long-stay hospitals is not easy. I remember the early meetings about closing down Darenth park hospital in north Kent some 12 to 14 years ago. Last year, the last patient left Darenth park. That is the sort of time scale that we are talking about. The creation and provision of appropriate residential and day care facilities for people takes a great deal of providing. We must ensure that those facilities presently available on long-stay hospital sites are bettered when people are moved into the community.
79 I welcome the fact that local authorities have been given a lead role by my right hon. Friend in seeking to clear the line of responsibility. I ask what powers they will have to ensure co-operation on a number of fronts by health authorities. I am particularly worried about the level of expertise within local authority social services depart-ments. Seebohm took us away from specialisation towards generalised social working practice. It is only quite recently that some social services departments have decided that they should go in, once again, for specialised workers, particularly in the areas of mental illness and handicap.
I ask my hon. Friend to tell us what discussions he has had with the Association of Directors of Social Services and the Central Council for the Education and Training of Social Workers, with regard to the future lead role that local authorities will have.
We have heard much about the training of social workers and that is going to be terribly important. It will also be important to train at lower levels than social worker level. Too often, people in the care of the social services departments are being looked after by very young, inexperienced people. Training is essential at that level too. I am not certain that the present qualifications for social workers will fit the bill of my hon. Friend's vision of community care in the future. Perhaps my hon. Friend will say what further thoughts he has had over the summer about these important matters.
My hon. Friend the Member for Macclesfield stressed the number of schizophrenics who return to hospital. Over a period of years, they do so on a revolving door basis. Will that revolving door remain when the present responsibilities are removed? Will local authorities be able to readmit schizophrenics to a hospital appropriate to their needs?
I add my reservations about local authorities being their own monitoring and inspecting agencies for the provision of that important care facility, which will affect many people. An extension of the hospital advisory service may be appropriate, but there must be a national scheme to monitor local authority provision of care.
§ Mr. Dafydd Wigley (Caernarfon)
A debate on community care is of much importance to use in Wales, not only because of the Welsh contribution to the development of the welfare state by people such as Lloyd George, Aneurin Bevan, Jim Griffiths and, more recently, the all-Wales initiative for mentally handicapped people, but because of our interest in the community dimension —the emphasis and value placed on the community.
I could not disagree more with the Prime Minister when she suggested that people do not live in a community, that there is no such thing as society, that we are all individuals and families. I strongly believe that the community is a vital dimension. It has been relevant to the sharing of problems in Wales, which is probably part of our Christian-Socialist tradition.
The sharing of a burden, whether it be problems faced by physically disabled people, the aged and infirm or mentally handicapped or mentally ill people, cannot be left only to friends and families; if it is, the burden falls 80 unfairly, usually on those least equipped to cope and often particularly on women. What about those who have no friends or families to help them?
I recall several cases that have come to my attention recently, such as the wheelchair-bound person in his mid-forties who had a degenerative condition. He lived by himself and had to contemplate going to bed at 5 pm because he could not get assistance to set his splints. The only possibility was to get a volunteer to help, which underlines the need for more community-based nursing services.
Another young man, in his forties, had a history of psychiatric illness. He lived in a flat in the community and discharged his social worker. He died from an overdose of drugs and his body was not found for three weeks, which underlines the need to consider who is in charge of such cases and who is the defined key worker.
A case came to my attention in the past week of a mother of a handicapped child whose husband had died. She had had her invalid care allowance withdrawn at a time when she most needed that support. In another case, a stroke victim's wife dearly wanted to have him home, but he was too heavy for her to handle, she was elderly and the domiciliary nursing services insufficient to enable him to live the remainder of his days at home. Those are only examples, but hon. Members can give further examples to show why we must pay greater attention to community care and ensure that facilities are available for those who need them.
In the past, perhaps too much emphasis has been placed on institutional care. I understand the points made by hon. Members about discharging people from long-stay hospitals without adequate services being provided, but in this debate I would rather concentrate on how we can ensure that people are not drawn into long-stay institutional care in the first place. We must ensure that that is done coherently, by providing the community-based services that are so needed. If those services were available, many people would not need to be incarcerated in institutional care. Inevitably, some people will always need such care, but many do not, which is why we must pay greater attention to community services.
In recent years there has been massive growth in private residential care. The explosion in demand has been created partly by the Government, through the social security system that they have adopted. The system has directed elderly people to residential care irrespective of whether it is what they want or best need.
It is undoubtedly right that Parliament should be considering the workings of the system to ensure three things: first, the flexible provision of care based on individual need with emphasis, where possible, on enabling the individual to choose; to facilitate continued independent living as a valid choice; and to provide proper services that make that practical, irrespective of the individual's ability to pay or otherwise.
Secondly, we must use public resources in the most effective manner to provide the most appropriate care for the individual in the light of the individual's needs. In many cases it may be less expensive to provide domiciliary services—home help, community nursing and domiciliary physiotherapy—than to provide a place in a private residential home. The decision must be taken, however, not because it is cheaper to do that but because it is right for the individual to make that choice.
81 Thirdly, we should be considering the efficient working of the system to allow effective assessment of individual need, the right of advocacy to enable the individual's wishes to be articulated and respected, the general availability of community-based services in all areas and the resources to ensure that there is growth in services in line with the inevitable demographic growth in demand. We need a certainty of provision to give clients the confidence, the security, that they are entitled to expect.
Those are the essentials of any new system towards which we may be moving and are the criteria by which we should be judging the Government's response to not only the Griffiths report but the Audit Commission report, the Firth report and the Wagner report in particular. I hope that today's debate will take those other reports into account.
The Government took much time to respond to the Griffiths report and many questions remain unanswered. I should like to highlight a number of the uncertainties, while welcoming any genuine move to greater personal choice and freedom and greater emphasis on community-based care. The first and overwhelming worry is finance. Many hon. Members have spoken of the need to ensure that the finance given to local authorities is ring-fenced and used for its intended purposes. The Government intend to approach the new policy from a cash-limited perspective, and I am worried about that. The present system is demand-led. People who cannot afford to pay for residential care can get help from the social security system without any cash limit on the global sums that are available, although there may be cash limits on individual sums. The Secretary of State suggested that the new system may be constrained and defined by a budgeted pool of money. On 12 July, he said:decisions on resources can only be made in the public expenditure round".—[Official Report, 12 July 1989; Vol. 156, c. 985.]That is a warning of things to come. From time to time, shortages of finance will make life extremely difficult for people.
The second worry is that the social worker's role may be compromised. He will have to have one eye on limited resources and the other on how to get the best deal for the client. Social services departments will be in the difficult position of trying adequately to monitor the services they provide while having to take cash-limited decisions.
For that reason we must consider the minimum general standards that are acceptable. We must assess not only quality but quantity. Paragraph 6.2 of the Griffiths report is right:Local authority social services authorities should be responsible for identifying people with community care needs in their area.It should be a statutory responsibility for local authorities to know what the needs are and to ensure that they respond to them.
I am worried also about the possible effect of privatisation and competition on the delivery of services. I wonder whether voluntary bodies such as Crossroads will be a part of such a competitive world. That has not been their nature in the past. People involved in them may not want to be a part of a fundamentally different approach.
I should like to draw the Minister's attention to the issue of uncertainty. What will be the position of a widow who sells her home and goes into a private residential home? She may get £30,000 from the sale of her home, which can keep her going for two or three years, but then 82 she drops below the threshold. At present, she would automatically get help from the welfare state. Under the new proposals, presumably her position will have to be assessed. When that happens, is she likely to be returned to the community? If so, she will think twice about going into a residential home in the first place. She may find herself in some uncertainty.
In summary, we need a system that identifies and assesses all the needs. We need an individual and personal plan tailored to the needs of each person. We need a generality of services in all areas, rural and urban, and an independent monitoring system. We need finance that is ring-fenced and not cash-limited. We need a crash recruitment and training programme for people to carry out this vital work.
§ Mr. David Nicholson (Taunton)
As both my parents, who are in their mid-70s but fortunately are in good health, live on the island of Ynys Môn next to the constituency of the hon. Member for Caernarfon (Mr. Wigley), I listened to his speech with not entirely uninterested pleasure.
I agree with the point made by my hon. Friend the Member for Eastleigh (Sir D. Price), and reiterated by hon. Members on both sides of the House, that these services need to be resourced more generously and effectively. I listened with considerable interest to the points made about carers, especially those made by the hon. Member for Birkenhead (Mr. Field), who speaks with such authority on these matters. Like my hon. Friends, I will be interested to hear the Government's response to those points and I will study the hon. Gentleman's speech in detail.
There are two large hospitals in my constituency—Tone Vale hospital, which deals with the mentally ill, and Sandhill Park hospital, which deals with the mentally handicapped. We all appreciate the extremes to which placements in long-stay institutions can go. In recent months, we have seen on television the dreadful scenes on the Greek island of Leros. As some Opposition Members have said, in previous years pregnant single young women and other members of families whose relatives have got tired of them were easily shunted into these establish-ments. I agree with my hon. Friend the Member for Macclesfield (Mr. Winterton) that we must be careful how we go about closing such hospitals.
I welcome the commitment made by my right hon. and learned Friend the Secretary of State, which was reiterated at least three times on 12 July—in columns 985 and 990 of Hansard and in reply to me in column 991 of Hansard— that he will ensure that NHS hospitals do not discharge patients until he is satisfied that proper arrangements have been made. I welcome my right hon. and learned Friend's assurances thatMy social services inspectorate will have an increased ability to step in and inquire into the delivery of services. I shall have increased powers to order reports and inquiries." —[Official Report, 12 July 1989; Vol. 156, c. 987.]My local health authority, Somerset, is making progress and its detailed proposals will be produced shortly. I welcome the inter-agency work between the Health Service, social services and the voluntary and private sectors, which are all playing their part. In the north of the county—you will have some knowledge of this, Mr. Deputy Speaker, since it affects services in your 83 constituency—the number of beds in the Mendip hospital has been reduced to 124, with considerable development of community services. Those of us in the remainder of the county will need to monitor these developments closely. Tone Vale hospital in my constituency has reduced the number of beds from 504 to 420 since 1987. Day services have increased by 40 per cent. and community mental health teams have become operational. The intention is to continue to develop community-based services throughout the county, with the objective of closing the large mental hospitals.
I have had the opportunity of studying the excellently terse briefing from the National Schizophrenia Fellowship. My hon. Friend the Member for Macclesfield has referred to the impressive and startling 1986 admissions figure—90 per cent. of schizophrenic admissions were readmissions after relapse. The National Schizophrenia Fellowship points out that withholding ministerial approval for hospital closures shuts the stable door after the horse has bolted, because most beds have gone. There should be recognition of that point. The fellowship referred also to the reply given to my hon. Friend the Member for Cheltenham (Mr. Irving) on 13 April 1988 in column 174 of Hansard on the number of community psychiatric nurses in 1986. Eight district health authorities had none, 17 had five or fewer and the best staffed, Leicestershire, had 43. That echoes the point that we constantly make about the NHS—there are considerable variations in services, equipment and efficiency.
Indeed, the December 1986 report by the Audit Commission states:A very uneven pattern of local authority services has developed, with the care that people receive as much dependent upon where they live as on what they need. In well over half of local authorities, expenditure on services for mentally ill people is less than £1 per head of population even though one in ten people each year consult their general practitioner about a mental health problem, and one in a hundred is referred to the specialist psychiatric services".This problem was brought home to me by a visit that I had two weeks ago from a constituent. The notes that she gave me should sound a note of caution when authorities consider putting patients into the community without ensuring that services are provided for them. I realise however that, on the whole, the position in my area is satisfactory. This lady's son was a former schizophrenic patient of Rampton secure hospital. Four years ago, he returned to Tone Vale hospital and two years ago was released. His parents bought him a house, and this was successful in giving him independence. All seemed to go well. He went back to Tone Vale once or twice for a few days and then returned home.
About five weeks before my constituent came to see me, he announced to his parents that as he was so well he had decided to "cut back" his medication—this often happens in these cases. A few days later, he went off in his car to the south-east. When he returned, his parents noted that he was "much more disturbed". They advised him to go into hospital as an informal patient, but he would not. The parents asked the medical services at Tone Vale to assess whether he needed to be sectioned and were asked three times by the GP, "Do you want him sectioned?" The 84 decision whether he should be taken in was, apparently, to be left to them. Surely that is a decision for experts in the medical and social services.
A few days afterwards, the son smashed the windows in the house, strewed pills everywhere, upset furniture, left and drove away to another part of the south-east, where he severely upset other relatives and appeared to be extremely disturbed. At this stage, in the car were a crossbow, three arrows and two Stanley knives. I should point out that his mother emphasised to me that he had never actually been violent, but there was an element of threat there. She continued:We feel that nobody listens to parents. We see tell-tale signs of illness and feel that if our son had been persuaded into hospital three weeks ago he would certainly be more stable by now.He was eventually taken into hospital and I believe that he is going to be sectioned.
Such loss of control over a former patient was, first, bad for the patient because he will require far more care and will face more difficulties in future as a result. Secondly, it was bad for the parents who had been through an extremely tense time because of the pressures placed on them. Thirdly, particularly given the weird weapons in the car, it was a considerable source of worry, provoked alarm and could have posed a threat to the wider community if anything had gone wrong.
The Minister must take care to ensure that our resources are properly used. We must ensure that these services are properly resourced. I agree with my hon. Friend the Member for Hendon, South (Mr. Marshall) that, despite our current difficulties, only a Conservative Government can ensure the economic success which will achieve that goal. The Labour party talk about resources, but when it was in power it failed dismally to provide those resources. I welcome the debate which has now started and the forthcoming appearance of the White Paper so that those resources can be properly and efficiently used in our society.
§ Mr. William McKelvey (Kilmarnock and Loudoun)
Thank you, Mr. Deputy Speaker, for giving me the opportunity once again to speak in the debate about the Griffiths report. If my memory serves me right, this is the third recent occasion on which the House has had the opportunity to discuss the report. The previous debates were initiated by the Opposition. I have to register my disappointment, as I did in the two earlier debates, that the Government are dragging their heels in implementing some aspects of this report.
We have not agreed to everything outlined by Griffiths, but I certainly think that we can all agree on our disappointment that there is no real movement by the Government. Some progress has been made, inasmuch as the Government have at last initiated the debate on the Griffiths report. However, it is disappointing that no White Paper is available for this debate. I was naive enough to go to the Vote Office to ask for a copy of the White Paper in case it contained points which I might want to raise in this debate.
I wish to cover two aspects which I have covered before. I do not want to be repetitive, but they are extremely important. Several Members have talked about the growth industry. Certainly in my area of Ayrshire the fastest growth industry involves residential homes. It has slowed 85 down somewhat because the last anticipated increase in fees was not given by the Government. Nevertheless, it has not reached saturation point as yet and the plans show that some people still think that it would be profitable to have a residential home in Ayrshire. The fact that it has a coastline and many large, comfortable, mansion-type houses which are easily adapted to residential homes probably means that it lends itself to such speculation.
A great many of the residential homes are extremely well run, although some of them could, perhaps, be better run. It is for that reason that many hon. Members on both sides of the House have clearly shown that, if we are to proceed evenly with an expansion and extension of residential homes for the elderly in the private and public sectors, we must have an inspectorate that watches both sectors from the constitutional point of view. It would be impossible and hopeless to have an inspectorate for each sector.
When I raised this matter in an Adjournment debate, a Scottish Office Minister assured me that he would respond by letter to the point I raised. Sadly, I am still waiting for his response.
The argument remains one which we should underline. It is not sufficient to leave local authorities to look after or inspect their own establishments. There are weaknesses in doing that, one of which I have outlined previously: people in homes are often afraid to complain because they fear that they may be turned out. If that happened they would not have sufficient finances to go to a private home and would face extreme difficulties.
Another difficulty is the plight of the carer. We have heard pious statements from hon. Members from all parties. I am as guilty as anyone of making pious statements about the role of the carer. However, no Members of Parliament could fail to be moved by the horror stories about the plight of individual carers which are told to them by constituents who come to their surgeries. As a young Member of Parliament 10 years ago, I used to he extremely concerned when I heard of cases and I sometimes thought that they lacked credibility. I could not believe that people were in positions where everything seemed to be so desperately wrong for them. Since then I have been to see some of these people and I have in my constituency an active carer who knows the business inside out. As a result of my experiences and much of the guidance that she has given me, I believe that there is an indisputable case for carers' problems to be scrutinised by the House in this debate.
We have raised with consecutive Ministers the problems faced by carers, particularly those related to their financial means. If an invalid care allowance is paid only to those who deserve to be paid, surely there is a case to be made that invalid care allowance should be a free benefit and not one which is calculated together with other benefits and, therefore, at the end of the day, proves to be worthless.
Elisabeth Reid, who is my mentor in these matters and works for carers, dropped me a note. Her lines are cryptic. She says:Willie, you'd better read again the 'Griffiths Report'. It frightens me! It is yet another money-shuffling exercise between Departments.The Minister said nothing today to dispel that woman's fears. It does appear to be a money-shuffling exercise. The. Minister could have said from the Dispatch Box—perhaps if will be said in the wind-up speech—that however we 86 move about the resources and finances for caring in the community, if we give local authorities the responsibility to look after and link together all the strands of caring in the community, we must protect that money by ring fencing. If not, it will be used for all other sorts of, perhaps good, causes. The money must be protected so that the local authority is accountable to its people. This will show that the Government actually mean what they say and ensure that the money so desperately needed in those areas is actually put up front.
In an intervention, my hon. Friend the Member for Monklands, West (Mr. Clarke) made a pertinent point about the disabled. It is all right to make fine statements and it is good for the Government if a couple of lines appear in the press, but it does not bear examination if money is not put in with the legislation as it is passed. Certainly, we ask for a guarantee that the money will not only be put up front and be adequate, but will be ring fenced so that it is protected.
The Griffiths report calls for the setting up of a system of registration and inspection of residential homes. It should be underlined that, whether in the public or private sector, the rules and regulations must be the same. One matter that concerns me about the Griffiths report is that it advocates the establishment of a new group of community carers to assist the professional care workers with tasks such as shopping and home help duties. The voluntary sector plays an important part in that. I hope that the Government are not attempting to direct young people into this work—young people who, through no fault of their own, cannot find work, especially in areas such as the one I represent. We do not want some form of home help on the cheap, and we will not tolerate it. I should be interested to hear the Minister's comments on my suspicions.
The thrust of the Griffiths report is the strengthening of community care and the extension of consumer choice, which we all welcome. Of course we want elderly people to have some choice. My hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody) spoke eloquently and passionately of the carer—usually the nearest available woman relative—who is forced into looking after that relative by her conscience and by circumstances. I have learnt through talking to such people that when the person to whom they have devoted many years of their life dies, their first feeling is one of overwhelming relief because at last they can enjoy some release from unrelenting drudgery. That feeling is immediately followed by an overwhelming sense of grief, and of guilt for having felt the relief in the first place.
If we are to have a system for looking after people in the community and if the onus continues to be thrust on those who want to keep their relatives at home, we cannot solve that problem by pious remarks in the House. The real solution lies in an established plan backed up with the necessary finance. The Government managed to pull £1 billion out of the air to sort out some of the anomalies of the poll tax in England. Let us hope that they will pull out whatever amount is needed to solve the problems of those who need care and of those who care for them in the community.
§ Mr. Andrew Mitchell (Gedling)
I have no doubt that this is one of the most important debates in which it has been my good fortune to be called to speak, because it is about one of our most challenging social issues. As a civilised society, we have an opportunity to put in place a structure that can make a real contribution and a tremendous difference to the quality of life of some of our most vulnerable constituents. We all know that too often there is confusion between all the different agencies and bodies involved, and that confusion allows people to slip quietly through the net.
The Audit Commission's report of 1986 has already been mentioned tonight, but it sums up the problems that existed and still exist in the service—problems of continual waste of scarce resources, with care and support either lacking entirely or being inappropriate to the needs of some of the most disadvantaged people in society as well as to those of the relatives who look after them. I shall return to those relatives later in my speech.
The Health Service already owes a great debt to Sir Roy Griffiths for his earlier managerial reforms, which I had the interesting experience of seeing implemented when I was a member of a health authority. His second major report confirmed that too often good intention is married to a system that is ill-suited to delivering community care and insufficiently accountable. That is no reflection on the professionals who deliver the care: they are saddled with the system. Nor is it to suggest that there has been anything other than a steep increase in the necessary funding. In recent years there has been a real increase of almost 40 per cent. in expenditure by both the NHS on community-based services and by local authorities on personal social services.
I hope that the White Paper will contain a blueprint for excellent management of community care coupled with clear accountability for its delivery on the ground and efficiency in that delivery. I am sure that there will be a role for the Audit Commission in that, too.
We need to be absolutely clear about several key principles and requirements. The first is that community care must be based on a clear response to the needs of the individual and their family. The individual and their family must have a major say in how to meet those needs. There must be clear and open regulation of standards and quality of care, and I look forward to an enhancement of the role of the social services inspectorate. While a national policy sets the framework, it is for one single and local entity to take responsibility for the services available and for their delivery.
Within that framework, we must make a real contribution to improving the ability of those who wish to continue to live in their own homes and environment to do so. That is partly a housing matter, of course. We need continued growth in the development of sheltered homes for the elderly and of bought sheltered housing, such as Bridge Housing in my constituency, which can offer great security to older people without penalising their capital. This is not a trouble-free area, as escalating service charges have shown, but I know that my hon. Friend the Member for Fylde (Mr. Jack) has done much good work in this area by promoting a proper code of practice.
88 However, if we are to enable elderly people to continue to live in their own homes, we must enable more assistance to be given to those who provide the lion's share of community care—friends, family and those who live next door. Too often, the presence of a willing daughter or daughter-in-law is taken for granted instead of being built on and supported as a cornerstone of the needs of the family. We especially need to support and strengthen the ability to cope of the vast army of volunteers who shoulder these responsibilities.
Supporting people in their own homes is not only a policy which runs with the grain of basic human desires: it is also in tune with demographic realities. By the year 2000 there will be over 70 per cent. more people aged 85 and over than there are today. All too frequently in the past, elderly people have been shoved in a home because the local authority lacked the money to provide the help that they needed to continue living in their own homes
If responsibility for all this is to rest with one authority, as it must, the Government are right to reach the conclusion that local authorities are best placed to take on that responsibility. That presents an opportunity and a challenge. We must ensure that the cry of inadequate funding is not allowed as a camouflage for failure; but equally, inadequate resources would merely saddle the local authority with the problem rather than giving them the means with which to effect a solution.
I recently re-read the report to his committee of the director of social services in Nottinghamshire on the Secretary of State's statement to this House on 12 July. His report is constructive and encouraging and, I am sure, bodes well for the future.
If local authorities are to succeed, it is essential that they see themselves principally as enablers, not as providers of local services, because, just as it is a caricature of local authority homes to say that they are bureaucratic and unfeeling places for elderly people, so it is a caricature of private sector homes to see them as motivated by profit and greed. I believe that local authorities will genuinely find their tasks easier to fulfil if they set out whenever possible to be enablers of community care and not to take upon themselves its provision. The safeguards which they and we require rest in effective monitoring and regulation, and I endorse everything said on both sides of the House about the need for a separate national body to carry that out.
There is inevitably concern about the interface between health authorities and social services, the break point of responsibility for someone who is released from full-time medical care. At present, the customer is presented with a kaleidoscope of people who may be responsible for helping them: the GP, the hospital, the social services, community services or the voluntary sector. We must ensure that there are clear lines of responsibility. Naturally an effective partnership between all those groups is essential, but a clear lead must be given.
I hope that the White Paper will properly recognise the role of the GP in determining the right level of community care in conjunction with the local authority. After all, the GP receives the notes when a patient is discharged from hospital. He is involved in the service of health as well as of ill health. We need to enshrine the role of the GP.
The parish priest can make a contribution as the eyes and ears of the community as he goes about his pastoral work. He should see it as part of his role to act as an early-warning system for developing difficulties; many 89 priests already do. I pay tribute to the Bishop of Southwell, who has recognised the role that his priests can play in this important area.
The support services for people who can continue in their own homes include a galaxy of helpers—home helps, meals on wheels, day care services, twilight nursing and incontinence services; but we often hear stories of district nurses ending up having to do the shopping. Do we not need to build up a much simpler "general health" or sitting service by which a low-skilled level of assistance can be supplied? It could be less specialised and provided at much lower cost but could give the extra specific support that is needed by the client.
I have talked mainly about the care of the elderly, but I should like to end by speaking about the care of the mentally ill. Some of the speeches in the debate have demonstrated a misunderstanding of our policy of closing some of the dreadful old asylums and placing people back in the community. All too often there is genuine public misunderstanding about that matter. Some people believe that community care is no care at all and is a cheap option, but nothing could be further from the truth.
In saying that, I draw on the experience of the health authority in Nottingham which looks after many of my constituents. It is closing some of the appalling Victorian asylums. The policy is working extremely well, precisely because the funding is matched to the speed at which the asylums are being emptied. The policy is not a cheap option. I continually follow up cases where it looks as though someone has fallen through the net. I regularly discover, as the authority confirms again and again, that it has lost track of none of the people who moved into the community.
What some hon. Members have been describing is the failure of the working of the policy but not failure of the policy itself. That is extremely important. Twelve people who were in Saxondale have gone to Broomhill house in Gedling village in my constituency. It is well staffed and people have been given what they never had in the asylums —a much better quality of life. There is day care support nearby and the policy is working extremely well. Hon. Members should go to see some of these old asylums. If they do, they will realise that people have a much better quality of life outside if they are properly supervised and looked after.
I am not, of course, being disparaging in any way about the service provided by the people who work in the old asylums. I spent half a day in an asylum in my constituency and I have no doubt that many of the people who work there are saints who must deal every day with appallingly difficult human problems. The money obtained from selling such dreadful places will provide the health care that my constituents want in the next decade and into the next century. The release of those assets will make possible far better, modern, up-to-date and brand new health facilities.
I welcome the Government's response to Griffiths and I welcome this important debate. I look forward with keen interest to the White Paper.
§ 8.2 pm
§ Rev. Martin Smyth (Belfast, South)
I am privileged to follow the hon. Member for Gedling (Mr. Mitchell) and should like to take up two of the points that he made. I am not convinced by his deduction about policy and systems.
90 In audits we discover that it is the systems that are important, not the working of them. I am not sure that the policy has always been right. I confirm the hon. Gentleman's view about the use of parish ministers. However, I regret to say that regularly the professionals in the field look askance at the clergyman who appears to interfere in the care of their patients or clients.
I wish to underscore the hon. Gentleman's point about the place of the doctor. In the suggestions before us the doctor is expected to communicate with the social services about his patients who require back-up help. He is not required to do so, but it is important to place a requirement upon the doctor because doctors are regularly out of touch even with what is available from the social services.
I was fascinated by the comment of the hon. Member for Kilmarnock and Loudoun (Mr. McKelvey), who said that he had taken part in three debates on the Griffiths report. Many hon. Members also comment on the fact that we have still not seen a White Paper. I was reminded of the old cinema serials which have been replaced by the modern soap operas. We watched them and were left in suspense, but the next part of the serial left us wondering why we bothered to turn on at all. I trust that when we receive the White Paper there will be no sense of disillusionment but that the input from the debates will have sharpened the Government's perspective. The Government have heard hon. Members from all parts of the House expressing deep concern and raising specific issues.
The Minister spoke about being in Coventry during the recent social services conference. I am sure that, like me, he discovered there a deep concern about the avalanche of legislation that is coming forth and about the lack of facilities and training. The Children Bill will come on line and we will have a Bill based on Griffiths. There is a deep feeling, especially among social service workers, that they are not adequately prepared to meet such change at such a rate. Specific attention should be given to the training and preparation of workers in the field.
The pressure of time makes it impossible to cover everything but I suggest that the implementation of the Disabled Persons (Services, Consultation and Representation) Act 1986 and the corresponding Northern Ireland legislation of 1988 would go a long way towards meeting a great many needs. I call into question the Government's intention about the implementation of the various sections. For example, at a recent meeting of the all-party disablement group, the Minister with responsibility for social services and the disabled was committed to the concept of advocacy. Will the Government fully examine the implications of sections 1, 2 and 3 as a means of putting that concept into practice? How do they propose to make the services fully accountable to disabled people? How do they propose to consult disabled people about their community care needs? Will the Department fully examine those three sections as a means of ensuring user accountability?
At that meeting, it appeared that section 7, which deals with people's discharge from hospital was to be the next priority for implementation. However, the Secretary of State later contradicted that, because in parliamentary answers the Government have said that they are still in discussions with local authority associations on section 7. Is there a time limit on those discussions about the. implementing of the sections? If they were implemented, 91 we would be on the road to providing the framework of legislation that is required to provide care in the community.
We must be careful when talking about resources. Most areas appeared satisfied to a degree, but when one probes one discovers problems. One area is convinced that it has a fine spectrum, and has its workers out in the field. However, it sees difficulties because of the soaring cost of land and property.
When I challenged the need for an inspectorate, especially in Northern Ireland, I had a telephone call from a constituent of my right hon. Friend the Member for Lagan Valley (Mr. Molyneaux) who asked me to visit his home. It was a small residential home with six people and it was ideal. It was not a large mansion-type institution but a home. That man said to me, "I am not by any means wealthy, but I am comfortable and I take £140 a week from the residents."
We must be careful about setting national standards for finance which will raise the overall cost and not meet the real needs of the people. We must examine more carefully the place and role of an inspectorate for national standards of care so that local authorities or whoever is charged with this will not just minimise it to suit its own position. However, if we consulted people, particularly the carers and those requiring care, we would discover that they would benefit by more personalised care in their own homes rather than being in a home or an institution.
Has enough attention been given, difficult though it might be to implement, to giving respite care not in an institution but in the residence of the person in need? All of us know that, especially as people get older, they can be disoriented if taken out of their familiar surroundings. It would be better for them to have respite care in their homes. In that context, I pay tribute to the work of bodies such as Extra Care, which have gone a long way to providing personal attention for those who desperately require it.
How will the Government's stated intention of shifting the financial aspects of community care in nursing and residential homes from the social security budget to the health budget work? What will be the effect on residents and nurses in private homes? In that context, I support the cry for ring fencing. We were recently informed of a local authority that used the funds that it had been given to implement an aspect of the Griffiths report to pay the wages of the road menders. I do not doubt that the roads might need mending, and that those involved might need payment, but that was not a proper use of the funds.
§ Mr. Peter Thurnham (Bolton, North-East)
I welcome the debate. I am sorry that Labour Members were hoping to have the White Paper before it, because I see it as proof of a listening Government who want to hear, on the first day back,. what we would like to see in the White Paper. This is an excellent opportunity for us to tell the Government what we want to see in it.
I agree with all my colleagues who have said that we need substantially more resources. I call on my hon. Friend the Minister not to be shy, and to ask the Treasury for more money, because more money will be needed. The issue is how that money should be used, and there are 92 differences about that between the Government and the Opposition. The hon. Member for Livingston (Mr. Cook) implied that if there were a Labour Government and all local authorities were Labour, everything would be simple and fine, but we know that if we go down that road we shall have the IMF cuts. We should remember the remark attributed to a former head of the DHSS: "If you are not confused about community care, it shows that you are not thinking clearly."
To understand why that is so, one should read the excellent speech of my hon. Friend the Member for Eastleigh (Sir D. Price), who went to the heart of the matter when he said that the essential ingredient is love by carers. We have over 1 million unpaid carers, two thirds of whom have no help at all, and whose care could be valued at upwards of £10 billion if it were paid for. They are dealing with a vast bureaucracy of social service workers —200,000 of them—who are mostly paid to do a job from nine to five and whose motives, by definition, are different from those of the unpaid carers who are doing this work through love. Here we have the essence of the conflict and of the Government's difficulty in seeing that the extra money that is desperately needed is channelled to help carers and the disabled rather than to swell this vast army of workers.
I shall illustrate the point with two examples that have recently come to my attention. Today I received a letter dated 9 October from the Association of Directors of Social Services, briefing hon. Members on today's debate. The letter says about assessment:The way in which individual consumers are assessed for community care services is crucial. We seek clarification on the statutory requirements being placed on local authorities … It is important, for example to know whether a consumer who has been assessed as requiring certain services has a legal entitlement to expect all those services within a given timescale. If so, how will the funding be guaranteed? If not, what right of appeal should exist?That is how the bureaucracy looks on the responsibilities placed on it by statute.
Let us compare that with the remarks made by Mrs. Pat Nelson at a Barnardo's conference held in Liverpool a few weeks ago, which was attended by Princess Diana. Mrs. Nelson is the mother of six, three natural children and three adopted Down's children. She said that the children had taught her what is really important in life:Courage, honesty, truth, love and relationships. They don't ask 'What is your job? How much do you earn? What sort of car do you drive?' They ask 'Can I trust you? Do you love me? Will you always be there for me?That can be compared with the example from the Association of Directors of Social Services. There is a complete difference in approach and the Government's difficulty is in seeing that the extra resources that are needed go where they are needed and not just into the bureaucracy.
I am a supporter of the Disabled Persons (Services, Consultation and Representation) Act 1986, which is a great credit to the hon. Member for Monklands, West (Mr. Clarke). That Act will not go away, and it is disappointing that the Government have not given it a better response. However, I see the difficulty, because the Act is oriented on local authorities. This is where we must pin down the local authorities' responsibilities. We must ring-fence the local authorities—although not by money because it is a mistake to think that if local authorities are given more money, that means more care—so that we can give them the extra responsibilities that are called for in the 93 1986 Act without leaving them with responsibility for additional provision. The money should be directed more to voluntary groups such as Crossroads.
More money is needed. My hon. Friend the Minister should not be shy. He should tell the Treasury that £10 billion is needed. It will not be needed straight away, because there will have to be time to pin down local authorities to what they should be doing rather than what they are pretending to be doing. Time is needed to build up voluntary groups such as Crossroads. I am pleased that Crossroads now has agreement to start a scheme in Bolton because it provides care for 12,000 people and has another 7,000 on its waiting lists. There are tens of thousands more in areas where it does not have schemes. Such groups should be built up and that is where the money should go.
I am a voluntary unpaid carer and chairman of the newly formed Conservative Disability Group. I hope that the White Paper will allow more money and more say for the voluntary groups and, immediately, more respite care for the carers.
§ Mr. David Hinchliffe (Wakefield)
It is clear from the debate that, although the Government have been in power for 10 years, they have yet to develop a coherent strategy in their policy on community care, particularly in relation to the elderly. In everything that they do, the Government have only one policy—economic. That is the kernel of tonight's debate. What has been said tonight, and what has been said before in the Chamber about community care, shows that the Government see their central challenge as how to free the market, in domiciliary as well as residential care, and how to reduce the huge £1 billion per annum Exchequer grant going to private residential care.
I shall break the consensus that we have had so far and comment on a fundamental question that has not yet been touched on. It is whether the market is an effective mechanism to determine the nature and quality of care for vulnerable and dependent people. That question must be addressed in the context of the way in which the Government intend to respond to the Griffiths' report. No one doubts that the private sector has played a part in the provision of care, and will continue to do so under every Government. Is it appropriate that the bulk of care provision should be left to the private sector, with the market determining the extent, the nature and, especially, the models of care that are being provided? I do not think it is.
A number of problems stem from the market approach and I shall mention some of them. First, it is an unplanned approach. We have heard much about the way in which services have or have not developed over the past 10 years, but I am concerned especially about the clear bias towards institutional care, with that being the easiest area for the market to develop.
The Government have landed themselves with a huge albatross around their neck, that of institutional care. They have allowed that sector to develop because they have institutional tunnel vision. They should be aware of the huge range of options that is available. Residential care, however, is the easiest option when one has in mind a business proposition.
Business expansion means institutional expansion. We increasingly see intimate private homes being taken over and expanded so that they become large institutions.
94 During the summer recess I had a dialogue with the developers of a new home in the Wakefield area, which will provide 100 beds. When I was starting in social work 20 years ago, I remember that from Government level efforts were made to establish a policy that homes should be built with no more than 35 beds. It is unfortunate that we seem to be returning to the huge impersonal institution. The owner of the home in the Wakefield area told me by letter that a home that provided 100 beds provided economies of scale. In other words, the owners can make more money if they pack in more people. That worries me.
Leaving care to the market means insecurity in many instances for those who need to be in private homes. The inability to meet fees has been mentioned several times by hon. Members on both sides of the House, and we are all aware that many of our constituents are having to top up and subsidise within their families because income support is inadequate. I shall introduce tomorrow a ten-minute Bill designed to give people security when they are in homes. That form of security is not provided now.
With the development of the private sector, we talk about community care, and the Minister has talked about putting money into that form of care. He has spoken of a hundredfold increase in provision, but he was referring to institutional care. The community care that he is talking about often means that people have to move into communities that are many miles from where they have lived hitherto. That is not community care.
The Minister told us that he seeks the advice of the House on what should be included in the White Paper, but the Government have had more than 10 years to develop a policy. Instead of developing one, they have been content to sit back and allow to develop what can be described only as a shambles of a policy of community care. Any action that the Government have proposed has been anchored to a free market ideology that prevents rather than facilitates the development of a wide range o f provision to meet the varying needs of the elderly.
I believe that the selfishness and greed engendered by 10 years of Conservative Government are rapidly coming to an end. We have on the horizon the likely election of a. radically different Government with a radically different philosophy, who will be seeking to develop markedly different policies from those which are now available under a Government tied to the market.
Central to the strategy of a Labour Government will be a major policy commitment that those who wish to remain in their own homes should be enabled to do so, even if that means enormous expense to support them and to support the carers who give up so much of their lives to ensure that others can remain in their own homes. In taking that course, carers face great difficulties. With such a policy, there will have to be the development of radically new models of care that do not stem from the institutional framework. We have been stuck with the institution because of the hangover of the Poor Law. We still have the mentality that prevailed those many years ago. We must bring it to an end and move in the direction that has been taken by many other countries. It has been decided elsewhere that there should be a move away from the idea that people should end their lives in an institution.
I look forward to the development of elderly person support units, which makes intensive efforts to ensure that the elderly remain, with support, in the community. The Labour party is advocating flexible home-care provision. It should be possible, if necessary, to support someone 95 intensively 24 hours a day, seven days a week and 365 days a year. That is reasonable and the option should be available if people prefer it.
Housing provision has been neglected as a result of the market being left to determine care. Many elderly people do not have the resources to purchase. This means that they cannot enter the private market and the private market has not developed strategies to care for those who are highly dependent. We must develop sheltered housing that enables those who are extremely dependent to be looked after in their own homes. They should be able to remain in their own environment. They should not have to be moved into impersonal institutionalised care. That must be a central plank of the policy commitment of the next Labour Government.
Above all, we need vision and commitment, but we also need planning. Thought must be given to the future. We cannot leave issues as serious as those that we are discussing to the whims of the profit and loss account, the market, or the speculator, but that is precisely what the Government have done with the support of £1 billion of public money each year.
We have had 10 years of bankrupt Tory ideology. That is the only way to describe the experience. Members of this place are only too well aware of the tragic cases with which they are confronted in their surgeries. My colleagues and I meet people who are facing appalling consequences. I look forward to the next few years. I believe that we shall see the election of a different Government who have a different strategy and philosophy from those which we have seen pursued by the present Administration. The next Labour Government will alter radically the provision that is made for the elderly and many other groups who are currently grossly neglected by the present Government.
§ Mr. Michael Irvine (Ipswich)
Two months ago in Ipswich, reductions were implemented in the amount of home help available for the elderly and disabled people. It was not that overall expenditure on the home help services was being cut; the problem was that the rapidly increasing demand for home help was putting severe pressure on even an increased budget. Part of the pressure was due to demographic reasons. We have seen an increase in the number of people living in Suffolk aged 75 years and over of nearly 60 per cent. during the past two years. That increase is set to continue.
An even more significant source of pressure stemmed from the expansion of home help services to provide personal care for the seriously disabled and for those recovering following hospital operations. As the National Health Service has become more efficient, as more operations are performed, and as people are discharged at an earlier stage following operations, there follows a massive increase in the burden on the home help services.
Home help that consists of shopping and cleaning may involve no more than three or four hours a week, but home help that involves intensive personal care of someone who has returned at an early stage after a hospital operation often involves five or 10 times that number of hours. That is a significant factor to be considered in the face of the increasing burden that is being placed on home help services.
96 The pressures are not set to diminish. Indeed, they are set to intensify. It is clear to me that significantly increased financial resources will be required to meet the pressures. I was glad to hear my hon. and learned Friend the Minister of State acknowledge that fact in his opening speech. I was glad also to hear that he has not closed his mind altogether to the ring fencing of the contribution from central Government. It is certainly the strongly held view of the Suffolk county council chairman of social services that ring fencing is a necessary and important safeguard.
However, increased resources and ring fencing by themselves will not be enough—every bit as important will be the effective and efficient administration of community care. Voluntary organisations make a magnificent contribution, but there is always the risk of lack of co-ordination with other groups and agencies. There is a need for permanent, specialist, high-quality administrative support to guide the voluntary groups and to make the maximum of their considerable efforts. We need co-ordination, accountability and clear lines of respon-sibility, and I am glad that the Government have accepted the recommendations of Sir Roy Griffiths.
It is important to recognise that a great deal more staff will be required to meet the additional demands and pressures of the next decade. I agree with paragraph 35 of Sir Roy's letter that accompanied his report, which said that there was a risk of over-elaboration, both of the professional input and of the amount of training required for such staff. As Sir Roy pointed out, many of the needs of the elderly and the disabled are for more practical help such as shopping, cooking, cleaning, and so on. It would be a waste of professional qualifications to overtrain people for that job. However, that does not mean that there should not be the most careful selection of those called upon to work as home helps.
The elderly, the disabled and the mentally infirm are vulnerable, and never more so than in respect of those who have access to their homes. The opportunities for theft, manipulation and the like are only too obvious, so those who help them in their homes must, above all, be honest, tactful, responsible and sympathetic. I am glad to say that, on the whole, standards are high, but there may be pressures on those standards in the coming decade because the very demography that is placing increasing strains on home help and other social services will be accompanied by trends in demography and social factors that will reduce the number of people available to carry out those services. There is a risk that the standards of honesty, tact, responsibility and sympathy might slip, and it is important that that is not allowed to happen.
I wish to touch on a theme mentioned by many hon. Members, which is the role of the carer at home. Family care and support is often the most effective and appreciated care of all. It is almost certainly the cheapest. In calling for improved and more plentiful community care, we must never forget the risk that when the state or a local authority takes responsibility, it might dull the sense of duty that every family should feel towards its elderly or less fortunate members. The state and the local authority can and should give support to those family carers, who bear a very heavy burden indeed and need respite and help. I agree with the wishes expressed by my hon. Friends the Members for Eastleigh (Sir D. Price) and for Macclesfield (Mr. Winterton) that, when the White Paper is published, proper account will be taken of that very important factor.
§ Mr. Tony Worthington (Clydebank and Milngavie)
In the short time available, I shall restrict my remarks to the issue of the mentally ill. I wish to draw attention to a statement made by the Secretary of State for Scotland:I propose to maintain the current arrangements which have generally worked well for sharing responsibility for services to the mentally ill between health and social work authorities."—[Official Report, 12 July 1989, Vol. 156, c. 534.]I simply do not understand where the Secretary of State gets his information from or how he can reach such a conclusion. The relationship between the social work and the health authorities in Scotland is quite disgraceful. For a long time I was involved with Strathclyde regional council and the linking with several health boards. Everyone in the social work authority saw as one of the areas of shame the total failure to develop adequate relationships with the health boards.
Scotland has twice as many in-patients in mental hospitals as the remainder of the United Kingdom. Throughout the whole of Scotland during 1987 only one local authority had a day centre for the mentally ill. There is no comprehension of the numbers of old people who are sent to prison; Scotland is only just beginning to count them. Scotland only received support financing in 1980, four years later than England and Wales. It was only in 1985 that support and joint financing were introduced to put Scotland on an equal footing with the remainder of the United Kingdom—10 wasted years after it had been introduced in England and Wales.
I regret to say that the Secretary of State for Scotland, unlike the Secretary of State for Wales, has failed to give any lead in that area. Once again, Scotland lags behind Wales, which has had a co-ordinated strategy for the mentally handicapped for the past 10 years and has now introduced a co-ordinated strategy for mental illness. Scotland has nothing like that. I do not know how the right hon. Gentleman can claim that the relationship between the social work and the health services is working well. In 1979–80, the very excellent report "Scottish Health Authorities Priorities for the Eighties"—SHAPE—iden-tified as category A priorities care of the elderly, the mentally ill and handicapped, physically handicapped and prevention and community nursing—all issues in the community care area.
Despite those category A priorities, at the end of that decade the proportion of expenditure on areas such as the mentally ill and handicapped had fallen—yet the Secretary of State says that it works well. The right hon. Gentleman played his part in producing the "Working for Patients" document, which achieved something quite remarkable —in its 100 pages it failed to mention mental illness. It takes a great deal of effort to write 100 pages on health and fail to mention mental illness. The numbers of the mentally ill are awesome—1 million people a year need some form of psychiatric care, and one person in eight will spend some time as an in-patient during his lifetime.
The White Paper is nothing but a cost-cutting exercise because it just deals with areas where a great deal of money is spent, such as acute care and drugs, and questions how that expenditure can be reduced. It does not address the Cinderella services such as mental illness and care of the elderly.
The White Paper is obsessed with increasing the number of a doctor's patients. I am reminded of a visit that I made during the recess to a hospital in my area and the 98 comments made there by mental health patients. One of them wrote to me saying that five years ago she found that getting a general practitioner to take her on to his list was a problem. That person said that she had since gathered information from other patients, one of whom was told, "I am not taking you. You will call me out at night." Another had to try three doctors, each of whom turned her down, before the fourth took her on his list. The letter went on:My own case was dramatic as a local doctor's receptionist accepted me and made an appointment for the end of the week. My hospital registrar then wrote to the GP telling him my history and on the Thursday I had a recorded delivery letter stating that a mistake had been made and the GP could not take me on. The appointment was therefore cancelled.That was before the "Working for Patients" document. I cannot see how we can have an adequate service that just needs smoothing.
We should point out to the rest of the United Kingdom that we had a Minister who was responsible for community care. The responsibility for health and social work was shared by the hon. Member for Stirling (Mr. Forsyth). However, he has now been given other duties saving endangered species.
We must stop the crass target-setting that is going on. Gartnavel hospital has 165 patients in long-term care. The target is for that to reach 19 in five years and many have already been discharged. That leads to the sort of thing that happened to one of my constituents. She had a brother who had been in a mental hospital for 37 years and she had been approached by medical staff who asked what she intended to do to provide a home for him. Such a thought was horrifying to the brother and the sister.
We must also change many of our stingy attitudes to the voluntary organisations. It is offensive to expect voluntary organisations to raise money which is then matched pound for pound. The backbone of many of those voluntary organisations is exactly those carers about whom many golden words have been spoken today. Lord McCluskey says:If the Navy needs three new frigates, we don't tell the Admiral of the fleet to run a charity bazaar in order to match pound for pound the monies to be made available from the taxpayer. In the field of community care those, particularly the volunteers, who seek to provide services are faced with just such requests. It is depressing for those who want to offer their skills to have to devote so much of their time to trying to raise money from charities and to jump through bureaucratic hoops.Such an attitude must be dropped.
One point that has not yet received adequate attention relates to the need to set up patients councils for the mentally ill and to ask the patients what they think is needed. The professions say that they own people. Whether they are social workers or doctors, they say, "A bit of me is what these people need." Patients councils would put more emphasis on, for example, the need for asylum, for there to be some place to which they could escape; on the need for work opportunities; on the need for housing opportunities and on the need for crisis facilities and support, particularly at weekends. Such issues would loom much larger than they have so far, as would the need to support self-help groups.
We are glad to have had this debate. The test is now there for the Government. Hon. Members on both sides of the House have had 30 years of pious words. They must come to an end. As Griffiths said, the one thing that we cannot do is nothing. We have done nothing for far too long.
§ Mr. Andrew Rowe (Mid-Kent)
I am delighted that the hon. Member for Livingston (Mr. Cook) has just re-entered the Chamber. I have attempted to educate him before but I will try to do so again because he is an hon. Member with much to offer if he learns a few lessons.
The important thing for the hon. Gentleman to understand is that Kent may appear still lower in the league table of home helps over the coming year because it has changed the whole nature of the service that it offers. It has preferred to go for home care service which, as my hon. Friend the Member for Ipswich (Mr. Irvine) pointed out, is a different kind of service and includes such assessments as whether somebody needs help to get out of bed or to get back into bed and to be cared for in a variety of different ways. That intensification of service is proving a great deal more useful and valuable than simply an hour or two from a home help. Kent will remain unashamed of its appearance among the home help statistics.
It is worth remembering that we should have a mixed economy in care. That is the other important element. I intervened earlier to say that it is a serious mistake for people who have been in the habit of choosing how to dispose of their resources throughout their lives and who have had the opportunity and good fortune to do so, suddenly to arrive at a stage in their development where they become the passive pawn of some institution, however well meaning.
As my hon. Friend the Member for Gedling (Mr. Mitchell) said, the picture of community care and the discharging of people, particularly from hospitals for the mentally handicapped, is far too gloomy. When a mental handicap hospital in my constituency was half empty, its administrators kindly thought that it would be fun for those already discharged into the community to visit their friends who were still there. They took them in a bus to the hospital but only one patient was prepared to get out of the bus because they were so terrified that they would have to stay, despite that being a well-run mental handicap institution. Where community care works well, it is vastly to be preferred to big institutions.
I congratulate the Government on the appointment of Sir Roy Griffiths. It is a fine example of the way in which private enterprise can assist the public sector. His contribution to the debate has been much valued on both sides of the House. He took a far more realistic view about the amount of resources available. I share with every other hon. Member who has spoken the belief that we need more resources for community care. We need them not only because of the demographic profile but to provide a better deal for carers, more respite care and for all the other reasons that have been given. However, if we were to add up the cost of all the demands that have been made in the Chamber, either explicitly or implicitly, we would arrive at a figure so unrealistically high that it would be a cruel deception to everyone to imagine that such a sum could be made available. When Sir Roy Griffiths said that he was concerned about the proper expenditure of whatever sum was available he was speaking realistically.
There is a clear need for a much better assessment of clients and potential clients. For example, clear evidence is mounting that a substantial number of confused elderly are confused because their bodies are in a state of 100 imbalance due to drugs. When people lose a spouse they can become very stressed and unable to sleep well. The doctor then gives them tranquilisers and they may then develop some sort of headache which the doctor treats with another drug, and so the spiral goes on. It has been shown that if a proper assessment of such confused elderly people is carried out and they are gradually restored to a proper balance, they are frequently able to live in their own homes without being a burden on the community care services.
It is vital that we build on the strengths of all the professions. People have professional pride and attach-ment and, just as some doctors are reluctant to see their patients handed over to social services departments, so teachers of children with special needs have a similar anxiety. A great deal of training and careful joint work will be needed to obtain an effective system of working together. Teachers, speech therapists and the professions allied to medicine must be brought into the system. One of the reasons why the parliamentary panel for personal and social services extended an invitation to the professions allied to medicine to meet it and the support group—the four professional social work associations—is that suddenly those professions find themselves with a third major purchaser of their skills. It is important for them to start making links.
It is vital that we give the client or patient a real choice. My hon. Friend the Minister should remember the demands that we made earlier for there to be opportunities for advocacy for those not able to choose for themselves from the varied or unvaried, menu, presented to them by the social services departments. I am cautious about having "professional" advocates because there is a danger that as they become more experienced they may start to hype up the demands of their client to what will eventually become a totally unrealistic proposition. We need to think about that.
One issue that is fundamentally important but which will not feature in the White Paper is housing design. How realistic is it to assume that we will be able to keep in their own homes the 6 million old-age pensioners whom we expect to have by the year 2000 if the homes in which they are expected to be kept are structurally unfit to shelter them? At a recent seminar that I ran with the Helen Hamlyn Foundation, which looks after frail elderly people, a shopping list of desirable features for a home for the frail elderly was put forward. If such requirements were included in a house that cost about £44,000 to build, the total cost of including them new would be about £8,000, or 16 per cent. of the total. If they were to be included later, the cost would rise to about 55 per cent. of the total. Every year we add to our housing stock more and more new build which cannot possibly accommodate a wheelchair or anybody not totally fit.
We have mentioned sheltered housing, which is valuable. There are about 44,000 units in the private sector and a similar number in the public sector. However, sheltered housing, no matter how desirable, often creates a ghetto; an area in which people meet only others like themselves. What sort of choice is that? We have to reintroduce to our new building the requirements that will enable us to have flexibility in the housing stock. If we do not do that, community care will become a farce.
My hon. Friend the Minister should take the issue seriously. We may have to go back to considering some 101 sort of space requirements on new build housing and finding a way of paying for it that does not necessarily fall on the shoulders of the first-time buyer.
I support the idea of a national inspection. It is unrealistic to expect local authorities to inspect themselves and the private sector well enough without some central guidance. I hope that we can have a central inspection.
§ Mr. Tony Banks (Newham, North-West)
I must pick up a point that was made by the hon. Member for Bolton, North-East (Mr. Thurnham). If I do not, my wife will certainly not forgive me because she is a social worker and she will not be amused when I go home tonight and tell her that she works in a vast bureaucracy on a nine-to-five basis. I can assure the hon. Gentleman that that is not the case for many social workers, including my wife. They are often called out at unearthly hours in the early morning, in order to take children into care. The hon. Gentleman should revise what he said and thinks about social workers. He will not be on my wife's Christmas card list this year.
I am not surprised that it has taken so long for us to reach this point in consideration of the Griffiths report, for the simple reason that Griffiths had at the centre of his recommendations the role of the local authority. That must have been a major stumbling block for the Government. I would dearly love to have seen the Prime Minister's face when the report was thumped down on her desk by some quivering civil servant or Minister who said, "Do you know what he has done? He has said that we have to give a central role to local authorities." The Prime Minister's hatred of all local authorities is well known in the House. Griffiths showed good sense and I congratulate those Conservative Members who were able to convince the Prime Minister, despite her well-known and practised prejudices, that she and the Government should go along with a number of the recommendations made by Griffiths, particularly with regard to the role of the local authority.
In the few minutes that I have left I wish to mention the hidden needs of care in the community. Hon. Members know from experience in their surgeries that many needs are hidden because few services exist to meet them. The hon. Member for Bolton, North-East said that two thirds of live-in carers receive no help from any of the services that could bring them some relief. They may be caring on a 24 hour-a-day basis for dependent relatives. That becomes a form of house arrest if they receive no support. In areas such as the London borough of Newham in my constituency, elderly people from black and other ethnic minority communities find the existing statutory services inappropriate and inaccessible.
The trouble is that we have no estimates of the real levels of need for care in our communities. Last week I went to look at the Newham Crossroads care attendance scheme, which is based in Forest Gate in my constituency. We discussed some of the problems in the knowledge that today's debate was to take place. Just 10 care attendants were present. They are paid by the Crossroads charity and receive support from the local council, as do most of the Crossroads schemes; payment, however, is limited to the rate for a 260-hour week. They told me that in the previous week they had already exceeded that, and were eating into the funds that they receive from jumble sales and other voluntary activities.
102 The care attendants relieve carers, sometimes for only a few hours a week, sometimes for a day a week. That is much appreciated, but they tell me that it is only the tip of the iceberg. The House, and the Government in particular, must address the problem of all the people who we know desperately need relief from caring for dependent relatives or friends. Most carers, I was told, are in the 55-to70 age range.
I asked each of the 10 care attendants to give instances of people whom they were currently looking after. Time will allow me to mention only three. A case that I found particularly pathetic was that of a mother who was looking after her daughter. That sounds perfectly reasonable; however, the daughter is 45 and the mother 76, and in no fit state to look after her daughter. She has the additional worry of what will happen to her daughter on her death —which cannot be far off, given the amount of work that she must put in.
Others had different tales of personal tragedy to tell, concerning younger people. A 29-year-old single woman is looking after both parents. Where has her personal life gone? Where is her chance of a future? Her sense of responsibility prevents her from going out, meeting others of her own age and forming her own relationships. Her life has been blighted. There is also the male equivalent: a single man of 35 is looking after his mother, and has problems in trying to lead his own life outside. I was told that the budget allowed no money for training.
This is what I found most disgraceful of all—listening to what was said by people whose commitment was clear although many looked as if they needed a bit of care and attention themselves. It is not surprising that there is a great deal of poverty in that part of London; but there is also a great deal of readiness to help out—and it is often those who can afford to give least who give most when asked to put their hands into their pockets or purses for charity.
Those care attendants receive the magnificent sum of £3.75 an hour for bringing relief to carers throughout the London borough of Newham, and two weeks' money is kept in hand. They do not receive as much as home helps or district nurses, but that is all that the charity says that it can afford. One young care attendant has to pay £70 a week for a bedsit in Newham: that is the going rate in the private sector.
None of the matters that we are discussing can be entirely divorced from others over which the Government have influence. It is no good talking about having more care attendants, and about how much they should be paid, if a Bill going through Parliament will force up the cost of private accommodation in boroughs such as Newham and make it even more difficult for people to come forward to perform such vital functions.
Most people who have relations in need of care are compassionate and concerned, and what they do not want from the House are pious platitudes and expressions of hope for the future. They want resources. They want a commitment. They want the Government to say, "We believe in what you are doing, and we will back it up with hard resources." I hope that, when the White Paper is published, it will contain strong recommendations to back up the pious sentiments that we have heard from Conservative Members tonight.
§ 9.3 pm
§ Mrs. Rosie Barnes (Greenwich)
Thank you, Mr. Speaker, for giving me the opportunity to participate in what has been a very constructive debate, with a remarkable degree of consensus from all corners of the House. I should like to dissociate myself from the remarks made a few moments ago about sheltered accommodation, which I found entirely contrary to my experience; but I have no time to dwell on that.
Some steps proposed by the Government have broad acclaim—for example, the fact that there is to be an identifiable point of access, including a named person, that there is to be a unified budget and that some of the restrictions on financial planning have been removed—and there is general welcome for at least some move towards an assessment system.
But that does not go far enough in terms of a national commitment to properly established national principles which are adequately funded. It does not go far enough in giving rights to people who need community care and in making the obligations statutory. Nor does it pay enough attention to the way in which what is proposed will bite.
In that connection, I suggest that something along the lines of the statements that are given to children with special needs should be given to people in need of community care. The statement, which should be multidisciplinary, should enable resources to be commanded, for without resources no proposal is worth the paper on which it is written. There must be a national level and quality of service, not least to ensure that the public money that we devote to this sphere is properly used.
I welcome the commitment to the concept of compulsory assessment and treatment of patients suffering from mental disorder in hospital, but I, too, call for some compulsory treatment for those who are still in the community and, like other hon. Members, I am thinking particularly of schizophrenics.
Parents of schizophrenic young people in my constituency are desperate to know what to do, because once those concerned are out of hospital and have decided to stop taking the medication, their situation becomes intolerable. Those who most want to care for them find it impossible to do so. In other words, they are not controllable by those nearest and dearest.
In taking an overview of the policies and proposals that we are discussing, I feel that the lack of definition of needs and rights is accompanied by what amount to no more than vague promises about the funding of what is proposed.
Government figures suggest that as many as 35,000 previously institutionalised patients have been released into the community in the last decade. An optimistic estimate is that no more than 9,000 of them have been offered full-time residential places in their own communities. That leaves 26,000 vulnerable people dependent on domiciliary care or community support. Some of those have fallen through the net and are receiving no help whatever. Some of those undoubtedly contribute to the number with whom the social services have lost touch and who form some of the homeless, whose plight we have discussed in the debate.
We must know on what basis the transfer of resources to local authorities will be based. The levels transferred 104 must not perpetuate the existing shortfalls, and it is agreed that considerable shortfalls exist. We have little or no knowledge on a national basis about the adequacy of current resources. Indeed, it is generally believed that there is a major shortfall, particularly in relation to carers.
Much has been said about carers, and I endorse everything that has been said. Many of those carers are children, and that fact must be taken on board. I reiterate what has been said about the cost implications of caring for people at home rather than in a home. The National Care Homes Association estimates that to look after people in a residential home on a 24 hours a day basis cost 84p an hour, whereas to look after somebody in their own home, providing a service on the basis of only 14 hours a week, costs £19.44 an hour. So, even allowing for some possible exaggeration of the figures, the differences are enormous. When we call for care at home rather than in homes, we must be clear about what we are talking. If we do not appreciate the facts, carers will continue to foot the bill for having their charges at home rather than in one.
The likely shortfall must be set in the context of what the Royal College of Nursing has described asthe lack of a defined and exclusively dedicated budget for community care".Today we have talked about ring fencing and I add my voice to the many who have asked for such ring fencing to ensure that the right amount of money is allocated to the right places.
The aging population suggests that we will be faced with an increasingly vulnerable group who will lean heavily on community care. That dependency will be coupled with a significant decline in the number of young people able to provide that care.
It is important to consider the bottom line regarding responsibility for the proposals. At the moment there is some input from the health authorities and, primarily, from the local authorities. The added dimension is the local hospitals, including mental care hospitals, which may be self-governing. When boundaries do not coincide and when it is unclear where funding will come from, it will be important to discover who will make the decisions. That must be resolved if the proposals are to be dovetailed into the National Health Service Bill, which we expect imminently. There could be an automatic temptation for a health authority to discharge someone from hospital and for the local authority to feel itself unable or unwilling to pick up the financial burden, which will then be in its court.
To make things work, we need national standards and national funding. Without that commitment, we shall, in common with so many before us, pay only lip service to community service.
§ Mr. Ian McCartney (Makerfield)
I want to discuss children and adults with learning difficulties. I have always found the term "mental handicap" a negative and ugly one. It describes many people who live in the community or who are subject to institutional care. The term does not adequately describe either the nature of their disability or the contribution that they can make to society. Because of the ugliness of the term, many people in the community switch off immediately when others discuss with them the concept of involving people with disabilities and learning difficulties in the wider community.
This morning I entered the House with a great deal of trepidation because as I went up the stairs of the 105 underground I was met by a phalanx of junior doctors and nurses wearing bandanas who were asking for a contribution towards the funding of the London hospitals. A few hours later, however, for the first time in 10 years, I sensed some hope because, from both sides of the House, there is a common approach and a recognition of the role of the public sector, the local authorities and the primary services in the development of care in the community.
It has taken 10 long, hard years for that lesson to sink in and perhaps that is why the Government have taken so long to publish a White Paper in response to the Griffiths report. It was never the Government's intention that the Griffiths report would be written in the fashion that it was. As the hon. Member for Macclesfield (Mr. Winterton) said —I am tempted to call him my hon. Friend, but that would get him into a great deal of trouble—Griffiths was driven to his conclusions by the weight of evidence, which has been shown today. I hope that the Minister will appreciate the quality of the debate, the genuine compassion and, most important, the deep understanding felt by hon. Members about what must be done in relation to the development of community care policy through to the turn of the century and beyond.
Many of us who have spent a lifetime working with people with learning difficulties have attempted to provide care patterns as a result of discussions with the families of those involved and with local authorities. We have attempted to produce a care pattern that provides choice for disabled people, whether they suffer from a physical disability or from severe learning difficulties. That pattern of care and the development of choice must underpin the Government's commitment to providing resources. We cannot have a national framework recognising the role of local authorities if, in the final analysis, we do not provide the resources to develop that expectation. I wish to discuss that expectation.
In the pattern of institutional care and care in the community, there are some essential choices that must not be made by us. We must provide the resources for disabled people to make those choices. In all our debates in the past decade we have failed to recognise that those individuals have the right to choice, the right to family life, the right to develop friendships inside institutions and to maintain those friendships when they leave the institutions, the right to proper housing and to care within housing in the community, and the right to education, training and employment.
Local authorities have a central and pivotal role to play. Since its inception in 1972, my local authority, Wigan metropolitan borough council, has developed four training centres and a factory and has developed within that factory the employment of disabled people to the point at which almost all the factory, including the management, is run exclusively by disabled people for disabled people, operating and selling its services in the market place, to other local authorities and to private industry. Wigan also provides sheltered working arrange-ments for severely disabled people with learning difficulties and physical difficulties. It has transformed their lives in the community, allowing individuals to make choices and their families to be involved in those choices.
At the very point at which we are discussing developing a national framework, all those schemes are put at risk by leaked reports and suggestions that local authorities will have to put these provisions out to tender. That flies in the 106 face of evidence and in the face of all that we were hoping to do to develop within the community choices for people with physical and learning difficulties.
We also have to provide choice in health care. My hon. Friend the Member for Leigh (Mr. Cunliffe) and I know all too well about cuts and the lack of resources in the development of health care facilities in our community for those with physical handicaps. We are currently fighting off proposals to close five units in the metropolitan borough of Wigan, all with a co-responsibility for care facilities within the community, linking them with the National Health Service and selling them off in an asset-stripping exercise to a property developer who will develop the sites for housing in the green belt where most of the sites are located. That does not ring true with what we are debating today and the attitudes that have been struck by hon. Members on both sides of the House. I ask the Minister to intervene at this early stage and put down the nonsense of asset-stripping large parts of the National Health Service and its resources. Those resources are needed as part of the core services for care in the community.
We must also develop within our care plan choices for personal expression. Many of the most profoundly disabled people can still express themselves through art, music and other cultural activities. We have to challenge the ethos that in this country the arts will be provided mainly through private donations and sponsorship. For many profoundly disabled people, the arts are the only form of expression that they have been able to develop., and much of that is at risk with the cuts in expenditure in local authorities and the development of alternative arts and crafts within local authority social service departments.
During this debate, hon. Members on both sides of the House have set out clearly the priorities for the Government. They are about the nature of the care to he provided, the types of framework necessary to ensure that that care is provided and the nature of the funding that is required.
If the Minister is serious about listening, this debate will have laid to rest the 10 years of mismanagement of community care and the ethos of the private sector and market forces delivering care. Let us hope it has been buried here and that we can have a fresh start, because out there millions of people, carers and the disabled, look to this House for salvation.
§ Mr. Tom Clarke (Monklands, West)
I think that the House will agree with my hon. Friend the Member for Makerfield (Mr. McCartney) that this has been an excellent debate. The cameras that have witnessed our proceedings would have done a great service to Parliament had it been possible to project the debate to a wider audience. The public would not have been disappointed.
The Minister of State said that he sought a non-partisan debate. In many ways, he has been given his wish. Whether speeches were robust or coded, it has to be said that there was precious little support for the Government's priorities for community care and for their failure to respond in any tangible way to the Griffiths report in the 19 months that have elasped since it was published.
My hon. Friend the Member for Kilmarnock and Loudoun (Mr. McKelvey) said that he attempted to obtain 107 the White Paper before he came to the Chamber. I am not surprised. After all, as my hon. Friend the Member for Livingston (Mr. Cook) reminded us, the Secretary of State told the House on 12 July that the White Paper would be available during the recess. That has not happened.
We are getting used to broken promises from this Government and this Secretary of State. It is not surprising to me that yet another pledge has gone, to coin a phrase, "just like that." The great pity is that so many of the Government's other pledges have gone with it. We have not seen the challenge for community care policies being matched by resources. It was clear from speech after speech from hon. Members on both sides of the House, that, whatever reservations we might have about some of Sir Roy's recommendations, we agree that we have had far too much rhetoric that has not been matched with resources.
As we have waited for the Government's response, the problems that have been identified have grown. The problems of the elderly have been mentioned and carers have been an important aspect of the debate. Only yesterday we had a compelling report from the National Association of Citizens Advice Bureaux which underlined the appalling problems of young people leaving care and facing, in many cases, crime and even prostitution. Opposition Members hope that that matter will finally be tackled in the Children Bill, when we debate it in the House next week.
The Government have said that the purpose of this debate is to give them the opportunity to listen. Have they been listening? Although I am pleased to welcome the hon. Member for Galloway and Upper Nithsdale (Mr. Lang), it seems to me that the capacity of the hon. Member for Stirling (Mr. Forsyth) showed a measure of listening fatigue. I am sorry if that is the case. If time allows, I hope to refer to some of the hon. Gentleman's comments later.
If the Government are truly listening to the House and to the voluntary bodies to which my hon. Friend the Member for Livingston referred, there are two things which must concern them above all others. First, the House has made it clear that there is an overwhelming case for ring fencing as we identify priorities. The hon. Members for Eastleigh (Sir D. Price) and for Caernarfon (Mr. Wigley) underlined that theme and it has been widely echoed.
My hon. Friend the Member for Birkenhead (Mr. Field) spoke for the House when he made a plea for a full national insurance record for carers. Yesterday, I had the privilege of meeting Maureen Oswin, who spent five years of her life looking after her sister who was dying of cancer. I was impressed that she displayed no bitterness. She made a genuine plea from the heart, based on her experience, for the House and the Government to accept their responsibilities to carers. My right hon. Friend the Member for Stoke-on-Trent, South (Mr. Ashley) and my hon. Friends the Members for Crewe and Nantwich (Mrs. Dunwoody) and for St. Helens, South (Mr. Bermingham) underlined that important plea based on their constituency experience.
I welcomed some contributions from Conservative Members. I hope that I do not embarrass the hon. Member for Gillingham (Mr. Couchman) when I say that his remarks on training were appropriate. We will not achieve 108 the objectives that we all share, which represent the major recommendations of the Griffiths report about cost-effectiveness, if proper funding for training is withheld.
The hon. Members for Belfast, South (Rev. Martin Smyth) and for Bolton, North-East (Mr. Thurnham) mentioned the Disabled Persons (Services, Consultation and Representation) Act 1986. I had a little to do with that Act, which received tremendous support from all hon. Members. Nevertheless, there was a time when I felt a little embarrassed about raising it. My embarrassment is a fraction of the embarrassment that the Secretary of State and his Ministers should feel when they attempt to defend the Government's squalid position on that vital legislation.
I want to examine in detail the relevance of the Act to the Griffiths report and to any debate on community care. Section 7 is crucial to every point that has been made, including the important points made by the hon. Member for Eastleigh, about people being discharged from long-stay psychiatric hospitals. There is talk about listening and consultation, but there was immense consultation throughout the passage of that Act, which was endorsed by both Houses without a vote. On 12 July the Secretary of State said:On the health side, I will ensure that discharges of seriously mentally ill people from hospital will take place only when adequate medical and social care is available for them outside hospital."—[Official Report, 12 July 1989, Vol. 156, c. 978.]How does he plan to do that without proper assessment under section 3? Practical measures must be introduced or the Secretary of State's words become mere rhetoric of the type that Sir Roy identified.
The Act says that assessment should be carried out prior to discharge. In the best spirit of everything that has been said today about the consumer, the Act says that the consumer should be consulted about assessment by the health authority and by social services. For many people who would not be able to be involved in the process, section 1 deals with advocacy and representation and ensures that their needs are not ignored.
If we are talking about consumerism, we are also talking, especially in terms of discharge from hospital, about national standards. The message from hon. Members, which we have heard clearly from constituency after constituency, is that people are sick and tired of hearing about the accidents of geography and patchy planning.
Hon. Members have told us about the National Schizophrenia Fellowship and the 90 per cent. of admissions of schizophrenics that are re-admissions after relapse. Where is the economy in that? How can the Treasury take a hard line with any justification, given that it is not even financially viable, apart from being socially unacceptable?
Again, on 12 July, in an off-the-cuff remark in reply to the hon. Member for Exeter (Mr. Hannam), the Secretary of State said:We do not think that, on this occasion, it is right to use the 1986 Act to implement any part of what we are doing today." —[Official Report, 12 July 1989; Vol. 156, c. 192.]Many hon. Members found that comment staggering. If that statement represented a change of policy, the House was entitled to hear about it long before it did and in a more formal way.
If this is a change of policy, I invite the Minister to tell us why the Department of Health issued the booklet "Discharge of Patients from Hospitals", which clearly 109 identifies the responsibility of social service departments and health authorities in terms of section 7 of the Disabled Persons (Services, Consultation and Representation) Act 1986. More important, given all the Government's discussions with local authorities and given that the House was told by Minister after Minister, including the Prime Minister, that section 7 and the rest of the Act would be implemented when resources became available, the House is entitled to an explanation as to why that commitment was lightly dismissed.
I turn to residential provision and the problems of the elderly. Hon. Members have said that they appreciate that all Governments would have a problem in terms of demography. More and more people are living longer. This should be seen as a challenge and opportunity, not something that is hanging around our necks. The Government have said that they will not take a particular approach until they have consulted and heard our debates, but they give the impression that they do not accept the case for the mixed economy. My hon. Friend the Member for Livingston confirmed that this is the Labour party's approach. It is realistic and reasonable. It would be difficult to remove the influence of local authorities in terms of not only enabling but providing.
I disagree with the speech of the hon. Member for Gedling (Mr. Mitchell), which appeared to be out of step even with the views of other Conservative Members. I shall not pretend that local authorities have a monopoly of wisdom, but the case for a national inspectorate for the private and the public sectors has been underlined. There may well be more support in Whitehall circles for the view of the hon. Member for Gedling—the hon. Gentleman may feel that I tend to flatter—than for the view of other hon. Members, but it would represent a setback in terms of enabling as well as providing.
I am sorry that the hon. Member for Stirling is not present. The Opposition do not ignore the role of the Adam Smith Institute in giving advice to the Government. A few days ago, it published a document on community care—[Interruption.] I point out to the hon. Member for Bolton, North-East that our proceedings are not publicly televised yet. With that document it published a news release which said:The report also calls for local authorities to turn over all"—I emphasise "all"—their care homes to private and voluntary care providers in order to avoid any possible conflict of interest. Michael Forsyth, Scottish Health Minister writes that 'There is no question of local authorities providing a full range of services directly themselves. We have made it quite clear that the maximum possible use should be made of the voluntary and commercial sectors so as to widen individuals' room for choice'.The Government cannot have choice if by their policy on social security and their approach to residential care they discriminate quite clearly and deliberately, as the Adam Smith Institute would advocate, against one of the sectors —in this case the local authority sector.
§ Mr. Nicholas Winterton
As an hon. Member who has served in local government, I believe that not only the officials but the elected members of county councils and other local authorities have considerable knowledge and an immense commitment to residential care. It would be a catastrophe if that was surrendered and given up.
§ Mr. Clarke
I am pleased to endorse the hon. Gentleman's comment. It would be a great tragedy if the Government tried to get themselves off the hook of Griffiths's major recommendation about local authorities by diluting the role which has so clearly been endorsed in this debate.
Tonight, we are speaking about community care in action. Hon. Members have wearily indicated that speeches in the past have not been met by the sort of action that we would wish to see. We want to extend best practice, including endorsing the consumer's right, to every part of the United Kingdom. At last week's Conservative party conference delegates had a great deal to say about active citizenship. In a first class speech my hon. Friend the Member for Newham, North-West (Mr. Banks) was able to underline what active citizenship under this Government means in practice for Crossroads.
Apart from the absence of a strategy for community care, people are worried that a number of contradictions exist between various Government Departments, many involving the Department of Employment. I am not even sure whether the Department of Health and the Department of Employment have got together on the training scheme which so worries Crossroads.
I shall quote from the Scottish annual Crossroads care report and mention some of the remarks made by its chairman, I. J. Cowan:On the 5 September when the Manpower Services Commission community programme ended and employment training started, 25 schemes were involved. Most investigated ET and decided it was unsuitable. In the event, eight joined the ET but at the end of the year only four remained and they were caring for 16 per cent. fewer families and providing 45 per cent. less caring hours. The other 20 schemes were supplying a similarly reduced level of care. The number of families cared for was down by 24 per cent. and the number of caring hours provided, down by 48 per cent.If we are to have community care involving all who are capable of making a contribution, the voluntary sector is entitled to ask for better than that. If we are to talk about carers in the way that we have done during this debate, we must deplore the absence of any proper planning which takes into account not just the views of the carers, profoundly important though they are, but the fact that section 8 of the 1986 Act already contains the opportunity —if the Government wish to grasp it—for carers to have an assessment of their own position and that of disabled people.
A document from SENSE, the National Deaf-Blind and Rubella Association, refers to the sad and tragic case —it is known to the House—of Beverley Lewis, a 24-year-old rubella sufferer who died weighing four and a half stone. Clearly, a domestic problem involving caring also existed. The following quotation is not what I or other hon. Members on both sides of the House who have given massive support to the Act have said; it is the organisation's opinion:Implementing the Disabled Persons Act. This Act if implemented could have completely transformed Beverly Lewis' life. It came too late for her but for the many other deaf-blind young people and adults it is essential if community care is going to work.It certainly is.
I congratulate hon. Members on both sides of the Chamber. Community care and our debates on it are rightly here to stay. The pressures on the National Health Service mean that 90 per cent. of the most vulnerable people in society are still out there in the community. I am 111 pleased that today at least we have had the chance to address some of these problems, and, together with my hon. Friends, I look forward to offering a meaningful solution to the need within our communities, which the existence of those problems invites.
§ The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman)
The hon. Member for Southport (Mr. Fearn) doubted whether this debate would make any difference to Government thinking and implied that the White Paper had already been written. The Government have listened carefully to the contributions to this debate. I agree with the hon. Member for Monklands, West (Mr. Clarke) that it has been a most valuable and interesting debate, but the hon. Gentleman cannot have it both ways. If we had published the White Paper last week he would have been the first to say that the Government were not listening. It was a sensible decision first to listen to the debate and then to publish the White Paper. I must tell the hon. Member for Newham, North-West (Mr. Banks) that we have adopted the Griffiths report not reluctantly but enthusiastically.
I want to deal first with the initiatives that we are planning for the mentally ill. This subject was raised by the right hon. Member for Stoke-on-Trent, South (Mr. Ashley), by my hon. Friends the Members for Eastleigh (Sir D. Price), for Bournemouth, East (Mr. Atkinson), for Macclesfield (Mr. Winterton), for Hendon, South (Mr. Marshall), for Taunton (Mr. Nicholson) and for Gillingham (Mr. Couchman), and by the hon. Member for Clydebank and Milnegavie (Mr. Worthington), all of whom rightly attach great importance to this issue.
As the House knows, I made a statement on 13 July clearly setting out the initiatives that the Government propose to follow. Our overall aim is clear and we have reaffirmed the policy pursued by different Governments over the past 20 years. We want to develop locally based hospital and community services, including long-term asylum facilities. I stress again that, as a consequence of, and not as a driving force behind, that policy some, but not all, of the large, isolated Victorian hospitals will close. This civilised and humanitarian policy, which I hope has the support of both sides of the House, will involve closures only when we are satisfied that there are adequate facilities in the community, and not before.
Hon. Members on both sides have expressed worries not about this general philosophy but about its implementation, and I want to deal briefly with certain aspects of our policy, beginning with procedure. We have made it plain that by April 1991 all district health authorities must have in place a proper care programme for the discharge of each and every patient. That programme will entail not only a register but a stipulation of who is in charge of the patient once he is discharged. This policy will apply not only to those discharged from hospital but to the growing number who never reach hospital in the first place.
The hon. Member for Monklands, West spoke about the draft guidelines which we have circulated to enable district health authorities to put in place this new requirement. I am delighted to see that the Royal College 112 of Psychiatrists is drawing up minimum acceptable standards for discharge and, most important, standards for following up patients after they leave hospital.
Secondly, I should like to speak about resources. In the fiscal year 1991–92 and succeeding years, new extra money will be available through the National Health Service to local authorities to develop additional social care services for the mentally ill. That is additional and new money and we shall discuss with the Treasury during the public expenditure survey round next year the specific amount to be provided. Only about 3 per cent. of social services authority expenditure is spent specifically on the care of the mentally ill. Those services have various pressures upon them, but that is a bald statement of fact. There is need for additional resources. There will be a specific grant paid on agreed plans for programmes to be put in place by local authorities.
Thirdly, I shall deal with capital provision. I am well aware that we need facilities in the community before the hospitals close and not afterwards. We have a number of initiatives, including exploring the use of private sector finance to build community facilities now in return for releasing the land to private sector developers when the hospital closes. We are presently looking at possible candidates.
§ Mr. Freeman
It is not asset stripping. It is accelerating the programme of expenditure which would not otherwise have been possible. We are looking at possible candidates and they have to prove themselves good value for money. I hope that we can make progress on that score. I must emphasise the heavy burden borne by local district health authorities in keeping open half-empty psychiatric hospitals. That is extremely expensive, and anything that we can do legitimately to speed up that process is all to the good.
§ Mr. Freeman
No. I regret that I have only 14 minutes to try to answer the points raised in the debate.
I shall devote two minutes to the homeless mentally ill, especially those in London. That issue greatly concerns the Department of Health and me. The Government are anxious to assist homeless people, whatever their circumstances or medical needs. My right hon. Friend the Secretary of State for the Environment will shortly report on his review of the homelessness legislation. My ministerial colleagues and I at the Department of Health have a particular responsibility in respect of that part of the homeless population suffering from mental illness.
It is difficult to get firm facts and figures, but the organisations with which we are in touch, such as St. Mungo's and the Bondway housing association think that on average 10,000 people sleep rough in London every night, and of those, about 30 per cent. have obvious mental health problems. There are of course smaller numbers in other towns and cities. Some of those people have never been in touch with the psychiatric services. Others have been, but for one reason or another have broken off contact with the services. I accept that a proportion consists of people who have been discharged in the past from hospital without adequate arrangements being made for their care in the community.
113 As I have already made clear, we are taking steps to make arrangements for providing continuing care in the community more effective. That will be done in particular through the requirement on district health authorities to introduce the care programme approach from 1 April 1991 and the new specific grant to social service authorities payable from the same date. Those initiatives will not immediately assist those in need of psychiatric treatment and currently among the homeless population. We are therefore considering how best to help that group.
Those experienced in working with that group, including the departmentally funded psychiatric team for single homeless people at Guy's hospital, are clear that it is not realistic to offer what will often need to be fairly long-term treatment to people with no settled accommoda-tion. Therefore, the aim must be to increase the number of hostel places and places in group homes with proper social work support to create the necessary bases from which people can receive treatment.
The experience of the Bondway housing association shows that reasonable supported accommodation accept-able to homeless people with mental illness can be provided economically. We are having talks with those with direct experience of helping this vulnerable group, and we shall soon be talking to the statutory services concerned. We recognise the problem, we intend to work with and build upon the achievements of the voluntary sector and bring our review to a satisfactory conclusion as soon as possible. I hope that the House welcomes that.
§ Mr. Freeman
Professor Gunn, on instructions from the Home Office, is surveying the population not only in the remand prisons but in long-stay gaols to identify how many of the prison population should be either in special hospitals but in psychiatric hospitals. We await that study with interest. There is no doubt in my mind that a significant proportion of prisoners should be not in prison but being cared for in hospital. Once we have that information, we shall proceed accordingly.
The hon. Member for Livingston (Mr. Cook) asked a specific question about the obligation on local authorities in relation to care. A statutory obligation to assess and then to decide the best method of care, whether at home or not, will be placed on local authorities. As many hon. Members have said, a proportion of those in residential homes would have preferred to stay at home and wish to be cared for at home. The revenue support grant will be reassessed each year for the level of provision necessary for local authorities to fund not only care in residential accommodation for new claimants and new applicants from 1 April 1991 but the level of domiciliary care that is needed. We shall spell out our proposals in greater detail in the White Paper.
Like the hon. Member for Livingston, the right hon. Member for Stoke-on-Trent, South and the hon. Members for Caernarfon (Mr. Wigley), for Wakefield (Mr. Hinchliffe) and for Makerfield (Mr. McCartney) all raised with me the important issue of the role of the public sector. I am glad to make the Government's position quite clear. We have no intention of introducing any element of compulsory tendering on home help provision or in any other element of local authority care. The speculation by 114 some hon. Members about privatisation of local authority care services is misplaced, and I am happy to clear up that misunderstanding.
We want a partnership between the local authorities, which play an important role, and the voluntary and private sectors. The Government do not seek, and it is not part of our policy, to prevent local authorities from providing care. Some local authorities—it is entirely a matter for them—will decide to continue to provide services and even enhance, improve or increase the level of care that they provide. That is satisfactory. We make no judgment about the level of care to be provided by local authorities. We regard services provided by the voluntary and private sectors as supplementary and not as a replacement of local authority care. Therefore, I agree with my hon. Friends the Members for Mid-Kent (Mr. Rowe), for Gedling (Mr. Mitchell), and for Bolton, North-East (Mr. Thurnham), all of whom expressed a similar sentiment.
My right hon. Friend the Member for Chertsey and Walton (Sir G. Pattie) asked whether certain jobs can or should be done entirely by the voluntary sector. While we welcome the contribution of the voluntary sector, we have no intention of heaping obligations on it, either exclusively or to a greater extent. He also asked about long-stay mental handicap hospitals and whether the management of them would be transferred to the social services department. We have no such proposals.
My hon. Friend the Member for Eastleigh raised two of the central issues of this debate, the first being the vital importance of carers. The hon. Member for Newham, North-West also referred to this point. They will find that the White Paper will emphasise that support for carers is the top priority. It will be seen when we publish the White Paper how we intend to manifest that priority.
My hon. Friend the Member for Eastleigh raised also the issue of ring fencing, or specific grants. The issue has been taken up by many hon. Members on both sides of the House, including the hon. Member for Livingston. The Government are grateful for the views which have been expressed and the arguments which have been advanced. I say in defence of the opposing view—that grants should not be ring-fenced or should not be made specific—that many hon. Members on both sides of the House have confidence in local government and social service departments, of whatever political persuasion, making the right judgments and arriving at the right priorities when determining the level of domiciliary care and of assistance for residential homes.
I invite the hon. Member for Newham, North-West and my hon. Friend the Member for Eastleigh to consider that the Government are seeking to provide additional money to supplement the funds that social services departments already have. We do not want the departments themselves to ring-fence funds. We want the additional money that will be transferred from the Department of Social Security through the payers' mechanism to be incremental funds to build upon that which is already being achieved in domiciliary care.
My hon. Friend the Member for Bournemouth, East referred me to the Schizophrenia After-Care Bill which was introduced in another place and which has now reached this place. I can give my hon. Friend the assurance that we shall be building upon the valuable lessons that have been set in the introduction of that Bill and in the debates that took place in another place.
115 The hon. Member for Birkenhead (Mr. Field), in what I considered to be a refreshing and interesting speech, asked a number of specific questions. He adopted an interesting consumerist approach to community care, which I am sure would be echoed by many of my hon. Friends, especially in the light of his support for the White Paper entitled "Working for Patients", for which we are grateful. If I may, I shall write to him about flexibility of contracts. His comments deserve a serious reply, and that cannot be done in the few minutes that are available to me this evening.
I am grateful to the hon. Gentleman for allowing me to mention that the independent living fund has been set up by my right hon. Friend the Secretary of State for Social Security. It is designed to help those with disablement live independently within the community. Applications can be made at the Nottingham office and local inquiries can be made at the social services department. The hon. Gentleman knows that vouchers have been discussed by some Conservative Members. I can assure him that his comments will be borne in mind carefully.
I find myself agreeing with both of the key points of my hon. Friend the Member for Macclesfield. Essentially, my hon. Friend wants registration and inspection to be carried out independently, and to be seen to be done in that way. Perhaps we may differ in the ultimate in how we propose that that should be done, but I take his point. I am sure that all my right hon. and hon. Friends believe strongly that there should be independent assessment. We believe also that the continuous monitoring of local authorities is essential. I can tell my hon. Friend that the social services inspectorate at the Department of Health takes that job extremely seriously. We shall spell out in the White Paper how we envisage that task being discharged.
116 The hon. Member for Crewe and Nantwich (Mrs. Dunwoody) referred to village developments. If it transpires that I have misunderstood her, perhaps she will be kind enough to write. I am a supporter of village developments, especially for the mentally handicapped, but only if they are not geographically isolated. They should be seen as proximate to the community and not inward-looking. If that is what the hon. Lady believes, I agree with the sentiments that she expressed.
My hon. Friend the Member for Gillingham talked about training. The Government agree with him. An additional central grant is to be made in 1990–91 of about £2 million, as a start, to support post-qualifying training in management in social care. My hon. and learned Friend the Minister of State, Department of Health is to meet the Association of Directors of Social Services tomorrow. He has had two meetings already with it this year.
My hon. Friend the Member for Ipswich (Mr. Irvine) referred to hospital discharges. He is right to say that they increase pressure for domiciliary care. We are concerned that there are some patients in acute hospitals who are blocking beds because they cannot be discharged as there is no domiciliary support for them. Our proposals will help to overcome that problem. The hon. Member for Belfast, South (Rev. Martin Smyth) and my hon. Friend the Member for Mid-Kent raised the question of advocacy. We very much support that principle, which will help those with mental illness and handicap to understand not only their rights but the services available.
The hon. Member for Greenwich (Mrs. Barnes) referred to compulsory treatment orders. We are still seeking professional opinion on that matter. I am sure that the House would wish to proceed with great caution, because it is not an issue that we take lightly. If we do recommend that it should proceed, I am sure that the House——
§ It being Ten o'clock, the motion for the Adjournment of the House lapsed, without Question put.