Social Care

Lord Shipley Excerpts

Thursday 29th November 2012 Lords Chamber

[Lord Shipley]

My Lords, I thank the noble Baroness, Lady Pitkeathley, for initiating this debate and declare my interest as a vice-president of the Local Government Association. My contribution will amount to a plea for urgent clarity in the future funding of adult social care. Time is short, given the enormous pressures on local authority budgets, where the cuts in central government grant amount to 28% overall in the four years up to 2014-15 but which in their implementation have impacted most heavily on the poorer parts of the country, where demand for publicly funded social care can be very high.

It has been generally agreed for some time that social care reform is essential. From the perspective of elderly people, local government, central government, the NHS, the voluntary sector and care providers, clear policy decisions are necessary to enable planning to take place and responsibilities to be agreed that will stand the test of time. Without that clarity, councils risk running out of money. That is a very serious matter, so I hope that the reports published yesterday that work is concluding on the recommendations of the Dilnot report prove to be true.

However, this is not just about Dilnot. There is a financial vacuum which needs to be overcome, of course, but it is not just about affordability. Government policy needs to be agreed as a crucial building block for allocating financial responsibilities. Policy-making affects individuals needing support; councils trying to cope with rising demand and reducing budgets; central government trying to cope with having less money to distribute; voluntary groups trying to plan and deliver services; the NHS trying to control its costs; and care home providers trying to maintain both capacity and standards of care.

From the perspective of local government, by 2019-20 there will be a funding gap of £16.5 billion—or 29%—between the revenue available and the spending pressures forecast. Assuming that social care is funded as now and that other essential statutory requirements are met by councils, there will be cuts of two-thirds in cash terms to all local government services other than social care. If concessionary fares are also fully funded and capital financing charges are met, 90% of current spending on other services will disappear. I believe this to be simply undeliverable for those other services include leisure, libraries and transport, all of which play a major role in the lives of elderly people and their health and well-being.

From the perspective of central government, net public spending on social care and continuing healthcare for older people will rise from £9 billion in 2010 to £13 billion in the early 2020s if current demand and spending assumptions apply—a rise of a little under 50%. There is actually a current funding gap, which has in practice been papered over through temporary financial solutions. The imperative of a long-term solution commanding all-party support has become overwhelming. Dilnot has been estimated to cost £2 billion. Current suggestions are that the cost will prove to be higher and require a higher cap. All this tells us that there is a very serious financial problem. I hope that the Minister will be able to say a little more about how the Government plan to address this funding problem and, in particular, what might be done in the very short term given that the focus of cuts is at the moment being applied to the poorer parts of the country.

We should remember that older people are a massive asset to their communities. They may become recipients of care but they are for many years essential providers of help and support to neighbours, families and friends, saving substantial sums of public money through their voluntary action. Implementing Dilnot would give many of them, and their families, peace of mind and confidence in their financial planning. It would also give the Government greater certainty about how to manage a 60% forecast growth in the number of over-75s within the next 20 years.

Perhaps I may draw your Lordships’ attention to the perspective of care home providers. Providers are claiming that there is now a funding gap of approaching £1 billion between the cost of providing quality care and the amounts paid to them by councils. Indeed, it is claimed that the average residential care home fee paid by councils does not meet the essential standards of the Care Quality Commission. If this is true, there needs to be an urgent review of why and what can be done because one of the consequences of inaction is a risk of more hospitalisations. We should note that fewer older people are now getting care, with a reduction from 1.2 million to 1.06 million in the past three years, which in itself may increase the numbers entering hospital directly. Yet we know that investment in prevention and in the voluntary sector saves money for the NHS. We also know that delayed transfers from hospitals are estimated to cost the NHS £200 million a year, which pooled budgeting might reduce.

While the Caring for our Future White Paper is in principle welcome, unless answers to Dilnot and related funding problems are given speedily there is a danger that councils will cut spending on social care, reducing levels of support to “critical only” and reducing fee payments in real terms to providers. Some older people who are not able to afford extra costs might then have to be looked after by the NHS. The long-term costs to the NHS of this could be substantial, which is why we need so urgently an agreed funding system for care.

In conclusion, we spend £121 billion on health and social care. I feel certain that the King’s Fund is right when it says that budgets should be pooled locally, with a single strategic assessment of the funding needs of the NHS and social care. It is vital that health and well-being boards should work well because they will drive the integration of adult care and health, which should in turn generate some efficiency savings to be redirected into service provision. It is vital that spending on prevention gets protected because in the end that is better for the individual but cheaper, too, for the public purse. Above all, it is vital that we get clarity in implementing Dilnot as the first step in building a system of adult social care that is sustainable into the future.

Much of this is about the medium to longer term but there is a massive problem now in some parts of the country. Over the past two years, I understand that the NHS has sent back to the Treasury some £3 billion. If that is the case, might the Government return that to health and well-being boards to enable them to find local solutions to their specific funding problems and for those parts of the country suffering the biggest cuts to get further support to reduce their impact?

Health and Social Care Bill

Lord Shipley Excerpts

Thursday 8th March 2012 Lords Chamber

[The Earl of Listowel]

My Lords, I support the amendment spoken to by my noble friend, to which my name is attached. I will strive to be as brief as possible at this late hour, but the issue is very important.

I will begin with an aside and refer to the short debate on productivity and manufacturing industry instigated at the start of business today by the noble Lord, Lord Bates. I will highlight the point made recently by Education Minister Sarah Teather that what happens in schools is important, but that the most important thing for children’s success outcomes is what happens in the home, outside school. As one academic put it, when one considers what makes the difference to a successful outcome for a child, only 10 per cent of it will depend on schools; the rest will depend on what happens in the background, in the family.

Of course, whether a parent is successful in their education is the single most important indicator that their child will be successful in their education. Businesses might be more aware, when they push for schools to teach children to read, write and do arithmetic better to get their apprenticeship skills, that they should think also very much about early intervention and getting it right in the family as well. If we are to compete with China in future, we need to think very carefully about the successful integration of services to support families and children.

I will speak briefly, on International Women’s Day, about another matter raised in an earlier debate today: namely, domestic violence and women fleeing to refuges. A few years ago I spoke to a child and adolescent psychiatrist, Professor Panos Vostanis of the University of Leicester. He had gone into these refuges and worked with the mothers and children over time, providing them with support. He said how important and effective it had been, but how rare the service was. He has now been commissioned by the European Union to conduct EU-wide research into support for families where there has been domestic violence.

This theme recurs in children's homes, refuges and other settings. It seems elementary that a mental health professional such as a psychiatrist or clinical psychologist should visit a children's home or refuge once a fortnight, to speak to mothers, work with children and support staff. That is best practice and it happens—but very often the model gets overlooked because, understandably, clinicians are under pressure and there are high thresholds of access for children and adults to these services.

Perhaps I may give one further example on the matter of schools. I recently attended an international conference on the mental health of children in schools. It was organised by Dr Rita Harris, head of child and adolescent mental health services at the Tavistock and Portman NHS Foundation Trust. We were given a presentation by two wonderful mental health nurses who had tried to revive a service in the Sunderland area. They found that schools had given up using child and adolescent mental health services because they would write to the service and it would respond by saying: “I am sorry, your child is not sick enough for us to see. Wait until he gets sicker and then we might see him”. The nurses had tried to mend the relationship with schools, build trust and ensure that every school had a mental health professional allocated to it. However, one school simply did not want any truck with them because it had had such a bad experience in the past of trying to work in this integrated way with child and adolescent mental health services.

The record is very poor. Given the concerns that many have raised in the past about the possible fragmentation that might arise from the Bill, and the many clinical commissioning groups that will come into being and the large upheaval that will take place, I am looking to the Minister for reassurance that the Government will improve a situation that has been so disappointing in the past, that we will see a better integrated service that will better meet the needs of children and families, that we will see better outcomes for children and they will be more successful in school in part because health and social care services will have been better integrated for them and they will have received, early in their lives, the support that they need. I look forward to the Minister's response.

[Lord Shipley]

My Lords, I rise to speak to Amendments 238AA, 238AB, 238BZA and 238BA and to declare my interest as a member of Newcastle City Council.

These amendments relate to the membership of health and well-being boards. As currently proposed, the boards will have at least one councillor of the relevant local authority—so it could be one councillor, or it could be more. The choice will be with the council. However, several other people who have membership will be officers or unelected co-optees. This means that the board as currently proposed is effectively a board of directors, not a council committee which—unlike all other council committees—is made up of those who are publicly elected. Yet the board as proposed is legally a council committee; and because it is legally a council committee, only councillors can vote—officers must advise. For officers to vote, specific regulations will have to be put in place, and of course they can be. However, I hope that the Minister is willing to think further about this. Councillors, being elected, have both a democratic mandate—unlike officers—and a perception of service provision which comes from a geographical perspective as well as a service perspective. At times that can be very valuable, particularly in a geographically large council area.

To have just one councillor—which is what the Bill permits—would be a mistake. It would mean a council committee, the health and well-being board, would be dominated by officers and co-optees. It would also mean that only one political group was in membership of the board, which in my view would be deeply unwise.

Given the board’s terms of reference, I do not argue that councillors have to be in majority. However, I do argue that councillors are important; that geographical differences in a council area should be acknowledged; and that more than one political group should be fully represented on a board. Amendment 238AA solves this problem. It defines the minimum number of councillors as three. That would give the board greater breadth and enable political proportionality to be effective. Amendment 238AB states that where a council is a county council and part of a two-tier system of local government, there should be a district council representative as well as county representatives because district councils have statutory duties in relation to health and well-being. Having one district councillor appointed in this way as a representative of several district councils is normal procedure for those councils when duties span the two tiers. The other two amendments are simply enabling amendments assuming that Amendments 238AA and 238AB are agreed.

In Committee there was a discussion about councillor membership—how many there should be, whether they should be in a majority and whether they should have powers over the budgets of other health organisations not managed by the council. There was no conclusion to that debate, but I have thought long and hard about it. I have concluded that the amendments in my name and those of the noble Lord, Lord Bichard, and the noble Baronesses, Lady Eaton and Lady Henig, which reflect all parts of this Chamber, give a solution to this problem and would enable us to balance professional knowledge with the necessary democratic accountability.

I do not propose to press this to a vote, but I hope that the Minister will be willing to engage in discussion on it. What is being proposed from all parts of the House is a solution to a problem that needs to be resolved. It will prevent difficulties arising further down the line should a council decide to have only one councillor as a member of the board.

[Baroness Finlay of Llandaff]

My Lords, I shall speak briefly to Amendment 238A, which is in the name of my noble friend Lord Ramsbotham. I rather hope that the Government will take on board its spirit, if not its actual wording. The reason is that in creating a joint strategic needs assessment, there will be a requirement for those involved to begin to work in a completely new way. Human nature is such that people tend to repeat the patterns of things they have done before. In addition, they do not know what they do not know. When they feel insecure, they are less—not more—likely to consult, because it is quite threatening to have to consult and go beyond the boundaries of what you thought you knew and discover all the things that you did not know.

The beauty of the amendment is that it creates an obligation to,

“consult relevant health professionals and any other”

person, without specifying who they are. It leaves it very broad but it pushes forward the boundaries. We have already discussed the problem of children. The difficulty, if people do not consult widely, is that if children miss out at a developmental stage and one aspect of their development—for example, motor development, speech and language development or emotional development—does not occur, they never catch up. It is missed out for good; they always lag behind.

It is really important to make sure that the provisions are there right the way through the trajectory from birth onwards to make sure that the needs of children as they develop are met, that deficits are identified early and that interventions take place immediately.