Care and Support

Earl Howe Excerpts

Wednesday 11th July 2012 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, with the leave of the House, I shall now repeat a Statement made earlier in another place by my right honourable friend the Secretary of State for Health on the care and support White Paper, the draft Bill and the progress report on funding reform for social care. The Statement is as follows:

“With permission, Mr Speaker, I would like to make a Statement on the future of care and support for adults in England. The coalition programme said that reform is needed urgently. We inherited a system that too often lets people down and is unfair, a system which was complex and confusing and which responded to a crisis but too rarely prevented it.

For many years, people have called for a system fitted around the needs of care users, not the preferences of the service—one that puts people at the heart of the service and delivers high-quality care with dignity and respect. We knew two years ago that we had to offer urgent support to social care. In the spending review 2010, we provided an additional £7.2 billion for social care over the course of this Parliament, including nearly £3 billion from the NHS to deliver more integrated care. This gives the current system resource backing, but not reform. We need also to build a better service for the long term.

The White Paper I am publishing today represents the greatest transformation of the system since 1948. The practical effect will be to give service users, their carers and their families more peace of mind. Services will be organised around each individual’s care and support needs, their goals and aspirations. Intervention will be earlier, promoting independence and well-being.

The White Paper will support people to remain active in their own communities, connected to their families, friends and support networks. We shall invest an additional £200 million over five years in the development of specialised housing for older and disabled people, so that people can stay independent in their own homes for as long as possible.

The role of carers is critical, so we will transform how the system views and treats carers. We will extend rights for carers to have an assessment and for the first time provide a clear entitlement to the support they need to maintain their own health and well-being.

The measures in the White Paper will make it easier for people to understand how care and support services work, and what their entitlements and responsibilities are. To give people greater consistency of access, we will introduce a national minimum eligibility threshold, as the Dilnot commission suggested. We will require councils to start supporting people as soon as they move into a new area, so that it is easier for people to choose to move home to be nearer to their relatives. Local authorities will be under a duty to ensure continuity of care and that care users are able to take their assessments with them if they move area.

We will establish a single website to provide clear and reliable information about all care and support services for self-funders and local authority-supported users and carers. As well as these improvements to national information, we will invest £32.5 million to ensure that there is better information about the range of local care and support services available in each area.

We want people to be confident that the care and support they receive is delivered by a compassionate and caring workforce. We will place dignity and respect for care users at the heart of a new code of conduct and minimum training standards for care workers. Alongside the new minimum standards, we will train more care workers, with 50,000 more apprenticeships by 2017.

A key requirement is for people to be confident that they will be treated with dignity and respect and that providers deliver high-quality care at all times. We will rule out the crude practice known as “contracting by the minute”, which can so undermine people’s dignity and choice. We should contract for quality and service, not by the clock. We will call on local Healthwatch organisations to make active use of their power of entry, allowing them to visit care services in their local area and make recommendations to the providers and local authority commissioners.

People should also be entitled to expect that services will be maintained if a provider fails. Working with local government and the care sector, we successfully handled the consequences of the Southern Cross crisis, but we also learnt lessons. So we will consult on how we can anticipate and act to ensure continuity of care if a provider goes out of business. Care itself, not the provider of care, is the most important factor.

A key theme of the White Paper is that those receiving care and support know what is best for them. It is right that they must be in control of their care and support. We will make sure that everyone is entitled to a personal budget, so they can be in control of their own care. We will offer all who want it a personal budget and, by 2015, a legal right to request this as a direct payment.

To make it easier for people to get the care they want, we will ensure that they have better access to independent advice. We will make it easier for people to see whether a care provider is good or not, so that they can make real choices through an online quality profile for each provider. We will work with a range of organisations to develop comparison websites so that people can give feedback and compare the quality of care for themselves.

Integrated care is important for everyone, regardless of age or the reason they need care and support. However, getting integration right is particularly important for people when they may be moving from one service to another. That is why we are transferring an additional £100 million in 2013-14 and £200 million in 2014-15, beyond previous plans, from the NHS to social care, to support social care services that benefit people’s health and well-being, and promote better integrated care.

The White Paper will help people get better joined-up care at key points in their lives. We will legislate to give adult social care services a power to assess young people under the age of 18 and we will ensure protection so that no young person goes without care while waiting for adult support to start.

We want people to receive the best possible care at the end of their lives, including a choice over where they die. The palliative care funding review recommended that all health and social care should be funded by the state once someone reaches the end of life and are entered onto the end-of-life care locality register. We think that there is much merit in this and will be using the eight palliative care funding pilot sites to collect the data and experience that we need to assess the proposal.

Alongside the White Paper, I am today publishing the draft care and support Bill. Many of the White Paper reforms need new legislation to make them work and the draft Bill is a major reform in its own right. The law for adult social care is complex and outdated. All those involved know how it has made the system harder to work in. The draft Bill sets out a single, modern statute for adult care and support. It brings together and simplifies provisions from at least a dozen Acts of Parliament, reflecting the recommendations of the Law Commission. It builds the law around the well-being, needs and outcomes of real people—clear principles, clearly set out in law.

I am also today publishing a progress report on funding reform. In July 2010, I asked Andrew Dilnot to review the funding of the system of care and support in England. I can confirm today the Government’s support for the principles of the Dilnot commission’s report as the right basis for any new funding model; that is, financial protection through capped costs and an extended means test.

It would, as Andrew Dilnot himself said, enable people to plan and prepare, so that they are not so vulnerable to the arbitrary impact of catastrophic care costs. The progress report sets out a detailed analysis of this funding model, giving us a better basis for making decisions about how these changes can be funded. Of course, any proposal which includes extra public spending needs to be considered alongside other spending priorities, which include the demographic pressures on the social care service itself. The right, the necessary, place to do this is at the next spending review. Our talks with the Labour Party were constructive, but no plan for funding Dilnot was agreed, or, indeed, proposed by either side.

A decision at the next spending review will allow time for continuing discussions with stakeholders and between the parties, and we can undertake open engagement on detailed implementation issues and options. These discussions will include the level of the cap, whether a voluntary or opt-in approach is a viable option in addition to the universal options and whether legislative provision is required.

However, as the report makes clear, we are also taking definitive steps now by accepting a number of the Dilnot commission’s recommendations. Most notably, we will introduce a universal deferred payments scheme. This will mean that no one will be forced to sell their home in their lifetime to pay for care. Provisions for this are included in the draft Bill.

The White Paper, the draft care and support Bill and the progress report on funding together set out our commitment to a modern system of care and support—one designed around the needs of individual people; one with dignity and respect at its heart; and one that brings care and support into the 21st century.

These reforms are the product of immensely helpful reviews by the Law Commission and the Dilnot commission and come from a positive and wide-ranging engagement with the care sector and the public, helping us to design the kind of care services and support that all of us would like to see for ourselves and our families. We are determined to secure these reforms—to achieve in this Parliament that which our predecessors failed to achieve in over 13 years. I intend to continue and develop this open co-operative approach to developing these reforms. I commend this Statement to the House”.

My Lords, that concludes the Statement.

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[Earl Howe]

My Lords, I thank the noble Baroness for her comments and questions. While she levelled a number of criticisms at the Government, I was glad to hear her positive comments—although I would characterise her speech as a glass half empty speech rather than the opposite. Nevertheless, I am grateful to her for recognising that this package of proposals represents progress. In many areas it is progress that her party and mine fully sign up to. However, she said at the start of her remarks that there was a lack of vision and strategy in these proposals. I was sorry about that because I do not share her view. The White Paper and the draft care and support Bill undoubtedly form the most comprehensive overhaul of care and support since 1948. They respond directly to the concerns that people have raised with us time and again.

I hope that when the noble Baroness reads the White Paper she will agree that the whole flavour is about creating a system that keeps people independent and well. There are many major commitments in the White Paper, including more support and equality for carers, housing investment, better information and personal budgets. Those things all combine to set out a new vision that tailors care around people’s well-being, rather than expecting people to conform to a system, which is what we have at the moment.

The noble Baroness criticised the Government for delay. I gently point out that more than 13 years ago there was a royal commission chaired by the noble Lord, Lord Sutherland. The previous Administration had 13 years to respond to it but did not do so. Nevertheless, progress was made in certain areas. We have gladly picked up on some of the areas of progress that the previous Administration put in place, not least in the area of carers. However, it is not true that since the present Government came to office we have seen no action. One of the first decisions that we made was to protect care and support in the spending review through an additional £7.2 billion over four years. That was an explicit recognition of the strains that local authorities were expected to come under. I announced through the Statement today further funding in recognition of those strains at local level.

It is true that some of the changes will take longer than others, but progress will be made within 12 months. It will include introducing quality profiles for every provider so that people have comparative information on the quality of different organisations, investing £200 million over the next five years to develop specialised housing, publishing a code of conduct and minimum training standards for care workers, and launching a new national information website at nhs.uk. I hope that the noble Baroness will welcome those innovations.

On the deferred payment scheme, there is a lot of discussion to be had. Our proposals are that deferred payments will be available in all local authorities. Currently they are available in some but not all. As the noble Baroness knows, the social care means test requires people to use their housing wealth when they go into residential care. We are announcing that we will allow people to pay later, giving them more time to sell their home at their convenience or even for it to be sold after their death. We are not confirming now exactly who will be eligible or the rate of interest that will be attached, but we have said we will consult on these issues with the care sector.

As regards the cross-party talks, I should like to put it on the record that we fully intend to continue to engage with Her Majesty’s Opposition and with the sector on options for implementing the Dilnot model as well as with Mr Dilnot himself. At this stage, we are open-minded as to what form that engagement should take. As has been the case to date, discussions on funding reform will be led by the Department of Health on behalf of wider government. We wish to continue what I believe has been a very constructive series of discussions, with the Opposition in particular. The disagreements and criticisms that blew up over the weekend were regrettable and we wish to draw a line under that. I hope the noble Baroness will appreciate from the correspondence that has flowed between our two lead spokesmen that that is indeed the intent.

The noble Baroness is not correct as regards the NHS underspend. It was not lost to the NHS. The overall year-end surplus of £1.6 billion for PCTs and SHAs last year will be carried forward and made available in 2012-13. That represents a 3% increase in funding available to the NHS relative to last year. As I mentioned earlier, we are allocating further funding on top of the £7.2 billion that we previously announced in support of local authorities.

There are many questions to answer in this package. I do not hide from that, but it is right that we take time to work through this, including engaging with all stakeholders to ensure that any reform is sustainable and fair.

[Baroness Northover]

My Lords, before we get into the session where all Peers can contribute, I remind noble Lords that the Companion states that ministerial Statements are made for the information of the House and that, although brief comments and questions are allowed, Statements should not be made the occasion for immediate debate. Perhaps I may emphasise brevity and therefore the courtesy of allowing as many noble Lords as possible to contribute.

[Baroness Campbell of Surbiton]

My Lords, I must briefly declare an interest. I am a 24-hour social care service user, and long may it last. Temporarily ignoring the social care funding elephant in the room, I feel there is much to welcome in this White Paper, which concentrates on independent living, empowerment strategies, and supporting people to stay at home and contribute to their communities instead of the current safety-net crisis interventions. That has been my life’s work.

I am also pleased to see that the Government are obviously keen to incorporate my Private Member’s Bill on social care portability. Naturally, I must ask the Minister whether the Government intend portability to offer an “equivalence of support” outcome so that disabled people feel confident that they can continue with their chosen occupations, responsibilities and lifestyle wherever they go, because this will put an end to the postcode lottery.

[Earl Howe]

My Lords, I pay tribute to the noble Baroness for all the work that she has done in this area, particularly on portability. This is a good news story. We are committing in the White Paper to breaking down the major barrier to portability: that people’s care is disrupted when they move local authority area. The draft Bill contains a clause that puts a duty on to local authorities to ensure that when a person—and their carer, if applicable—moves local authority area, their needs continue to be met until they are reassessed by that local authority. The clause also sets out that local authorities are under a duty to share information, and the receiving local authority has the power to assess the individual—and carer, if applicable—before they move. This seeks to ensure that the move is as seamless as possible. I do not doubt that this is an area that we shall debate over the coming months.

[Lord Lipsey]

My Lords, I emphasise the extraordinary importance of all-party consensus on this matter. Without that, older people and their families will not know what to plan for in the long term, and indeed insurance companies that could help out will not be able to design policies to help them do so. Will the noble Earl deplore the leaking of the documents in front of us this afternoon? The leaks greatly exaggerated the benefits that the actual policies announced will deliver, and have derailed the all-party talks. These policies should have been floated with the Opposition before they reached the public domain. I am not saying that he did it, but will he apologise as a way of getting those all-party talks back on an even footing?

[Earl Howe]

My Lords, I fully agree with the noble Lord about the need for cross-party consensus. If we are to have a long-term sustainable solution for the funding of social care, we must have that political consensus. Indeed, that was the intent behind the cross-party talks. I very much regret the leaks. These were not our doing, but they did create an impression of bad faith. Again, I regret that. No bad faith was intended from our quarter or indeed from any other quarter in government. I think there was an element of misunderstanding about our intentions, but I agree with the noble Lord that the cross-party bonhomie has been disrupted. We very much wish to put the whole process back on track, and I hope that his party will respond accordingly.

[Baroness Jolly]

My Lords, I am a glass half-full sort of person, so I heartily welcome the White Paper and the draft Bill on care and support, and note the progress report on funding reform. We are certainly looking forward to pre-legislative scrutiny. Can the Minister give the House some indication of the timetable and the process? Will he also tell the House what the Government’s view is on including enabling clauses in the draft Bill to allow the Dilnot-based scheme to be implemented?

[Earl Howe]

My Lords, my provisional understanding —and I stress that—is that pre-legislative scrutiny will begin in the autumn, probably in November. Between now and then, plans will be put in place to decide the composition of the pre-legislative scrutiny committee so that the process will conclude by the end of this Session of Parliament. In principle, there is no reason why enabling clauses should not be inserted into the legislation. As I have emphasised before, it would be preferable if they were clauses on which we could all agree.

[Lord Howard of Lympne]

My Lords, I declare an interest as chairman of Help the Hospices. I welcome both the extra money that the Government are making available for the palliative care pilot projects and the Government’s acceptance in principle that end of life care should be free at the point of delivery. Can my noble friend give the House some indication of the timetable by which this very desirable objective might be achieved?

[Earl Howe]

My Lords, the short answer to my noble friend is that we need to look in detail at the funding implications. At this stage all I can say is that our intent is to introduce this at the earliest opportunity. However, I am afraid I have not been given the green light to give him chapter and verse at this stage. As soon as I am able to do that, I will gladly do so.

[Lord Laming]

My Lords, may I ask the Minister two quick questions about domiciliary care? First, do the Government accept that during the past decade, there has been a marked deterioration in the availability and quality of community care? It has deteriorated so much that, as the Minister said, it now often seems to be measured in minutes, depriving very vulnerable people of dignity both in feeding and in toileting. Secondly, if that is the case, what mechanism are the Government going to employ across 150 local authorities to make sure that they deliver the standard of domiciliary care about which he spoke?

[Earl Howe]

The noble Lord is quite right; there is huge concern about the sometimes tick-box attitude to domiciliary care, very often resulting in nugatory time spent by care workers with those they look after, which one is tempted to say is hardly worth while in some cases. We are very aware of this. Part of the answer lies in our plans for personal budgets, which should give service users much greater scope to define what they want and what their needs are. The service should then work around those needs and requirements. However, we are also talking about the workforce here.

We are clear that the minimum standards for health support workers and adult social care workers in England that are being developed by Skills for Care and Skills for Health will set a clear national benchmark for the training of support workers and their conduct when delivering care. We expect that the standards produced will inform proposals for a voluntary register for adult social care workers in England, which could be in place by next year. This will allow unregulated workers to demonstrate that they meet a set of minimum standards and are committed to a code of conduct.

All those things combined should move us away from the kind of culture that in some places, although not in all, is degrading the quality of care that is delivered.

[Lord Warner]

My Lords, I congratulate the Minister, and pass these congratulations on to his right honourable friend, on making progress on the Dilnot commission recommendations, as well as on the other measures in the White Paper. I declare my interest as a member of the Dilnot commission.

I also congratulate the Minister and his right honourable friend on extracting his documents from the dead hand of the Treasury. In that connection, I ask him to confirm two things. First, it will, I believe, be impossible to deliver a deferred payment scheme by April 2015 without a clear decision on the cap that will be required to underpin it, and the extended means test. Can he confirm that decisions will have to be taken on these two issues in order for a deferred payment scheme to go ahead?

Secondly, his right honourable friend rightly said that he was in the market for open cross-party discussions on the way forward. Does this mean that the Treasury will participate in these and will not blackball politically contentious proposals that may be found for funding and sustaining the implementation of Dilnot, even where those proposals may recoup some money from the very population groups that are going to benefit from a better adult social care system?

[Earl Howe]

First, I thank the noble Lord for all that he did as a member of the triumvirate of the Dilnot commission. There is no doubt that we owe him and his fellow commissioners an enormous debt. I am grateful to him for his kind remarks about this set of announcements. We propose to introduce deferred payment without the cap necessarily being in place. We believe that that can be done. I understand the direction from which the noble Lord comes, but a system that obliges local authorities to offer deferred payment where certain eligibility criteria—yet to be defined, admittedly—are met is deliverable in the absence of a cap. That is not to say that we do not wish to work hard to define what that cap should be.

On the noble Lord’s second question about the dead hand of the Treasury, I would not characterise my esteemed colleagues in that venerable department as dead hands. However, I acknowledge his central point about affordability. That is why we have felt it necessary to defer final decisions on how the funding of the Dilnot principles will be worked through until the next spending review. That inevitably means that my colleagues in the Treasury will have a direct interest in the result; it would be strange were it otherwise. Nevertheless, that does not preclude creative and constructive discussions between our two parties.

[Baroness Browning]

I welcome my noble friend’s Statement, but does he accept that there is still a significant challenge in providing appropriate packages of care, particularly for elderly people, on discharge from hospital following an emergency admission? This relates to the type of care required when there is a significant change in needs and people are unable to return to their home, or sometimes even to a residential home. There is a transition, but some of those people could make more progress in their recovery. I am thinking of stroke patients in particular. I hope the Minister will be able to reassure me that these changes will include looking again at this group.

[Earl Howe]

I agree with my noble friend. Only last week, I talked to people at the Norwich and Norfolk University Hospital who emphasised that very point. Very often, the absence of packages of care that are tailored to the needs of the individual results in delayed discharge from hospital and often a deterioration in the condition of the patient. That helps no one. There is therefore a burning need for commissioners, providers and those providing care in the community to work together to define appropriate packages. I fully agree with my noble friend that those who have had strokes are particularly in need of the kind of packages that can best assist them when they move back into their own homes. This is an area that is crying out for further work. We hope that it will flow from the creation of clinical commissioning groups and health and well-being boards at a local level.

[Lord Sutherland of Houndwood]

My Lords, I am very happy to welcome the ministerial Statement as one of the first distant tweets of a swallow, perhaps announcing some hope of spring. However, as we all know this year, summer does not inevitably follow spring. I do not take the view that the glass is half-empty; I take the view that it is currently about 20% full. The real question is about how you put the other 80% in. That has to do with money—there are no two ways about it. Until that is confronted, I will not be convinced that the Government or—even more so—the Treasury understand the scale of the issues facing us. Demography has been announcing them for 15 or 20 years and they will get more and more urgent. There is a requirement not just for an incremental change but for a reassessment of priorities, as the Statement suggested.

One suggestion in the Statement is the importance of the integration of care. I thoroughly agree with that but have a question for the Minister. Can he reassure us that it will at least be considered that the integration of care be followed by the integration of budgets between health and social care? Many of us believe that that is one element that has to be put in place. I would not want it ruled out as an issue.

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[Earl Howe]

I am grateful to the noble Lord and thank him for all his work in this area over the years. However, I am sorry that he regards the glass as only being 20% full. I would regard it as much more full than that, bearing in mind the contents of the White Paper that I outlined earlier. No, we are under no illusions about the scale of the issue, its importance or the need to get it right if the NHS is not to bear the brunt of serious strain within social care. It is an urgent matter. We are determined to fill the glass to its fullest at the earliest opportunity.

On integration, as I am sure the noble Lord knows, we have options open to us already to ensure that budgets can be pooled at a local level. This is happening in many areas. It is a very useful device to enable the NHS and social care to share responsibility for delivering care to patients and service users, who after all do not mind very much whether the service is delivered by the NHS or by social care as long as the right service is delivered. We need to work much harder on that area, too.

[Baroness Bakewell]

Can I draw the Minister’s attention to the characteristics of the very old? Time speeds up when you are old. Christmas comes round more regularly and the years pass faster. Coupled with that is increased anxiety about what those years will bring. The timescale of these matters that concern funding have a particular poignancy for people who have only a few years of life left. I urge the Minister to persuade his colleagues that the nature of defining these sums of money will give a lot of ageing people who are worried peace of mind—a phrase used in the White Paper.

[Earl Howe]

I pay tribute to the noble Baroness for all her work on behalf of the elderly. Of course she is right in her perception of the way that the elderly view time passing. We have yet to sort out the precise funding mechanism for Dilnot. However, in the mean time, as I have emphasised, we are channelling significant extra funds to local authorities to tide them over. We believe that that will be of help in the short term. Also, the deferred payment scheme should deliver considerable peace of mind to many elderly people who find that they need to move into residential care and, for whatever reason, do not wish to sell their houses. I hope that that proposal will find favour with her.

[Lord Neill of Bladen]

I wonder if—