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16 Oct 2001 : Column 192WH

Elderly People (Long-Term Care)

11 am

Mr. David Heath (Somerton and Frome): I am grateful for the opportunity to introduce this extremely important debate. It is about one of the most important matters that we can discuss, because in the long run it affects us all in one way or another. It is a truism to say that the way in which elderly people are treated is the measure of a civilised society, but I have great concerns about the level of provision and the way in which it is organised. Those concerns originated some years ago, when I was for a time actively engaged in discussions with care home owners and my social services department. They were given added immediacy a few months ago with the very sudden closure of a nursing home on the edge of my constituency, as a result of which the residents, who had lived there for a long time, were given just a week or so to find new places to live. None of us would wish that to happen to elderly and poorly people, who are some of the most vulnerable in our society.

I do not use the term "crisis" loosely—it is often overworked in politics—but I fear that we truly face a crisis in long-term care. A crisis is not merely developing but has already developed in many parts of the country, especially where there is a preponderance of elderly people. The Minister will be familiar with the national figures. About 50,000 long-term beds have been lost over the past five years, with an accelerating loss of 28,000 beds over the past two years. That has been accompanied by loss of placements and loss of front-line care staff—not only in care for the elderly but across the board within social services.

In my county of Somerset, we are not immune to that trend. Indeed, the west country has a significant population of elderly people. In the year to April, Somerset saw a 10 per cent. reduction in the number of available nursing home places. Again, there is an accelerating trend—a further 200 beds have already been lost this year since April and it is reasonable to expect that at least another 100 will be lost before the end of the year. That is bad enough in itself. However, there is a specific problem within that bald figure, in that we have particularly lost places for sufferers from the various dementias. That is a difficult group of people to cater for effectively, and once places have been lost it is much harder to find alternatives for them.

Along with the loss of nursing care places, we have lost a significant part of our home care service. In some parts of the county it is difficult to provide an adequate level of domiciliary care, not least because providers are finding it extremely difficult to recruit and retain suitable staff. I underline the word "suitable", because not everybody has the vocation or the ability to do such demanding work for very little pay. It is hard to ensure that sufficient numbers of staff are in the right places. As a result, it is not unusual for there to be a four to six-week wait for the delivery of larger-scale care packages. That is not something that we in Somerset wish to see.

The automatic corollary of the loss of nursing home and residential home places is the problem of bed-blocking. In the south-west, there has been a phenomenal increase—54.1 per cent. in two years—in the number of delayed discharges. That is worrying in

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anybody's book, and it has knock-on effects for our hospitals. It makes it difficult, for example, to transfer patients from accident and emergency units to ordinary surgical or medical wards. That affects staff morale, because they are unable to do the job that they would like to do in the way that they would like to do it. Delayed discharges also directly affect the patients themselves. They affect their well-being in the ordinary sense of the word, but a prolonged stay in hospital can also often lead to an increased risk of hospital-acquired infections. That is a worrying prospect, given that, as we must remember, we are dealing with elderly people.

I do not wish to gloss over or neglect a major national policy difference between my party and the party of government in the United Kingdom, but I do not wish to dwell on it either, as it has been sufficiently advertised elsewhere. Of course, the difference exists only between my party and the UK Government; we have no such difficulties with our partners in government in Scotland. Nevertheless, in England there is disagreement as to whether personal care should be paid for. We believe that, as the royal commission said, it should be paid for.

The differentiation that the Government have introduced into the process of delivering service is artificial and deeply damaging. Deciding whether care should be paid for on the basis of who provides it rather than according to the type of care provided seems an absurd way to proceed. That has a particular resonance in respect of dementia, which I have raised before on the Floor of the House. It is impossible to draw a line between services that comprise personal care and nursing care. It seems that the only definition that applies is whether a registered nurse provides the service, and that cannot be right.

I am also concerned about the position of disabled people. They need support, whether they are in their own homes or in residential homes.

Mr. David Drew (Stroud): Another problem is the handling of information on individuals and homes. Is the hon. Gentleman familiar with minimum data sets? They would be a credible way in which to improve the handling of information, thereby helping those involved in personal and nursing care. I hope that he agrees that, at the moment, there is a real shortfall in the system.

Mr. Heath : I am happy to agree with the hon. Gentleman and I am grateful for his intervention. We need a much fuller assessment of individuals' needs; to try to make such assessments prior to, or at the point of, admission is frankly absurd. What is needed is a period of reflection, in which an assessment can be made and a proper database established and maintained according to the needs of the individual patient. Such a model is not unusual in other areas of care in this country; nevertheless, it has not been espoused in this case.

Having criticised the Government for this basic policy difference—as I said, although I do not shy away from that difference, I do not wish to dwell on it—I congratulate them on recognising that there is an immediate problem. I wholeheartedly welcome the new money that has been provided—an additional £100 million this year and £200 million next year. That

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underlines the Government's recognition of the real problem that exists in various parts of the country. I appreciate that this is significant money; it is not peanuts. However, it must be viewed against the assessment by the directors of social services and the Local Government Association, which has bluntly stated that a £1 billion shortfall exists in the funding of care for vulnerable people across the country. Set against that context, obviously much more must be done.

I will not be churlish. I welcome the money that has been given to Somerset's social services department to assist it in achieving its goals—I understand it to be £726,000. However, it is unfortunate that that share is proportionately less than the staff at Somerset might have expected. Traditionally, Somerset has been rather good at providing investment and the services that people need.

Paddy Tipping (Sherwood): The hon. Gentleman makes a strong point about the allocation of £300 million; some £100 million for the current financial year and £200 million for next year. I understand that the vast proportion of the £100 million goes to the worst performers, which seems to be a change in the Government's position. I hope that the £200 million for next year will be allocated on a more rational and equitable basis.

Mr. Heath : I am grateful to the hon. Gentleman for making exactly my point. We do not know how the money will be distributed next year, but I fervently hope that the Minister will tell us that it will be on a formula basis. There may be arguments about the basic formula, but the present lack of formula is a perverse way of providing incentives and recognising the needs of local authority departments.

What are the causes of the marked reduction in the number of care places available over a short period? A number of problems play a part in the decision to close a home or reduce the number of places. Fear of the impact of the Government's new standards for care homes is part of the equation. The staff of some homes know that such standards will never be met, while others have an exaggerated fear of what may be imposed on them in future and do not want to be part of that game. For some, the new standards represent the last straw that breaks the proverbial camel's back.

One argument is that a more flexible approach is needed that recognises the paramount needs of the residents and the fact that they are not always best served by the closure of a home. Closure of a home is the worst outcome for an individual resident. A more flexible approach may be of great benefit. Another problem is the shortage of staff, not only of trained nurses but of the untrained staff who provide home care in many cases. Such staff, who are traditionally low paid and predominantly female—the two often go together—are asked to take on extraordinarily complex and demanding tasks. Many of us would never wish to find ourselves engaged in such tasks.

The competition with the private sector means that many people are tempted away by easier and better paid billets outside the public sector. The arrival of a new

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supermarket is a disaster for the local care homes and social services providers. A Tesco store opens and suddenly no staff are left to make beds and care for elderly residents in homes. We must recognise that market forces demand that something be done to provide better pay and conditions for the staff in this important sector.

Another element is property values. In my part of the world we have seen those values increasing, especially at the upper end of the market. Large country houses have traditionally been used for residential homes, and the property value of such buildings is vastly in excess of the value of the business. The constant temptation must be to forget about running a business and take the capital sum offered by someone in the City who wants to play at being a squire in Somerset. That is happening more and more often.

The fees payable also constitute a problem. The average increase in local authority fees paid to care homes is around 2 per cent., as against a 5 per cent. average increase for those who pay privately for residential or nursing care. The equation does not work. The problem for care home owners is that they do not have dealings with the rest of the country—they deal only with the social services department where they are situated. As far as those owners know, the local authority is simply mean and not prepared to pay them the rate for the job. That is certainly not the case in Somerset, however, and I am sure that is not the case in the vast majority of social services areas, but because owners see only those with which they have dealings, they do not understand that this is a national issue. Can local authorities afford to pay sustainable fees to maintain the sector and placements that they need?

We often say that throwing cash at a problem is not an answer, but in this case cash is the most important single factor. We must get enough money into the system to achieve sustainable fee levels without losing the other care professionals for which social services departments are responsible. Many departments could be forced to provide cash for care services for the elderly at the expense of other important services for vulnerable people.

We need to find a way of putting more cash into the system, although not preferentially—a point made by the hon. Member for Sherwood (Paddy Tipping). We must not produce fee competition between neighbouring authorities. Some authorities may find that, because they have responded poorly in the past, they have more money in their budget and can pay higher fees to attract staff and placements from neighbouring authorities. That cannot be the answer, nor can it be the answer simply to exhort social services departments to do more. We know from the Local Government Association that three quarters of all social services departments overspent their budgets last year, which represents a total overspend of £183 million. That is a substantial overspend; if I were a council leader, I would be worried about my social services department, or any other department, overspending to such an extent. There is clearly more than a little strain on the system when social services expenditure by local authorities is £1 billion over the standard spending assessment—the Government assessment of what those departments should be spending. The system is not functioning properly.

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What are the answers? There are no easy answers and I do not want to abuse the intelligence of anyone listening to this debate by pretending that there are. However, we should have local sustainable strategies that involve the private sector, the home care sector, the user groups—if that is the appropriate term—the health authorities and the local authorities. I know that in Somerset that is very much part of the way in which the local authority has thought previously and continues to think about dealing with the problems. However, the Government must support sensible strategies that are put forward with the cash to make them work.

To return to a matter that was raised earlier, there is a need to identify what funds will be available in the future. They should be on a formula basis, not a speculative favoured-son basis or any other; they should be fair and respond to demonstrable need. The funding stream should continue into the future.

It is important not to forget that there is a need to respond to the increasing demand for home care and domiciliary care. Many years ago when I was in practice as an optician, I did a lot of domiciliary work and I was not paid a penny for it. There was no recognition of domiciliary work in optics at that time and I was paid as if I was in my surgery. The fact that I had driven halfway across the countryside to see one bedridden elderly lady was neither here nor there to the national health service. It did not care about that, or whether I did it or not. However, I did, and so did many other professionals. We must recognise that domiciliary care is promoted to give people the independence to live in their own home. If we are to promote that, we must fund it properly and recognise the difficulties that it involves. We also need flexibility in the application of care home standards, and the Government would do well to signal that clearly to the private home sector so that some of its worst fears, at this stage, are allayed.

Most important, we need a national review of the capacity that we have—or rather do not have—to deal with long-term care. We must recognise that there is a long lead-in for any changes in that capacity. Homes are not built overnight, and staff are not trained overnight. There is a significant shortfall in capacity, and we need to do something about it nationally, so we need a clear national strategy.

I would love the consensus that exists in Scotland to extend to England and, dare I say, Wales. At present it is not on the table, although it may be. Policies in Scotland sometimes have a habit of eventually seeping their way through the system and become the national policy of the United Kingdom Government. The battle may not be lost. Meanwhile, I urge the Minister to address the matter, which is of desperate importance. I suspect that many hon. Members will recount their own constituency experiences and express that same view.

11.23 am

Hywel Williams (Caernarfon): I am particularly glad to be given the opportunity to speak because I wrote Plaid Cymru's submission to the Sutherland royal commission on long-term care. We in Plaid Cymru agreed with the recommendations of the royal commission and many older people in Wales looked forward to the Government acting on its

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recommendations, particularly those on funding. The hon. Member for Somerton and Frome (Mr. Heath) might not have wanted to dwell on the differences between Scotland and Wales and England, but we in Plaid Cymru and, certainly, our colleagues in the Scottish National party see the differences as highly significant.

We were all disappointed when the Government acted because, as we all know, free personal care was introduced in Scotland, but not in Wales and England. The matter of funding is particularly significant in my constituency and my part of Wales. In Gwynedd, we have a particularly high level of residential care for older people, and a relatively higher percentage of older people who may be subject to charging. We also face difficulties because much of the residential care stock is old and requires significant investment to bring it up to standard without compromising the standard of care provided to current and future residents.

Furthermore, levels of personal wealth in my constituency are low. Inherited capital from the sale of a parent's house has a particular significance for the local economy. That inherited capital is, of course, disappearing—I have had visits to my surgeries from constituents who are worried about that because they are passing on to many children shares of the small amounts of capital that they have accumulated.

My constituency also has a large number of care businesses, many of which are run by small, local operators. They are not large businesses or companies; they are often run by husband-and-wife teams. Those businesses are now facing greater uncertainty in their planning, and reference to that was made earlier.

In respect of the royal commission, a partial answer was given to the problem of funding in Wales and England. That partial answer has led to further problems. The system is unpopular—that goes without saying—and one might almost say that it is in disrepute. People who have saved all their lives see their savings reduced and lost to them and their children merely because they are in need through no fault of their own. That is a tax on need.

How does one distinguish—this is an old question—between social and medical care? I taught social care workers for many years in my previous career, and I certainly find it difficult to distinguish between those two types of need. Again, there is the well-rehearsed question: what is a social bath, and what is a medical bath? To ask another question: is putting on incontinence pads a medical matter, and putting on trousers over them a social one?

Mr. George Stevenson (in the Chair): Order. We have a problem with the microphones. If hon. Members move forward to the front row, everything will be okay. However, that does not guarantee that everyone who wishes to speak will be called. I apologise to the hon. Gentleman for interrupting his speech.

Hywel Williams : Thank you, Mr. Stevenson. Being heard is much better than not being heard.

The questions that I was posing are old ones, and clearly absurd. However, they are not the result of professional absurdity. Such questions arise directly

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from the Government's decision to differentiate between the medical and social elements. Deciding on what is a social need and a medical need takes time. Again, that is not the fault of the professionals involved. I understand that decisions have been held up by local panel meetings and constituents have approached me asking to hurry up the process of deciding who should be responsible. However, a system that is intrinsically complicated cannot be hurried up. That is the response that I have had from social services.

As I noted earlier, care providers in my constituency have postponed decisions on large capital investments because of the uncertainty about whether to build on the basis of meeting medical need or social need. Those are real decisions, and extra costs are involved. The effect is that care beds are being lost or denied, and there are delays in discharge from hospital, for example.

We in Wales want a system of care funding that is straightforward, effective and fair. From our point of view, the people of Wales, through our National Assembly, should take the decision on the nature of that system of funding. As Sutherland said, people who are in need should have that need met whatever their personal circumstances. That is the civilised response, and it is also Plaid Cymru's view.

11.29 am

Mr. Kelvin Hopkins (Luton, North): I congratulate the hon. Member for Somerton and Frome (Mr. Heath) on initiating this important debate today, and I am grateful for the opportunity to speak in it. I shall discuss two main issues. I do not expect my hon. Friend the Minister to give way to us today, but I hope that she will take note of what we say and consider possible future changes.

I profoundly believe that long-term care for all elderly people should be free at the point of use, and that we should implement the royal commission's recommendations and move to the Scottish position now. Many Labour Members feel the same as I do, and we shall not rest until that change takes place. I recommend to the Minister the memorandum prepared by Unison, the trade union for which I had the honour of working for many years, which has made an excellent case in much more detail than I can go into this morning.

National assistance limits on personal resources were first introduced more than 50 years ago. If the figure used then were indexed forward, it would come to more than £200,000, not the £18,500 that is now the limit below which local authorities pay. That would constitute not means testing but a wealth tax; indeed, I might suggest that if the Government want to raise extra revenue they consider a proportionate, progressive equitable wealth tax that would help pay for long-term care.

The hon. Member for Caernarfon (Hywel Williams) mentioned the problem of inherited capital, which will have a significant effect on the housing market. Sustaining owner occupation now depends to a large extent on inherited capital—on parents handing on the equity in their houses to their children. If that is increasingly taken away as the population ages, it could create housing difficulties as well as long-term care difficulties, with which the Government will have to deal in the longer term.

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The second issue that I shall discuss is local authority homes. My constituency contains three local authority care homes that are currently under threat of closure. The Government, no doubt for very good reasons, have decided to raise the standards required of care homes. Two of the care homes involved were purpose built, and I know that they are extremely good, because I have visited them. Indeed, in one of them my late mother-in-law lived for some time and was very happy, receiving excellent care from permanently employed, properly paid, trade union-organised local authority staff. I want those homes to remain open and in operation. However, if the new standards are imposed and they have to be modernised and upgraded without that being fully funded by central Government, the local authority will not be able to afford it, and will effectively be forced to close them and to put more of their long-term care residents into the private sector instead of in the public sector homes available at present.

We have already heard about problems with long-term care in private homes, and the fact that some homes are finding it difficult to make a profit. Whether profit is appropriate in the case of such a service is another issue, but they are finding it difficult to sustain those homes financially and are having a hard time. Property prices are rising, and some see the advantage of selling off, possibly for conversion to owner occupation, as that would be a more profitable use of their resources.

I ask the Minister seriously to consider supporting local authorities that may be forced to close their homes because they cannot afford to modernise them in line with the requirements of the new standards—or, alternatively, to reconsider the care standards. Some purpose-built homes that are still reasonably good—the homes in Luton are extremely good—do not quite match the required standards. We could build new homes to the required standards but, for the time being at least, keep the old homes, as they are, without pressing local authorities to modernise them—in effect, to rebuild them—simply because the rooms might be too small. If and when those standards are imposed on the private sector, the costs of meeting them would be too high, and many private homes would therefore have to close. The homes would be unprofitable, and they would be sold. Indeed, there is a desperate shortage of rented property in my constituency, and the private sector could do very well by selling off its homes or converting them into flats for owner occupation. That would lead to a crisis; a shortfall in care home provision would be created in my constituency.

I therefore make two pleas to the Minister: look again at free long-term care, and give a little support to local authorities that might be forced to close their homes. Although I am publicly opposing such closures, I also appreciate that my local authority faces a desperate financial problem.

Mr. George Stevenson (in the Chair): Many hon. Members wish to contribute to the debate, so I ask those who are called to speak to be as brief as possible.

11.36 am

Dr. Andrew Murrison (Westbury): The hon. Member for Somerton and Frome (Mr. Heath), who represents a constituency that neighbours mine, is extremely lucky,

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as Somerset has been marked out for special funding from the £300 million package that the Government announced on 9 October 2001. That announcement did not carry with it criteria for the award of additional funding, and as Wiltshire has done rather badly out of it, I should be grateful for the Minister's clarification on that matter.

Earlier this year, my Wiltshire colleagues highlighted the inadequate settlement for education funding in the county, and it appears that similar treatment is now being meted out to the other end of the spectrum—the elderly people of Wiltshire.

The hon. Member for Somerton and Frome and I share an interest in the Royal United Hospital, Bath, and I welcome the additional money that has been allocated to Gloucestershire, Somerset and Bath, in so far as it might ease bed blocking at the RUH.

Wiltshire has the longest waiting list for residential and nursing home placements in the south-west that are funded by local authorities, despite the fact that the county's health authority funds 50 places through transfer of funds to the county council, and also that a joint review conducted 12 months ago said that Wiltshire's social services were among the nation's best. I fear that additional funding for neighbouring counties and authorities will, paradoxically, have a bad effect on poorly resourced Wiltshire because neighbouring authorities will be allowed to buy up services from Wiltshire homes and Wiltshire's elderly will be adversely affected. I urge the Minister to re-examine the case for including Wiltshire in the list of 50 authorities earmarked for additional funding on 9 October, because the county's elderly deserve a better settlement than the one that has been offered.

Several hon. Members rose—

11.37 am

Dr. Vincent Cable (Twickenham): The competition among hon. Members to speak reflects the widespread concern about the matter under discussion.

The story that was told by my hon. Friend the Member for Somerton and Frome (Mr. Heath) reflected the experiences of all hon. Members. I wrote a letter to the Minister a couple of weeks ago describing the problems of local social services in relation to spending, such as spill-over in terms of cuts in provision, bed blocking, and upstreaming local hospitals. My letter crossed in the post with the Minister's offer of more funding, so I do not wish to pursue that point.

Instead, I want to highlight another aspect of the problem that has come to the surface as a result of a lead story that appeared last week in, I think, the Sunday Express. It referred to what it characterised as a scandal in a residential home in my constituency. The home is called Lynde House, and it is part of the Westminster Healthcare group. I want to refer to the case, as it serves to illustrate some of the broader problems that are being experienced in the private sector.

The institution, which is part of a large group, is in many ways at the top end of the market; the typical fee is about £660 per week, as it is very well appointed. It appears to be a luxurious home, and it is, no doubt, a very good one in many respects. However, I started to receive serious complaints several months ago, and I

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have now received more than 20 well-documented cases. They were discussed, often in highly emotional terms, at a public meeting that was organised by a local parish priest. The complaints resolved themselves into two types. First, there were complaints about the treatment of physical conditions. For example, elderly people with incontinence problems were left for long periods without being changed and did not get a response when they rang the bell. The underlying problem was that described by my hon. Friend the Member for Somerton and Frome. There is a serious problem in the labour market, with shortages of nursing and other care staff. Staff are badly paid and poorly motivated. There is a high staff turnover and employees have little commitment. Within a context of highly deficient and unsatisfactory management, the elderly people in the home suffered.

Secondly, when people and their relatives complained and endeavoured to make the problems known, they met a rather unsympathetic management. In some cases, very old ladies were expelled or suspended from the home, or required to sign letters promising not to complain in future. I was confronted with the rather chilling phrase that these old ladies were "destabilising management". That illustrated the profoundly unsatisfactory culture that had developed, and it deserved to be publicised.

In terms of the broad lessons to be learned, I highlight two issues and would like to hear the Minister's response to them. First, although inspection will be improved under the new care standards system, the current system rests heavily on the work of health authorities and their inspection units. The case that I have mentioned was difficult to deal with because the health authority had inspected the home and given it a clean bill of health. I have wondered why, and I suspect that it might be because inspection is rather formal. It involves a lot of ticking of boxes and physical measures, but does not get to grips with the quality of care or intangible things such as problems with client-management relations, which in this case were not picked up in the inspection, despite being on the record. It is also possible that because the inspection units work with the local providers rather than exercising tough, independent assessment the relationship becomes too cosy.

Either explanation may be correct, but it is clear in this case that the inspection system failed. I have asked the chairman of the health authority, who is being very co-operative, to investigate the matter, but I think that the way forward is to have an independent overview. Someone independent of the provider and the health authority should be brought in to examine what is happening and to evaluate the complaints and the way in which they have been dealt with.

The second general point, which goes to the heart of the points made by my hon. Friend the Member for Somerton and Frome, is that such situations arise largely because of the problems of market supply and demand. There is a problem with contracting supply. Those who remain in the market, such as the home that I have described, are able to charge considerable fees. They can cut corners because people have few choices

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and they can bring pressure to bear on complainants because plenty of other people are willing to come there. That is the cruel logic of supply and demand.

I do not wish to aggravate the problems in my area by creating such a stink that the home is obliged to close. We need it, as we need other residential homes, but I want improved quality, as I am sure do the relatives. That will come only when there is improved supply. I share the views that have been raised by many hon. Members that it is crucial to examine care standards, not to suffocate but to improve the supply of accommodation—whether that comes through the public or the private sector.

11.43 am

Paddy Tipping (Sherwood): The debate is important and timely, and concern has been expressed by many hon. Members in the Chamber this morning. The hon. Member for Somerton and Frome (Mr. Heath) described long-term care in Somerset as being in crisis. I am not sure whether long-term care in Nottinghamshire is in crisis, but there are certainly real problems, especially in the nursing home sector. North Nottinghamshire health authority reports the loss of almost 150 beds and Nottingham health authority reports the loss of 150 beds this year. That is 300 beds lost from the stock, with two consequences. First, when a nursing home closes immediately, the care that is given to the frail people who are transferred to another home is not appropriate and leads to severely diminishing life chances. Secondly, the choice that is available to elderly people and their families diminishes as the stock reduces.

There are three pressures on the nursing home sector. The first is the general increase in costs due to improved standards; the second is the minimum wage, which I support; the third is the need for extra qualified nursing support in the nursing sector, which involves a demand issue—some nursing homes have not been able to recruit the necessary staff at the right price.

Those issues also relate to the residential sector. Many families face financial difficulties in respect of so-called third-party costs. As the hon. Member for Somerton and Frome said, local authorities increase their payments for residential care by roughly 2 per cent. a year. The real increase in cost has been far greater than that, and relatives have been asked to meet the gap by entering into contracts, the terms of which have varied. Put simply, many families are struggling severely to meet their share of the increase in costs.

I welcome wholeheartedly last week's announcement of £300 million—£100 million in this financial year and £200 million in the next. Will the Minister spell out how that allocation has been made, especially in this financial year? Having spent some time looking at the figures, I can see that cities such as Birmingham and Sheffield have done particularly well. Clearly, they have real needs. However, I have an impression—I put it no more strongly than that—that the top 50 worst performers are being rewarded, while those local authorities that have worked hard in the past, and have not talked of crisis, have not been adequately rewarded.

How will the £200 million for next year be allocated? It is a question of equity. It is important that elderly people across the country are treated with fairness, and

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it cannot be right if local authorities that have not achieved are rewarded. Indeed, that runs against the bulk of Government policy.

The debate is primarily about residential and nursing care, but the real issue is domiciliary support. Good domiciliary support costs a great deal. The cost of providing meals, home helps, IT and aids and adaptations means that it can often be more expensive to keep a person in their home than in residential care.

In real terms, significant sums of money are going into public services—an increase of between 5 and 6 per cent. in the funding for the national health service and for education each and every year—but social services departments are badly stretched. They do not have that amount of growth; they have problems with their budgets. There is such a problem in Nottinghamshire, and I want assurances that there will be adequate funding so that the problem does not become a crisis.

11.49 am

Mr. Paul Tyler (North Cornwall): I entirely endorse the point about domiciliary care made by the hon. Member for Sherwood (Paddy Tipping), but in the interests of brevity I shall not go over it again. I congratulate my hon. Friend the Member for Somerton and Frome (Mr. Heath) on his comprehensive introduction to the debate, in which he said, "We all have an interest in this subject." That statement is abundantly true, and it lies behind the consensus that has been evident during the debate.

I declare a personal interest: my mother will be 100 years of age in a few weeks. She is, as one would expect, in long-term care. I should like to take the opportunity to pay tribute to the way in which she has been looked after in a private home, which has been fantastic.

I endorse the concerns expressed by my hon. Friend the Member for Twickenham (Dr. Cable), but it would be wrong not to put on record that the vast majority of people who care for the elderly, be they private owners of care homes or be they their staff, who, as he pointed out, have a difficult job, are trying, in the most difficult circumstances, to look after our elderly in a responsible and skilled way. That is the kernel of the problem, to which I shall return later in the debate.

I want to endorse and reinforce some points that were made earlier. It is a demographic fact that longevity is part of the problem, and that is especially true of Cornwall. Not only do we have a wonderful climate, which is why my mother will soon be 100, but we have many people, some of whom will have retired from the constituencies represented here today to the most beautiful part of the UK. We therefore have a disproportionate number of elderly people who require long-term care in Cornwall. We also have many large properties in coastal and seaside resorts, which is something that applies to other parts of the country, and they have traditionally been seen as appropriate—my hon. Friend the Member for Mid-Dorset and North Poole (Annette Brooke) will agree with this point—for conversion into care homes. That combination of demographic and physical factors has resulted in a concentration of homes that is becoming a problem. The problem is especially acute where local authorities find themselves at a considerable long-term disadvantage, which was a point made by the hon. Member for Sherwood.

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The 2 per cent. increase in funding, which nowhere near meets the cost, will, if we are not careful, be year on year. Those who pay privately for care cross-subsidise those who do not. Such people may feel that that is an unfortunate fact of life, but it is creating frustration and resentment, which we can well do without. Those who run private homes are desperately trying to make ends meet, but they are finding it difficult to meet that objection with a logical argument. Neither they nor social services departments have created that situation; it is the result of the Government's funding. However, I shall not rehearse all Cornwall's problems because they are similar to those that were mentioned earlier.

As far as I can see, there are no villains to the piece; they are all victims. Care home owners clearly have a difficult task and most are dedicated to the work that they do. Care homes are not seen by most of their owners as simply a profit-making commercial enterprise. They generally entail a personal commitment. Staff, to whom I have already referred, now find that people with less skill, dedication and commitment than themselves can, as my hon. Friend the Member for Somerton and Frome pointed out, stack shelves in a supermarket at a better rate of pay and with fewer difficulties in terms of conditions and responsibilities. Staff are having intolerable pressures put upon them although they are doing a difficult job. Training and career development are important, and it was interesting to hear from the hon. Member for Caernarfon (Hywel Williams), who has obviously been involved with those issues.

We must ensure that there are greater career opportunities for carers. We all know councillors for whom this problem has caused genuine and terrible dilemmas. Finally, and most importantly, there are the residents themselves. For all those people, it is critical that we try to remove the endemic, persistent and consistent uncertainties that have been there for so-many years. For everyone concerned, but in particular the vulnerable residents, I hope that we can ensure a degree of certainty during the next couple of years.

I hope that the Minister and her colleagues will look over the border to Scotland to see how our colleagues and her colleagues are working together to achieve a more equitable solution. However, we cannot wait too long.

11.54 am

Mr. Paul Burstow (Sutton and Cheam): We have had a good debate and I am grateful to my hon. Friend the Member for Somerton and Frome (Mr. Heath) for enabling us to have it. We need to explore the issues that he and other hon. Members have raised and we must put some questions to the Minister.

The message coming from the contributions made today is that we have experienced an extraordinary loss of capacity in the care sector outside hospitals, and that is why we now have problems in hospitals. There has been a lack of understanding of the consequences of a number of policy initiatives over the past five years, if not for longer. On the one hand, there are serious staff shortages with two out of three social services departments reporting staff shortages and many care homes struggling to compete with the supermarket down the road because they cannot afford to pay their

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staff as much. On the other hand, there is a physical shortage of capacity, particularly in the care home sector. My hon. Friend gave the figures on that.

The problems caused by the combination of those two factors have been exacerbated by the new standards that have been introduced. They are welcome but the cost consequences of complying with them have not been followed through. When care home managers examine the standards, they will realise that adjustments must be made to their properties. When they work out the cost of them and see that they will have to have fewer people in their homes with a lower fee income, they will be even less able to repay any loans that they receive to make the changes. Their bank managers would laugh them out of the room, so they will not even go to see their bank managers but will investigate the retail possibilities that might result from closing the home and realising a rental or other income. That is why, in some parts of the country, the issue is not to increase fees to retain capacity, but to encourage people back into the market.

For example, in Kent and Somerset many homes have gone—they have been boarded up and sold. We must recover capacity in those areas or we shall be faced with the prospect of social services departments recruiting overseas, with the prospect of elderly people being exported overseas to be cared for. Increasingly, that is the prospect in Kent and other parts of the country.

My hon. Friend the Member for Twickenham (Dr. Cable) rightly referred to the concern about the result of those pressures on care for individuals. There is strong evidence of a powerful correlation between low levels of training and abuse in homes. There is much research evidence of that in the United States and equivalent evidence in this country. We must recognise that part of the problem is the insufficient training of staff who are not as skilled as they should be in treating people with dementia. My hon. Friend the Member for Somerton and Frome referred to the difficulties of dealing with people with dementia and to the need to provide appropriate care.

That brings me to the roll-out of the "free nursing care" that started on 1 October and that will have the unwelcome consequences that the Government have not foreseen in setting their objectives for tackling bed blocking. Not only was that policy introduced at breakneck speed—the final guidance was issued on 25 September, which left staff in the NHS three working days in which to implement the final version of the guidance—but not all the documentation was available at that stage.

There is concern that the guidance will create perverse incentives. Those with the highest needs will pay less because the cost of their nursing care will, appropriately, be picked up, while those with the lowest needs will pay most. That may lead places with poor practices that drive up dependency being rewarded because they may receive extra money for nursing care because they do not provide the social and other activities that promote independence.

My hon. Friend the Member for Somerton and Frome referred to dementia care. People with dementia do not simply turn up in nursing homes, but the Government's work book for rolling out free nursing

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care shows that people with dementia could be banded at the high-need level and receive free nursing care worth £110 a week. What will happen if, as surveys have shown, people with an equivalent level of need are in residential care homes? Will they be made to up sticks and move to a nursing home with all the consequences involved, or will the rules be flexible enough to provide free nursing care for people in residential care homes?

Will the bands introduced for free nursing care be uprated annually? If not—we have already heard that self-funders' fees increase by 5 per cent. a year on average—the gap will start to widen again. A greater proportion of care, as well as accommodation costs, will have to be paid for. Will there be an annual uprating, and will it take into account regional variations such as weighting allowances and the cost of regulation? The fact that the regulatory system will continue to move forward and change must also be reflected.

I have a question relating to the roll-out of free nursing care. What is the appeals mechanism? At the moment, it is very unclear what it will consist of, and it would help if the Minister could spell out how people will gain access to it and whether support from independent advocates will see them through the process. Often, we are talking about people who, because of their condition, are the frailest and least able. They need support to be able to get what they are entitled to.

On capacity and free nursing care, a care home owner who runs a small nursing unit and has a number of people banded in the medium care band will need to have a registered nurse in the home all the time. That will cost a substantial extra sum. To cover the cost of one nurse, 20 to 25 residents will need to be in that band and receiving moneys from the NHS. If such an owner has fewer residents in the medium band, how on earth will he be able to pay for his obligation to provide a registered nurse all the time? The Minister needs to clarify how we are to ensure that smaller nursing homes, which will be vital in dealing with bed-blocking issues this winter and beyond, are not suddenly put out of business by an initiative that is well intentioned but perhaps not fully thought through.

The capacity issue brings me to the final set of questions. Last week's announcement of an extra £200 million in a full year is very welcome, but we need to be clear where the funds are coming from. Is the pot of money new, or is it to be taken from the £900 million for intermediate care that has been talked about on numerous occasions? It would be nice to know whether the funds were new or had been taken from contingency reserves or somewhere else.

What is the target in respect of bed blocking? Is it to make available 1,000 beds by the end of the winter, or 1,000 beds a day to the end of winter? The target is unclear and it needs to become a lot clearer, so that it is not missed by the local authorities that are in the frame.

That brings me to the 50 local authorities that have benefited from the special grant that will come their way. It is not merely a question of rewarding the local authorities that are the poorest performers, because much of the money is being targeted on health authorities with trusts that are not delivering. The announcement has triggered a response from care home owners across the country. They are saying, "Isn't it

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time that our fees increased—not next year, but now?" They are giving notice to their local authorities that they want their fees to go up now, and that if they do not, they will refuse to continue to take state-funded places. Indeed, that is already happening in York, and is causing great concern as a result.

Let us consider the case of an authority that does not receive the extra cash but neighbours one of the 50 authorities that benefit from it. That authority will see its neighbour jacking up the rates that it is prepared to pay, but it will be unable to pay the same rate. It will no longer be able to afford to place people in the homes in which it used to place them. Suddenly, it will be a bed-blocking local authority. However, because the local authority that receives the money this year will have an on-going commitment to fund the person that it placed in the nursing home, it will ask the Government for the full amount next year. So although the £200 million is welcome, it will be fully committed to this year's expenditures. Any other local authority that wants to do well in future will need extra resources to deal with its capacity problems.

If we do not have the capacity to provide long-term care in Kent, Somerset and the other places that hon. Members have mentioned, the year-round gridlock in our system will continue to get worse. Private investors will not come back into the sector to reopen homes and establish new care facilities. Will the Minister guarantee that long-term investment will be made, and not just year by year by the tap being turned on and off? Local authorities and the private sector need to know that for three, four or five years funding will be provided so that they can invest in guaranteed delivery.

12.4 pm

Mr. Simon Burns (West Chelmsford): I welcome the debate. Every speaker has referred to long-term care as being a problem or as being in crisis. Both those propositions are true, partly because of changes in the way in which society and individuals want to provide care for elderly members of their family.

Outdated legislation provides the framework for a policy that has moved on dramatically. I refer, of course, to the National Assistance Act 1948, which laid down the definition of health and social care at a time when there was no emphasis on providing domiciliary care. There were long-stay hospitals where the elderly, with appalling quality of life, were left to languish until they died. That was a national disgrace. Fortunately, in the past 50 years, society has become far more civilised and caring in its provision for elderly people. Community care has developed, which I strongly support, and there is an emphasis, when it is feasible, on domiciliary care that allows the elderly to remain in their own home.

We have also seen the development in private residential homes of a home from home for those elderly who are so frail that they cannot live in their own home. That has created significant problems, partly because, following the 1948 Act, people have been subject to means testing. We may have missed an opportunity to address the funding of residential care when the Government first set up the royal commission on long term care. For many years there has been resentment that people who have been thrifty and put aside money for their old age, and who can no longer live at home and

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must go into residential care, must be financially responsible for their own care until their assets are reduced to £18,500. Yet, on the other side of the coin, the state pays for care for people who have not been thrifty and made provision for their retirement. In fairness, I should point out that people who have failed to make provision for their retirement have not always spent the money as they went along. It is not always that they have not been thrifty; there are people who were unable to put money aside due to economic or physical circumstances. However, a group of people exists who were not thrifty when they could have been, which causes resentment.

What can one do to ensure that the system works? The policies on which the Conservative party fought the last election offer an alternative positive step forward. First, we propose a voluntary insurance scheme, which will be part of the ethos of the responsibility of the individual. If that ethos were established at the start of people's working lives, the premiums that people had to pay would be so negligible that they would not mind paying the money. It would be a voluntary system whereby they could bypass the means test. When they reached retirement age and needed residential care, they would be able to draw on the insurance policy and protect their assets, which they could then pass on to their children or grandchildren if they wished.

The other alternative is a scheme put forward by my hon. Friend the Member for Woodspring (Dr. Fox) to create a long-term care fund, into which individuals could put a lump sum. It is estimated that the lump sum, at current prices, would be about £25,000 to £30,000. If people did not need those funds for long-term care—75 per cent. of people in this country do not—the asset could be passed on to their children or grandchildren for their long-term care. Both proposals are worthy of consideration because it is unacceptable that in the lifetime of this Government 160,000 homes have had to be sold by individuals or families to pay for residential care.

I mention briefly the problems of free nursing care, which have been mentioned by many hon. Members. Many people feel betrayed by the Prime Minister's announcement, which was made, typically, before a general election, that from 1 October this year nursing care would be free. In the Committee that considered the Health and Social Care Bill, the official Opposition had an agreement with the Government that we would accept the policy of not changing the rules and regulations on residential care because we supported the provision of free nursing care. We believed that that was the quid pro quo.

We now feel betrayed, as do many organisations and individuals, because we took what the Prime Minister and the Government said at face value. We believed that the Government were sincere about providing free nursing care for all from 1 October. What a sham that has become. It is now apparent that nursing care is not free for all. There is the banding system, and the definition of nursing in small print excludes significant sections of the community that most normal and reasonable individuals would consider to require nursing. For example, people who suffer from dementia and Alzheimer's disease will almost certainly not receive free nursing care because the Government have

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categorised their care as personal care. That is a disgrace and a betrayal, and the Government should look again and provide what they promised.

I also draw attention to the problems of the residential home sector. Beds are withdrawn and closed down for a variety of reasons. As many hon. Members have said, there are problems with funding and self-funders pay a 5 per cent. increase in fees each year, whereas local authorities pay less. Local authorities effectively use their position in the market to force contracts on residential care home owners. That is partially because of the severe strain on the social services budget. A number of homes have been put out of business because they cannot afford to continue. Similarly, legislation on the standards of care expected of homes causes a severe problem for existing homes—particularly small homes—and will have an impact on those thinking of building purpose-built homes. I question some of the small print on the size of rooms and other standards that are being demanded, and I urge the Minister to examine that matter. In the light of our experience and of what is expected to happen, will the Government consider whether more common sense and flexibility can be introduced into the system?

Mid-Essex, where my constituency is located, offers a classic example of the kind of situation that must be avoided. The number of beds in the area is shrinking; homes in Chelmsford and the surrounding area are regularly closing down. Ten years ago, there were enough beds to meet the need for residential care, but that is no longer the case. As a result, elderly family members are having to move away from the area to find a home. That causes them grave distress, because they may have spent their entire life in the Chelmsford area, and they may not want to travel 30 or 40 miles to an unfamiliar area. It also puts a strain on relatives, as they have to travel further to visit. In short, it is an unsatisfactory situation that must be addressed.

I will now conclude as time is running out, but I urge the Minister to listen carefully to all the points that have been made across the political divide during this important debate, and to be prepared to think again, rather than simply to tell hon. Members that everything is fine, that the Government are wonderful, and that the rest of us have got it wrong.

12.16 am

The Minister of State, Department of Health (Jacqui Smith ): I congratulate the hon. Member for Somerton and Frome (Mr. Heath); the debate has been useful and interesting, and I agree with him that it deals with an important issue. We live in a society in which increasing numbers of people live to an advanced age. One in five of us is over 60. During the next 25 years the number of over-80s will increase by 25 per cent., and the number of over-90s will double. Those figures are to be celebrated; we should take pride in them. I want to take this opportunity to wish a happy birthday in the coming weeks to the mother of the hon. Member for North Cornwall (Mr. Tyler). Older people are not a burden on society, and they must not be characterised as such; they are a resource of wisdom and experience.

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However, our ageing society creates a new set of challenges so we must modernise the present system of care. I agree with hon. Members that that system can be confusing, unfair and unresponsive to individual needs. The Government have set out to address the matter. As a result of the changes announced last year in the NHS plan, older people can now have greater confidence in the ability of health and social services departments to deliver the services that they want in the quantities that are required and of the right quality.

Several hon. Members have raised concerns about the capacity of the care home sector. I point out to the hon. Member for Somerton and Frome that, although the Government do not underestimate the importance of that matter, the figure of 50,000 in relation to the loss of beds is incorrect. It is also necessary to bear it in mind that although some beds have been closed, others have been created, because some homes have expanded their provision. In 2000, there was a net loss of around 7,700 independent sector places, according to a recent report published by Laing and Buisson, is an expert in that area. It is, however, also interesting that Laing and Buisson reported that

That is encouraging, although, as I will explain, the Government are not complacent about the situation in respect of care home capacity.

The reduction in capacity can, as some hon. Members have pointed out, be consistent with a policy of promoting independence. Everyone—including older people—wants to keep people out of institutional care if that is possible, and I note encouraging figures that show that 5 per cent. more households received intensive home care packages in 2000 than in 1999. In Somerset, recent indicators show that more older people have been helped to continue to live at home. However, we must ensure that such a change is planned so that alternative services are available. That is why the Government have already provided significant additional resources for social services and why the further cash injection of £300 million was made for this year and next year, details of which I shall explain later.

As part of the implementation of the NHS plan, local authorities and health authorities are now required to work with local independent sector providers to determine nursing and residential bed requirements and to agree a strategy to remedy shortfalls. The Government are undertaking a study of the supply of residential and nursing homes in England and are examining future requirements, profitability and closures. My predecessor brought together a strategic commissioning group that has examined improvements in commissioning. We need to maintain capacity and encourage diversification and innovation, so that we can provide options for adults who need care and support.

To that end, in line with the £300 million investment, we recently published an agreement with local government, the NHS and independent sector providers of health and social care, and housing services. That agreement, "Building Capacity and Partnership in Care", sets out principles and practices that can be followed at a local level. Acrimonious disputes between councils, which are commissioning and paying for services, and independent providers, particularly of

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residential and nursing homes as well as domiciliary services, are not good. The people who suffer are local people who need those services. They are at the centre of our worries today, which is why I can understand the distress caused by care home closures. Better emphasis needs to be placed on commissioning at a local level. We must take a fresh look at how national and local government, the NHS and independent sector care providers can work and plan together to the advantage of the service user. Real collaboration will result in standards rising and better outcomes for services. The agreement that we published last week is intended to help that process.

Hon. Members referred to national minimum care standards. The development of those standards is part of our overall reform to modernise the regulatory system for social services and nursing homes. The hon. Member for Twickenham (Dr. Cable) emphasised the need for a coherent and regulatory inspection system. While recognising the need for standards, the hon. Member for Luton, North (Mr. Hopkins) expressed worry about how such standards would be implemented.

The national minimum standards for care homes for older people were published in March. They will promote better quality care and help to stop abuse by grounding practice in the principles of dignity, choice, privacy and respect, which we all agree are important. They will guarantee residents access to an effective complaints procedure and ensure that they are cared for by trustworthy and reliable staff who are properly trained for a difficult and sensitive job. Those standards were consulted on extensively. We listened to the concerns of providers and produced sensible standards that will give providers a reasonable time to adapt and achieve the support of national organisations that represent consumers and providers.

We made several specific changes to the proposed standards in response to the concerns that were raised. I am confident that such decisions will ensure that necessary improvements in the quality of care homes will be achieved smoothly and that stability and sufficient capacity are maintained.

However, it is also important to communicate effectively the reality of what the standards will mean for care homes. Some slightly exaggerated claims have been made in some areas. I take responsibility for ensuring that we communicate with care home owners because, in introducing the standards, we need to maintain high quality and ensure that the good care homes to which hon. Members referred maintain their capacity through the change.

It will be for the National Care Standards Commission to decide in the particular circumstances of each home whether that home conforms to the standards necessary to meet the assessed needs of its residents. The focus of that commission will be to work with providers to help them meet national standards. That is important. Through the process we need to maintain capacity and the good work done in our care homes.

Richard Younger-Ross (Teignbridge): Will the Minister give way?

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Jacqui Smith : No, because I am short of time.

Hon. Members referred to last week's announcement on extra funding for bed blocking. We recognise that more money is needed in the system to make a reality of the right quality of care for older people at the right time and in the right place. That is why the extra £300 million announced last week, which is in addition to the £900 million identified for intermediate care, is aimed at stabilising the care home market, which may mean that local authorities need to reconsider the fees that they offer in partnership with their independent and voluntary sector partners. We aim to attack the bed-blocking problem and ensure that developments take place in the context of improving services for older people, as we set out in the national service framework for older people.

We are focusing £45 million of this year's £100 million on the 50 councils that need greater help. Another £45 million will be distributed to the other 100 councils on the basis of the standard spending assessment, and £10 million will support other initiatives to support and promote change for the good of the users of the system.

My hon. Friend the Member for Sherwood (Paddy Tipping) and the hon. Member for Westbury (Dr. Murrison) expressed anxiety about our decision to target that money. The issue is not fair shares for councils but tackling areas in which users of the service are disproportionately affected by the problems. That is why we focused on areas in which people are suffering the most, and we were right to do that. The conditions surrounding the money that we are allocating to the 50 councils that are receiving the extra help are tight. A target will be agreed for reducing delayed discharges from hospital, and councils will need to take clear steps to improve their partnership working and strategic planning.

As for the £200 million for next year, we have already said that no local authority will receive less than it received this year, but for the reasons that my hon. Friend the Member for Sherwood gave, we need to keep under review how to promote best practice in the system and ensure that we make the changes that our constituents want.

On 1 October, we delivered on our commitment in the NHS plan to provide free nursing care for all, with £100 million worth of investment this year. From that date, no one need pay for the care of a registered nurse in a nursing home—care that in other settings is already provided free by the NHS. For people who were already receiving nursing care in other residential care settings, it is the continuing responsibility of the NHS to ensure, as before, that that NHS provision is free. We have removed an anomaly by ensuring that care provided by a registered nurse in a nursing home is free, and we are moving away from a means-tested system of nursing care to one that is based on assessed need. Clinical need, rather than income, is the determining factor in deciding the band of nursing care in which people are placed. That will be introduced alongside other measures designed to make the system fairer—a 12-week property disregard, and money for local authorities to introduce a deferred payment scheme.

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In response to points made about Scotland, we should have this debate in the light of reality. The hon. Member for Caernarfon (Hywel Williams) suggested that changes had already been made in Scotland; they have not. We have delivered on our commitment to introduce free nursing care in England. Changes are still under discussion in Scotland. It is right in a devolved system—

Mr. William O'Brien (in the Chair): Order. I now call the hon. Member for Aberdeen, South (Miss Begg).

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