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3.40 p.m.

The Countess of Mar: My Lords, if ever there was an occasion when noble Lords could justifiably turn to the Government and say, "We told you so", this is it. They will recall their struggle to persuade the Government that funds allocated to local authorities for community care should be ring-fenced. Sadly, that battle was lost and we are now finding that many local authorities, especially those shire counties in the south-west of England, are having to make very painful decisions on behalf of their vulnerable and elderly clients.

I believe that local authorities approached the introduction of care in the community constructively and responsibly. The fact that central government allocation of funds is strictly cash limited has ensured that the rapidly escalating expenditure under the social security system has been successfully capped. Of course, that is exactly what the Government meant to achieve.

If the provision of community care really is to meet the needs of those for whom it is intended, it must be properly funded. I live in Worcestershire. On 17th November this year the chairman of Hereford and Worcester County Council social services committee announced that the council could be facing a £2.4 million deficit unless stringent measures are taken. She said:

The chair of Shropshire County Council policy and resources committee, on 15th November 1994 predicted a shortfall in their community care budget of between £1 million and £1.5 million this year. She said:

    "Our figures arise from significantly increased use, particularly of nursing home places, as well as packages of care. The extent of spending was not anticipated in early community care plans which were drawn up for the first time 18 months ago".

Similarly, Gloucestershire County Council is facing a £2.5 million shortfall. A Conservative and Independent member of the council's social services committee is quoted as saying,

    "Community care is one of the most important innovations to come from the Conservative Administration. It was working well in this county but it is asking the impossible when £2.5 million of grant is suddenly removed from us and similar or larger sums from the other shire counties. It puts our staff in an impossible position".

Why is it that social services departments in those local authorities are suddenly finding themselves in an untenable position? There are two main reasons. First, after a slow start, demand for home care and residential and nursing home care has greatly exceeded early estimates. In Hereford and Worcester community care workers are having to deal with 1,000 extra referrals a month; requests for home care are up by 20 per cent. on last year's figures, and the number of children in local

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authority homes has also escalated. In Gloucestershire there has been an increase of 40 per cent. in clients being assessed. Perhaps the Government's publicity machine worked too well!

The other reason for the shortfalls is the sudden and arbitrary decision of the Government in December 1993 to redistribute their allocation of the special transitional grants between local authorities. The shire counties lost nearly £80 million, while the metropolitan districts and inner and outer London authorities gained that amount. Will the Minister please explain why so much money was taken away from the shire counties so suddenly? They had drawn up their budgets on the basis of funds promised by central Government only to find that, without any prior discussion, those promises have been broken.

What is the result of that combination? The director of Gloucestershire Social Services wisely says,

    "this is not a budget crisis, as managers within the Department have a responsibility to maintain expenditure within their budgets. They can only do this however, by applying much tighter criteria for the delivery of services. This will have severe implications for users and carers in the county".

The reports I received from Hereford and Worcester and from Shropshire are similar. They are not profligate local authorities. Their staff are prepared to cut their coats according to the cloth, but they must make painful decisions. In some cases services will have to be refused and in others they will be withdrawn if clients do not fall within the priority categories. Services will inevitably be reduced and rationed to people who are at risk and there will be extended waiting times for services.

Time does not allow me to expand upon the impact that those strictures will have upon clients and their carers. I simply say that we should not be surprised to hear a catalogue of horror stories similar to those which prompted Her Majesty's Government to develop a community care strategy in the first place. I am extremely grateful to the noble Lord, Lord Ashley of Stoke, for enabling us to debate this subject this afternoon.

3.45 p.m.

Baroness Macleod of Borve: My Lords, the noble Lord, Lord Ashley, introduced the debate with his usual eloquence, which we have come to expect. Unfortunately he is suffering from a badly trapped nerve which must cause him a lot of pain. However, I congratulate him in his absence on the way in which he introduced the debate.

I want to concentrate on widows and the elderly—and I must declare an interest in both. When I was young our sell-by date was three score years and ten. Following advances in medicine, science and the experience of doctors, it has now become three score years and twenty. In declaring my interest your Lordships may like to know that I am very near three score years and twenty and feel therefore that I can speak for a few minutes this afternoon.

During the time of the present Government—the past 15 years—enormous help has been provided for the elderly. All sorts of things have been introduced to

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enable them to live better, to work if they are not too old, to be happy, to be surrounded by as much comfort as we are able to give them and, with any luck, to allow them not to have to worry too much about the future financially. We have come a long way, perhaps further than with any other part of our society.

If we look around we can see what various boroughs are doing to help the elderly. This morning I rang my own borough of Enfield, which is where my late husband and I lived and worked for many years. It is doing an enormous amount to help people stay in their own homes, with in many cases the help of carers and government finance. I can say to the Minister that we should be proud of what we are doing for our old people.

It is estimated that over 800,000 UK citizens are over 85 years of age, of which 60 per cent. are infirm. If one is infirm one needs specialist care. It is not enough for someone to come in occasionally and make a cup of coffee. Carers cannot look after infirm patients and it is a large number of people to cater for in their own homes. However, there are now many more purpose-built homes which cater for local authority people, private residents and those who have a limited amount of money—under £3,000—to go towards their keep. That is a help, but it is a drop in the ocean of the enormous costs involved.

We are a very ageing population. However, not all the widows whom I meet are elderly. One can be a widow from the age of 19 to 99. Many widows need help and consideration from carers in the community. I should like to pay tribute to the carers and to the inspiration behind the carers. They are very specialised people, or perhaps I should say very special people. They go into other people's homes to help them. They are not necessarily there all day. Sometimes each carer will have three different patients per day and she goes round from house to house. I pay tribute to the inspiration behind the carers.

As always with the elderly, lack of money is the dread. Very few of us, even in your Lordships' Chamber, are not worried about getting old and all the costs involved, which leads me to one very difficult subject. I refer to funerals. I do not know whether noble Lords are aware of how much a funeral will cost anyone who is left behind, but it is way over £1,000. Fairly recently—about eight years ago—the Government provided a grant of £1,000, which is of enormous help. That can be paid by the social services at once. But if the funeral itself costs way over £1,000, then money is very tight in many families.

I have a very great interest in the children as well. However, so many noble Lords will be talking about the children that I thought I would leave that subject to those who have perhaps more up-to-date knowledge than my three score years and twenty allow.

3.52 p.m.

Lord Brimelow: My Lords, the noble Lord, Lord Ashley, has thrust a very powerful light into the shadowy uncertainties surrounding the financing of long-term care. The previous speakers in the debate—so far I have agreed with everything that has been said—

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have adopted a rather broadbrush approach and have tended to describe what is instead of concentrating on the uncertainties. I wish to focus a very modest hand-torch on a limited subject; what is actually going on at the moment in the health area of Islington and Camden, where I live.

I am very worried about the future of district nurses in Camden but I am also very uncertain about how discussions at present in progress will turn out. Perhaps I should explain the background. Not all long-term care ends with death in an institution or in hospital. As the noble Baroness, Lady Macleod of Borve, has stressed, there is a great deal of care at home which has been very well rendered hitherto. The uncertainty is in regard to the future.

In the health area of Camden and Islington the provision of community services, including district nursing, is in the hands of the Camden and Islington Community Services NHS Trust. The trust is under pressure to effect economies. The current two-year contract between the trust and the Camden and Islington health purchasing authority calls for a reduction in costs over the next two years of 7 per cent. As part of its search for economies, the trust is proposing to reorganise district nursing. It proposes to establish within the Camden and Islington area 29 nursing teams, each headed by a nursing sister—technically a G-grade nurse. Acceptance of this proposal would mean the disestablishment of 32 G-grade district nurses—more than half of the present complement. My understanding is that the posts of head of team and deputy head of team will be open to competition.

The trust says that there will be no compulsory redundancies, but among the district nurses there is anxiety that those who fail to secure appointment as head of team may be offered posts of lower grading, with presumably a reduction of pay. They are worried and uncertain about their future. They also fear that, if they turn down a post offered, they may be held to have made themselves redundant. The district nurses are now working to see whether they can find an alternative system whereby the economies imposed on the trust can be achieved. They are uncertain whether they will succeed in finding such an alternative system. The prevailing uncertainty is worrying quite a number of general practitioners.

I have read the job description of the G-grade sister who will be the head of a team. In my opinion, it is not a job description suitable for a district nurse engaged in nursing. It is a job description of an administrator. In it the word "nursing" is not even mentioned. It is all about co-ordination. I fear that we may be moving towards a bureaucratic system in which actual nursing is done by smaller numbers of lower qualified nurses; in other words, a service which is likely to be inferior to what we at present have. My fear may prove to be unfounded, but I am uncertain about the future.

The present system is flexible and not bureaucratic. For terminal care, and terminal care in the community for people who have been cared for over a long period in hospitals or other institutions but who for one reason or another wish to leave or have to leave, the sisters attached to the health centre nearest to where I live are

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quite splendid. They are well qualified, but, much more important, they have the tactful understanding which comes from long years of dealing with people who are about to die. I speak from personal knowledge.

I fear that we may be about to lose something excellent for something less good, but I am not certain. With the devolution of authority to trusts and to local health authorities, I am not certain who is really in control of developments as a whole. The Departments of Health and of Social Security may not even know in detail what is happening. They may be glad not to know. The Government have told us that the NHS is safe in their hands, but how much of the local administration within the departments—

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