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4.54 p.m.

Baroness Eccles of Moulton: My Lords, society's responsibility for organising appropriate care for the growing number of elderly people is a major policy issue confronting all countries of western Europe. It can rightly be seen as one of the yardsticks by which a civilised society can be judged. I am grateful to the noble Lord, Lord Ashley of Stoke, for giving us an opportunity to debate this important subject today. I am sorry that he is in pain and is unable to be with us.

Since the 1980s there has been a dramatic increase in the level of funding provided by the Government for long-term care generally and for elderly people in particular. This is reflected in the substantial growth of the nursing home sector, and as a result the number of beds run directly by local authorities and health authorities has declined.

Over the past decade the growing number of elderly people needing nursing home care have felt enormous benefit from this change in delivering services through the voluntary and independent sectors rather than through local government and health authorities. However, although the running of these services has now moved predominantly into the independent sector, it is important to emphasise that this remains an area of care mainly funded from the public purse. As my noble friend Lady Gardner of Parkes has already mentioned, contributions from those who can afford it have been a longstanding feature of our system, not a recent phenomenon.

In turning to the more recent history of community care, I would like to pay tribute to the foresight and tenacity with which the late Sir Roy Griffiths worked with the Government to introduce the new arrangements. In April 1993 the progressive transfer of

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funding from central Government (that is, the Social Security fund) to local government began. When the transitional funding period of four years is completed, the budgets of social services departments in local authorities will have been increased by about 40 per cent.

The health authority of which I am chairman—here I must declare an interest—is coterminous with three London boroughs—Ealing, Hounslow, and Hammersmith and Fulham. All three boroughs have taken on these additional responsibilities with enthusiasm and commitment. In the 18 months since the new arrangements came into being the number of patients in hospital awaiting transfer to nursing homes has reduced.

These developments in the care provided for elderly people have produced many visible benefits and we can take great pride in them. However, I believe that there is a need for a stronger regulatory framework. Local authorities and health authorities need effective powers to make sure that the standards of care provided in the independent and voluntary sectors are those that you and I would wish to see for our own elderly relatives. The current registration and inspection regulations, while allowing health and local authorities to exert considerable control over the physical standards of such homes, are at present relatively ineffective in ensuring that adequate standards of care are provided by staff.

Another important area is being considered at present through a draft circular issued for consultation by the Department of Health. This circular is not the one to which the noble Lord, Lord Ashley of Stoke, particularly referred; it is a second circular which is out at the same time. This circular discusses the financial framework within which health and local authorities operate. At present we are relying on financial arrangements drawn up in two Acts dating from 1968 and 1977.

In response to consultation on this draft circular my authority has taken the view that new financial arrangements are needed which will allow local government and health authorities to reflect the reality of the care that so many elderly people need, which is a combination of health and social care. Furthermore, the same elderly person may, over time, require different proportions of the costs of his or her care to be met by local and health authorities. In many cases on admission to a nursing home it is appropriate for costs to be met by the local authority. However, towards the end of the person's life the health service should in many instances be providing a good deal of the care and meeting the costs.

We recognise that inevitably the boundaries of the NHS have been changing ever since it was created nearly 50 years ago. Community care policies have resulted in better care for elderly people, albeit now predominantly provided outside the NHS. At the same time funding in the NHS has increased dramatically over the years and there are many areas where the boundaries of the NHS have expanded. If I had time, I would have liked to have cited some of those. The concept of the next generation contributing to the costs of caring for their elderly relatives is being faced by many European

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countries. So too is the issue of how far individuals should make financial provision to allow for the cost of their own long-term care to be met through insurance or other arrangements.

In conclusion, I believe that we can be proud of the developments in community care which have taken place in recent years and which now provide, still it must be emphasised mainly through public funds, far higher standards of care and infinitely improved physical facilities. However, like all great social issues, it needs periodic reassessment. I believe that we have a particular responsibility to inform and guide the development of policy in this fundamentally important area of life. I very much hope that the new guidance referred to earlier, in its final version, will not miss the opportunity to provide a financial framework which matches the excellent multi-disciplinary service which we are committed to delivering.

5 p.m.

Baroness Farrington of Ribbleton: My Lords, I am grateful to my noble friend Lord Ashley for introducing this subject and providing the opportunity to discuss the very real problem which people face.

I agree with the noble Lord, Lord Jenkin, that it would be possible to debate at great length the many examples of success in the field of care in the community. I am particularly grateful to those who have referred to the fact that we are not speaking about an additional amount of public expenditure but a switch of resources from one public expenditure head to another, a transfer of funding from social security into care in the community through the local authorities.

It is extremely important that in this debate we recognise that care in the community could only ever be a success were it to be conducted against a background of the recognition of need and not against a background of a reduction in public expenditure. In addition, for there to be faith between the partners who were to work together, it was essential that the Government recognised that when local authorities told them that in the current financial year the sum that was needed was £1.2 billion to be told that £0.7 billion was all that was available, leaving more than a 40 per cent. shortfall, would inevitably lead to the problems to which the noble Lord, Lord Mottistone, referred.

In the current year an additional problem has been faced by some authorities. Because of a late switch, without consultation, which was mentioned by the noble Lord, Lord Mottistone, the money which was expected by some local authorities was suddenly cut dramatically. The authority of which I am a member—Lancashire County Council—was in that position. A late decision, announced without consultation, left only £6.5 million for new demands during the current year.

It is against that background of not being able to meet new demands that we must view the problem of the blurring of the distinction between that which is clinically determined to be health care and that which is rightly the province and the responsibility of the local authority social services departments.

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As a new Member of your Lordships' House I listened very carefully to all the expressions that have been used. The one that causes me gravest concern is the constant reference by Members on the Government Benches to "having regard to resources". We are discussing people who are clinically determined to be ill and in need of health care. The decision as to whether that health care can be provided by the health authorities free of charge within a different setting from the hospital is to be governed by judgments about resources and not clinical judgment.

I remember when care in the community was first discussed. I happened to be with a friend who is older than I am, whose husband was in a long-stay mental hospital suffering from Alzheimer's disease. To my surprise and distress, she burst into tears. I asked what the problem was. Her prediction was that the hospitals would be closed down without alternative provision being made. She predicted that the government of the day would use the resources from the sale of assets of the long-stay psychiatric hospitals, in one of which her husband was a patient, to fund other policies, and there would not be a clear and distinct switch of that money into funding for other services.

My friend feared that she would see the day when she would be forced to give up her small savings and her ownership of her home in order to help to fund the cost of caring for her husband were he not in a hospital. Her ultimate distress was her fear that she was asking for her husband to be kept in a place which was not the most appropriate because she could not cope with the changes that she feared.

I worry because I reassured my friend that there would never be a question of curtailing resources for patients with Alzheimer's disease and there would never be an attempt to place a charge on their families in order to fund their care, either in the community or in alternative residential accommodation other than a long-stay hospital. Her husband is now dead, but if I were to give advice to someone else in that position today I might be more constrained in my enthusiasm.

We do not face the future with hope in those authorities which are struggling to find the resources necessary to make care in the community work. Gloucestershire, Lancashire, Hereford and Worcester, Bury, Bradford and all the authorities on the Isle of Wight have problems. The noble Lord, Lord Mottistone, was so right when he referred to the problems of the Isle of Wight. I ask the noble Baroness not to say, in answering the debate, that it is a matter of local authorities using their judgment in respect of their own resources.

The Isle of Wight has been challenged by a Government Minister for underspending on education against its SSA. It has been told by the Home Office—the noble Earl, Lord Ferrers, was mentioned—that it must spend more than its SSA on fire services. Now, doubtless it will be told that if only it switched funding from somewhere else it could cope with this unexpected

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pressure on its social services. It is critically important that the Government recognise the need to fund care in the community.

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