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Baroness Hayman: I said in my earlier remarks about the circle of quality improvement that it is important that we have feedback from the commission to NICE or to the national service frameworks about the

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difficulties of implementing a particular piece of guidance--because it is conceivable that NICE might not get it absolutely right and might need to understand and learn from the experience of people trying to implement the guidance--and therefore it might be sensible that it gets feedback so that it can adjust the guidance. But, in the same way, if the guidance were being ignored across the board, that too would need to be fed back into the process. Of course, Ministers would have to consider that--that was the allusion to the reference in the White Paper. I am trying to say that we are a long way from any of that at present.

Baroness Gardner of Parkes: My concern is that NICE will be levelling down rather than levelling up. Throughout the document on NICE we are told that cost effectiveness will be considered. Surely that means that, for example, the multiple sclerosis cases will not be encouraged by that and that treatment will not be universally available. Can the Minister reassure me on that point?

Lord Walton of Detchant: Before the Minister answers that question, is she aware that the chairman of NICE has made a public statement to the effect that the recommendations of that body will be based upon what is best for the patients and what is most cost effective but will otherwise not be ruled by issues of finance and cost?

Baroness Hayman: Yes, I can perhaps reassure the noble Baroness. Cost effectiveness is not the same as something being expensive. It may be that something is expensive but very cost effective and clinically effective, and therefore ought to be introduced. We have tried to stress in the work of the national institute that it should be a mechanism not for levelling down but for ensuring that when there are new developments--when new technology and new drugs become available--which are clinically effective and cost effective, they should be available to the broadest range of patients as soon as possible. We have to recognise too that we must look into areas--and NICE may well want to look into areas--where practice is steeped in the mists of time but may not necessarily be particularly effective. We have to look at both sides. I certainly would not want to think that it was a levelling down. In some of the instances that have been referred to, we would hope that the existence of NICE ensures that more people have access to new and effective treatments more quickly.

Lord Clement-Jones: I thank the Minister for that full reply and for her replies to the supplementaries, which have clarified matters considerably. There is a slight philosophical issue here of whether one thinks that the glass if half full or half empty. I suspect the Minister thinks that the glass is half full; I think it is half empty. I have some concerns about the future.

I have seen how national service frameworks in embryonic form, in terms of the Calman Hine framework, have operated. That has operated very flexibly but, on the other hand, some authorities and trusts have not put it into effect in anything like the most effective form. It is possible to retain that kind of flexibility.

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I accept the Minister's point that we do not yet have experience of what she called a rounded set of provisions. The bodies that I have spoken to and about have had experience of a rather narrower set of circumstances where a specific circular requiring trusts to act in regard to beta interferon has not been obeyed. That is why they are full of foreboding. We all know that NICE is a terrific acronym to try and gain the good will of the medical profession--what "nicer" name could one have, so to speak--and I appreciate the requirement to have effective action plans and the fall-back powers of the Secretary of State. I cannot say at this point that we are convinced. I do not believe that the philosophy behind the amendment is over-prescriptive in the way that it operates; it is simply designed to get action and to make sure that trusts and health authorities put into operation those best practice standards that NICE will bring forward. It may be a slow process--there may not always be a best practice standard in existence--but, nevertheless, those which are in existence should be complied with. We shall consider what the noble Baroness has said and we shall probably come back to this point--perhaps in a form which looks at the Secretary of State's power to give directions-- at Report stage. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendment No. 82 not moved.]

Clause 14 agreed to.

Lord Hunt of Kings Heath: I beg to move that the House do now resume.

Moved accordingly, and, on Question, Motion agreed to.

House resumed.


Lord Hunt of Kings Heath: My Lords, before we move to the Statement on long-term care, I should like to take the opportunity to remind the House that the Companion indicates that discussion on a Statement should be confined to brief comments and questions for clarification. Peers who speak at length do so at the expense of other noble Lords.

Long-term Care: Royal Commission Report

4.36 p.m.

Baroness Hayman: With the permission of the House, I shall now repeat a Statement being made in another place by my right honourable friend the Secretary of State for Health. The Statement is as follows:

    "At the general election in May 1997 we promised to set up a Royal Commission on the long-term care of the elderly. In December 1997 I announced to the

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    House the establishment of that Royal Commission to be chaired by Professor Sir Stewart Sutherland, Principal and Vice-Chancellor of Edinburgh University.

    "Since then the commission has met formally on 15 occasions, taken oral evidence from 67 individuals, conducted seven public hearings in different parts of the country, received evidence from 400 organisations and received a total of 2,040 written submissions. Between them, the commissioners met over 1,000 individuals, made 100 visits and held 140 meetings of one kind or another. They were assisted by a reference group representing the leading organisations concerned with the care of the elderly. The commission presented its report to me on Friday, 26th February, after it had been submitted to Her Majesty the Queen. It is being published today.

    "I am grateful to Sir Stewart Sutherland and all the members of the commission for their diligence and the swift delivery of their report. All 12 commissioners signed the report. Two commissioners have submitted a note of dissent on three particular aspects--and even they were not entirely unanimous.

    "The task of the commission was to look into how best to provide sustainable long-term funding for good quality care of the elderly and how the costs should be shared between taxpayers and the individual. Its report rightly makes clear that this is something on which 'there is no obvious answer' and calls for an 'informed debate' on what it has recommended.

    "I support that call. The Government's response must await the outcome of that debate which I hope and expect will commence with today's publication of the Royal Commission report. I hope that it will be useful to the House for me to highlight a number of the Royal Commission's major conclusions and recommendations. First, it concludes that there is not a demographic time bomb with which our economy and society cannot cope. Secondly, it concludes that the possible need for long-term care is a risk that cannot be met adequately from individual income or savings so some pooling of risk is necessary. Thirdly, it concludes that private insurance will not deliver the necessary cover at an acceptable cost. Fourthly, it concludes that the costs will have to be met by contributions from the taxpayer and individuals. Fifthly, it concludes that the costs of long-term care can and should be separated into living costs, housing costs and personal care costs. Sixthly, it recommends that people receiving care should be expected to contribute to their living costs and to their housing costs but the costs of their personal care should be met by the taxpayer. The note of dissent rejects this separation and the proposal that individuals should not contribute to the cost of the care element. It gives greater priority to the quality of care.

    "The commission estimates that to adopt its proposals would cost the taxpayer between £800 million a year and £1,200 million a year at 1995 prices. It estimates additional costs to the taxpayer of lesser options such as a short-term disregard of house

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    value at £90 million a year, changing the limits of the present means test at between £150 million and £200 million a year and making nursing care in nursing homes free at £220 million a year.

    "As the report states, 'This is a complex issue and there are no easy solutions'. We have to get this right. In considering the commission's proposals we will all need to bear in mind, firstly, the taxpayers' money used to relieve the costs to individuals cannot also be used to improve the quality of care or extend it, though this might be a higher priority with some older people. Secondly, these proposals, like all aspects of taxation and benefits, would shift money from one income group to another--in this case to some better-off people from some who were worse off.

    "The report recommends that the best way to help carers is to improve the services provided for the people they care for. The note of dissent argues that priority should be given instead to respite care.

    "The report emphasises the need to improve cultural awareness in services offered to ethnic minority elders. It also recommends that the Government should consider applying to the personal care needs of younger disabled people the same principles they recommend for care of the elderly.

    "While the commission has been sitting the Government have been getting on with making improvements to the treatment and care available to elderly people. So we have already made a start on a number of aspects covered by the report. These include: extending direct payments to over 65s; breaking down barriers between the health service and social services; improving local standards through the long-term care charter--a clear manifesto commitment; changing the law to allow local NHS and local councils to pool budgets; £750 million over three years for initiatives to promote rehabilitation and prevention; providing for more consistent standards of care in health and social services; preparing for independent inspection of nursing homes, old people's homes and social care through regional care commissions; starting work on a national service framework for older people to lay down how the NHS and local councils should provide them with high-quality services in every part of the country; encouraging care providers to promote independence rather than dependency; and launching a new strategy for carers with £140 million over three years.

    "We also accept--as does the Royal Commission--that there is a strong case in principle for phasing out the payment of residential allowances and transferring these resources via a special grant to local authorities. But we will need carefully to work through the implications of this change on both the benefit system and on the independent care sector before we take any final decisions.

    "The Royal Commission's major recommendation that a national care commission should be established to monitor trends, set standards and represent consumers will need to be considered in the light of these changes already in place or in the pipeline.

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    "The Government have also been taking other action to help elderly people. These measures include: restoring free eye tests for pensioners; commissioning a report from the Health Advisory Service on the treatment of elderly people in acute hospitals; instructing all hospitals to take immediate action to improve the supply of bed linen, food and drink to elderly people; making a start on providing greater financial security by reform of the pension system; improving the Government's overall approach through the Better Government for Older People initiative and establishing an inter-ministerial group to take this forward across government.

    "Along with the rest of the country the Government will study the report of the Royal Commission with great care. In the course of our consideration we will apply the principles set out in our welfare reform Green Paper, in particular expecting people to insure against foreseeable risks and make provision for their retirement; making sure that those most in need can enjoy a dignified and fulfilling life; providing public services of high quality to the whole community; and making sure the system is flexible, efficient and easy to use.

    "At the general election we committed ourselves to setting up this Royal Commission. That was because we recognised that, although only one in five old people need long-term personal care, as people approach old age many become anxious about how well they will be looked after, who will look after them, how much it will cost and who will pay.

    "I hope that the Royal Commission's report and the debate it will stimulate will help us find a way of ensuring that people have access to high-quality long-term care that is fair to both individuals and the taxpayer. I hope that it will be founded on a consensus that will stand the test of time-- a dependable contract across the generations. That is of great importance because what elderly people seek, second only to good health, is financial certainty and security. And that is what this Government are determined to deliver".

My Lords, that concludes the Statement.

4.45 p.m.

Earl Howe: My Lords, the House will be more than usually grateful to the Minister for repeating this important Statement. I am sure that it will be welcomed on all sides of the House, not least because it marks the fulfilment of the remit given to the Royal Commission in December 1997 which it was asked to complete within 12 months. The commission has not quite succeeded in keeping to that timescale but has very nearly done so, following a very substantial workload. For that, members of the commission are to be thanked and congratulated.

When the Royal Commission was announced, we on these Benches emphasised the need for the Government to pursue their agenda for long-term care with decisiveness and speed. If I have one message for the Government today, it is that they should try to do just

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that. The Statement is perfectly right. These are highly complex issues. However, the commission has taken extensive evidence; it has reported; and now Ministers must decide.

The central problem in relation to the provision of long-term care, is, as the Minister indicated, its unfairness. Despite substantial increases in the means test threshold introduced by the previous government, many old people have had to sell their homes in order to pay for residential care. Such people often feel cheated. Having paid tax for many years when rates were high, they are now in receipt of sometimes poor levels of care, having sold their assets to pay for it. Others who have not saved for their retirement at all have all their costs paid for them.

The unfairness goes wider than that. The availability of local authority-funded care varies widely depending on where people live. Nor is there any consistency in the cost of such care. People are unable properly to plan ahead in the face of such uncertainty.

The other perceived unfairness of the present system relates to nursing care. Whereas nursing care is provided free in hospitals, at home and in residential homes, it is means tested in nursing homes. Particularly since the National Health Service and Community Care Act 1990, indeed over the past 10 years, the private and voluntary nursing home sector has expanded considerably. The result is that fewer old people receive free NHS nursing care than was previously the case.

The Royal Commission has come forward with the recommendation that nursing care should be funded by the NHS wherever it is provided. As the Statement makes clear, that carries with it a considerable price tag--although I am not at all clear why the figures have been presented at 1995 prices. Perhaps the Minister will comment on that.

Even if that proposal is accepted by the Government, the cost of nursing is not the only issue. The so-called hotel costs will still require a very large outlay on the part of older people in care. It is perfectly possible to imagine that pensioners will have to sell their homes, as they do now.

In 1996 the previous government published a White Paper, A New Partnership for Care in Old Age. Had it been brought in, the partnership scheme would have encouraged old age pensioners to take out insurance enabling them to protect £1.50 of assets for every £1 of insurance. That would have meant that a pensioner paying £20,000 in insurance would have had £20,000 of care paid for by the insurance company and they would then have had £46,000 of assets protected instead of £16,000. People not yet in long-term care but who might foresee a need to be in later life were also planned for. Under the scheme they would be encouraged to take out indemnity insurance to protect their assets and pay for the cost of their care. Those plans were seen by the then

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government as an addition to the existing community care arrangements and would not have affected people unable to pay for insurance.

There were criticisms of those proposals. One was that insurance schemes would not help everyone but only those who could afford the payments. Large numbers of pensioners on low incomes are not eligible for means-tested benefits and the scheme would not have included them. There was also a fear that when insurance money ran out pensioners would be ineligible for local authority assistance.

While that scheme was not a complete or perfect solution, it was a good start, and draft legislation was ready to be brought forward to Parliament. Will the Government reconsider the merits of that scheme, which appears in no way to cut across the Royal Commission's recommendations? Indeed, it seems absolutely consistent with what the commission says about the need to pool risk.

Will the Minister confirm that one of the key words contained in the Royal Commission's remit, apart from "fairness of outcome", which we all want to see, was that any system of funding the long-term care of the elderly had to be "sustainable"? Will she also say what the implications of the report are for younger people with long-term care needs? I think particularly of young adults with severe learning difficulties who are looked after at home, often by elderly parents. It would be hard not to describe the kind of care provided for those individuals as nursing care. The commitment and stamina required of those elderly people are often very considerable, with little in the way of respite relief. What does the report do for those people?

Can the Minister say how the High Court ruling last December in the case of North and East Devon Health Authority ex parte Coughlan affects the Government's policy on the funding of nursing costs?

I believe that the Statement leaves matters unsatisfactorily in the air. I agree that we should have consensus, if we possibly can. But if the Government are not minded to accept the Royal Commission's recommendations, when will they put forward their own proposals? In opposition the Labour Party promised that it would act swiftly and radically to address the problem. What is the time-scale for some definite proposals? The Government need to address the issue in the round, not only as it affects today's pensioners or those soon to retire but also as it affects future generations of pensioners. How are the middle-aged now meant to plan for their retirement in the absence of a clear policy?

4.53 p.m.

Lord Clement-Jones: My Lords, I join the noble Earl in thanking the Minister for giving us an interlude in the Committee stage of the Bill, which has presented some problems in reading the paper--or not reading it. We very much welcome this eagerly awaited report from Sir Stewart Sutherland. Although noble Lords present have not been able to study all the recommendations, there is the chance to consider some of the points arising from the report and to ask the Minister about a number of areas relating to it.

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Long-term care is an issue for the elderly and for society as a whole. We on these Benches welcome statements about hoping that action will be founded on consensus. But that very much depends on the Government's approach and, with respect, on whether we can agree on proposals in this area.

The costs involved are very large indeed. In 1997 the cost of long-term care for the elderly and disabled totalled some £12½ billion. That figure excludes the notional cost of carers, which many people expect to rise as carers might prefer to pay for care themselves or leave it to the state or some other agency. That is in itself a worrying matter. In this context the conclusion of the Royal Commission that there is no time bomb with regard to costs seems somewhat strange. It appears that the costs of care will rise from some £12 billion to something over £35 billion in 2040. That seems to these Benches a significant rise in expenditure.

We welcome the proposals from the Royal Commission majority group about the separation of nursing costs from accommodation and other non-health costs. We believe that it is important to make no distinction between nursing homes and residential homes, hospitals and nursing care at home. Following on the noble Earl's question on the Coughlan case in December 1998, does that case not decide this matter, anyway? Is it not now settled law that those costs should be borne by the state? It is important that the Government give an indication about that since not only is that proposal the underlying basis of the majority report of the Royal Commission but the Government's view on the matter is long delayed. We have not had a government response on the Coughlan case; it is important that we have one in order to make sense of the Royal Commission's report.

Do the Government agree with the estimate of costs put forward by the Royal Commission of something like £200 million for the separation of costs and the bearing of nursing costs by the state? Do they recognise that there are savings to be made against that figure? Older people would not have to go to acute hospitals and occupy beds, for instance, in the case of major flu epidemics such as the one we have just experienced. In many respects that £200 million may be an over-inflated figure.

Do the Government accept that we need a comprehensive NHS community nursing service to cater for all the different institutions if the Royal Commission's proposals are taken forward? Will the Minister urge the Chancellor to take action in next week's Budget? The Government have had the report since mid-January. We know that the Prime Minister met the chairman of the Royal Commission at that time. Surely the question of how the disregard on assets is to be treated, for example, is already part of the Government's thinking. An opportunity is available next week to show the Government's earnest on this whole matter.

A major theme of the report is the need to integrate health and social services. In the light of the report, does the department believe that the Bill should go further? We have had debates in Committee on the integration

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of health and social care. Do the Government believe that the Royal Commission is urging them to go further in that respect? How will the national care commission interface with CHIMP? The Government have yet to consider whether they wish to adopt the idea of a national care commission, but some thoughts from the Minister on that subject would be helpful.

There is then a question of timescale. It is obviously of great importance that the Royal Commission's report should not fester on a shelf. It must be dealt with quickly. A ministerial group on old people exists, the setting up of which we greatly welcomed. Will that group of high-powered Ministers consider the report at the earliest moment? What is the time-scale within which the Government believe that it will be dealt with?

I was interested to note the discussion initiated by the previous government, to which the noble Earl referred on the question of private insurance. It is difficult to comment on that area. We know that the Royal Commission took a great deal of evidence--particularly abroad--on the question. But in the overall summary of the proposals this appears to have been dismissed with too much ease when it is considered that people aged about 60 have one chance in three of having to pay long-term care costs of the order of £30,000 and that a private insurance premium of about £10,000 is one way in which people with reasonable incomes can cope with such an eventuality. It means that potentially one removes a swathe of people from the problem of catering for accommodation costs, if it is assumed that one takes away nursing costs. There appear to be some interesting ideas that have not necessarily been fully addressed in the summary of the report of the Royal Commission. Clearly, we wait for further clarification.

Will the recommendations on carers in the report be built into the Government's strategy on carers? That is an important area.

Finally, it is important that in this debate we do not focus simply on costs. It is very easy to treat this as some kind of supplication to the Chancellor and the Secretary of State for Social Security. One must focus on how best throughout older people can remain healthy, independent and active for as long as possible. This is a valuable report which must be taken forward in that spirit.

5.1 p.m.

Baroness Hayman: My Lords, I am grateful to both noble Lords for their welcome of the Statement. I feel some sympathy for them. When I was preparing yesterday it crossed my mind that it would be even more difficult for them today. In this context I should point out when the report was available. The noble Lord, Lord Clement-Jones, suggested that we had had it since mid-January. I must make clear that the Royal Commission presented its report to the Secretary of State on 26th February having submitted it to Her Majesty the Queen, as it had to be. We are publishing it today and trying to get it into the open for public discussion as soon as possible.

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We very much accept the point made by both noble Lords that it is important to make progress in this area, although--as I believe emerged from their observations--just because there is a Royal Commission recommendation does not mean that there will be unanimity of response to it. Major issues face society to which there are not simple and indisputable answers. It is important that there is a general debate about them in order to provide a way forward that commands support throughout the community. The analysis carried out by the Royal Commission has been enormously helpful in that regard and is the foundation on which that debate should take place to enable some of the longer-term decisions to be taken. I do not believe that in terms of the basic issues, we can short-circuit that process, although we are already addressing some matters that concerned the Royal Commission. We shall be doing that at the appropriate time. For example, we have said that we want to establish a more consistent and fairer way of charging for non-residential social services. This matter was touched upon by the noble Earl. Now that we have received the report of the Royal Commission we can look at how to take forward the work on the review of charges for domiciliary and day care services. We also need to take forward the work with the voluntary sector and other interested parties to ensure that users of services and carers are involved in that process and their views are taken into account. The Statement outlines a number of other areas such as joint working and pooled budgets. These are matters to which we shall return later today in the context of the Health Bill that is now before your Lordships' House.

I was asked a specific question about the implications for younger disabled people. I believe that the Royal Commission makes clear that because it has reported in a fairly limited timescale it has been unable to go into the needs of younger disabled people with as much care and detail as it has for care of the elderly. But its general view is that the recommendations can apply equally to that group. We shall need to look very carefully at the implications of that recommendation for younger people with long-term care needs. As a government we have given high priority to the needs of disabled people in the form of the Disability Rights Task Force, the Disability Rights Commission Bill, the social services White Paper, the welfare reform agenda and the new deal for disabled people. Now we must look at the recommendations of the Royal Commission in the light of the existing work and the principles that have been established.

The noble Earl asked why the figures were based on 1995 prices. The answer is that it was the latest year for which the Royal Commission could find comparable figures for all the diverse sectors that it considered, including health, the DSS and social services. Therefore, in the interests of achieving a level playing field for purposes of comparison the Royal Commission had to go back to 1995.

The noble Lord, Lord Clement-Jones, asked whether the Government accepted the commission's estimate for nursing costs in nursing homes. Obviously, we need to check the analysis. There are many analyses of the different component costs of different

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recommendations, but the estimate is certainly not outwith what we expect to be the kind of costs in nursing homes that are considerable and where there is an anomaly to which reference has been made. This is one of the areas in which the Royal Commission looks at both short and medium-term measures that can be taken within the ambit of its broader recommendations.

Referring to the effects of ex parte Coughlan, in response to the noble Lord, Lord Clement-Jones, it is not a matter of knowing what the law is simply by looking at the decision in that case. There was a recent decision in R. v. North and East Devon Health Authority that nursing care should be provided by the NHS. The health authority then made an application for leave to appeal against the High Court's decision. In the light of the impact on policy of the view of the High Court about the funding of nursing care and given the importance of clarifying the judgment and making clear the current legal position, we decided to support the health authority's application for leave to appeal. Leave to appeal and for the Department of Health to intervene was granted on 4th February 1999. We shall need to consider guidance to health and local authorities once the result of that appeal is known. We do not have a definitive understanding of the legal position at the moment.

In response to the noble Earl, Lord Howe, the Royal Commission concluded that private insurance would not deliver the necessary cover at an acceptable cost. It looked at the partnership proposals of the previous government, to which the noble Earl referred, and its response was that it was rather complex and difficult to see where the benefits lay and to whom. Therefore, it did not give a great deal of support to that particular way forward.

5.9 p.m.

Lord Laming: My Lords, we are grateful to the Minister for repeating the Statement. Does the Minister agree that the analysis undertaken by the commission encourages all of us to adopt a much more positive approach to ageing? We should celebrate the fact that more people are living to an advanced age and have a certain quality of life as they approach their older years. Does the Minister agree it is rather ominous that the Statement makes reference to such matters as the complexity of the issue and suggests that there are no easy solutions? Further, a good deal of the Statement repeats what is in the Government's programme, with which I entirely agree. Is it ominous that the commission has, despite its hard and speedy work, contributed to the debate rather than set out the way forward on how those who become dependent should have their care funded in the future? Does the Minister agree that questions about the financing of long-term care for a large number of people, as raised by the noble Earl, remain?

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