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Care Services: Older Adults and Disabled People

My Lords, I congratulate my noble friend Lady Fookes on a masterly opening speech in which she very succinctly focused our minds on the importance and the difficulty of this subject. As she said, and as other speakers have implied, this debate foreshadows the forthcoming Green Paper on adult social care and lays before the Government the range of questions which we expect that document to begin to answer. They are not easy questions. We start from a rather unusual position for a policy review. It is not often that the Government explicitly states of a publicly funded service that it is not sustainable; but that is what the consultation document, Care Support Independence openly acknowledged by citing changing demographics and changing societal expectations. It made the point that those expectations, even now, are often not being met. The document speaks of the need for a, ""radical rethink of how we pay for and deliver care and support services"," and, ""a new settlement between individuals, families and the Government"." That may not be quite the right way to put it, and I will come back to that, but the point is that the Government are telling us that the review in prospect is to be no ordinary one. The background to all this, as noble Lords have said, is that the proportion of older people in our population is growing. You sometimes hear people say that this will not impact unduly on the health and social care budget, because even if people are getting older, they are at the same time freer of illness and disability. Perhaps they are thinking of the noble Lord, Lord Rix, when they say this. Statistically, alas, that is not accurate. Wanless reported that the number of older people suffering from some sort of disability is growing nearly 10 per cent faster than the number of those without a disability. In 20 years, at least 1.7 million more people will have a need for care and support of some kind than at present. What should we be aspiring to? The Government have set out their vision of how a decent care and support system in the 21st century ought to look. The key words are ones we have heard today: promoting independence and choice, high quality care, targeting support where it is most needed and affordability. It is the last of these where the rub lies. There is a funding cake but the cake is not big enough. We know that, because, as the noble Viscount, Lord Tenby, and others told us, rationing is already happening at a local level. Eligibility criteria are being constantly tightened. Where should the extra money come from? One answer that the Government are looking at is for some sort of compulsory savings scheme to cover the cost of care. Some very persuasive voices out there are saying that this is the only way to go; but to many people, compulsory saving may sound suspiciously like a form of extra taxation from which they may never benefit. Certainly we need to look at such a system and see how it might work; but compulsory saving will never be practicable for those on low incomes or, crucially, for those with learning disabilities or who are seriously disabled at a young age. When we look at caring for young, long-term disabled people, I am not averse to the idea of a quite separate structure of public funding, recognising that many of these individuals will not have the chance to acquire financial means of their own. The injustice that is most often talked about in the current system is that while the prudent and thrifty are penalised in old age by being made to sell their houses to pay for care, the feckless poor have everything paid for them out of the public purse. So far, in 12 years, the Government have said and done almost nothing to resolve this issue, even though Tony Blair highlighted it in 1997 as an injustice. I hope the Green Paper faces the issue head on, either by coming up with a solution—as, I may say, my own party did at the last election—or by admitting that, for now and for the times we live in, it is too difficult a nut to crack. The issue cannot be ducked. The other injustice in the system, the postcode lottery, was mentioned by the noble Lord, Lord Rix. If we think there is a postcode lottery in the NHS, there is an equally blatant one in adult social care, which is why the consultation paper floats the idea of moving away from the current system, whereby eligibility for care is decided by local authorities, to a nationally based system. Personally, I am drawn to that idea. As Help the Aged and others have pointed out, the usual argument about local decision-making being better because it can respond more easily to local need is in practice a fiction, because most councils can do little more than provide the essentials to those whose needs are the most serious. The current debate around social care is not just about the funding gap; it is also about what might be termed the care gap. CSCI have estimated that 6,000 older people in England with high-level support needs are receiving no social services and no informal care, 275,000 older people with less intensive needs also receive no care, and 450,000 people receive some measure of support from family and friends, but their full care needs are unmet. Those are disturbingly large figures, but if we then look at the demographic curve over the next 20 years and the projected ratio of workers to retired people, we see another gap emerging between the number of people needing care and the number who are in a position to deliver it. Some 80 per cent of adults of working age are in some form of employment; the available cohort of women carers is reducing. Like it or not, informal care looks set to be a major element of the care equation for the indefinite future. The London School of Economics has estimated that demand for informal care will actually outstrip supply by 2017. By 2041 there will be a shortfall of 250,000 intense carers—people who give care for more than 20 hours a week. In other words, if we do nothing, a quarter of a million fewer disabled people will receive informal care in 2041 than at the moment. How are we going to bridge that gap? The answer suggested by various think tanks and informed academics is that we need radically to rethink our views about family and community responsibilities. We cannot look simply to families. Increasingly they are becoming dispersed and fragmented. I am one of those who believe that we need to look beyond the narrow framework of family at neighbourhoods and voluntary groups. In doing so, a fundamental question is to be addressed about the balance of responsibility between society in its various guises and the individual. The respective roles of government, the community, the family and the individual need to be better defined if we are to reach a consensus on what is fair and practicable for the future. If we believe that the wider community has a potential role in delivering care and support, we need to do some hard thinking about how best those forces might be mobilised, and by whom. The Government have an obvious role in facilitating such a process, and so, I believe, does the Church. What would such facilitation look like? Unfortunately the clock is ticking and there is no time for me to expand at length on that interesting theme, but the Minister may care to read some stimulating ideas coming out under the banner of, among others, the Joseph Rowntree Foundation. Like my noble friend, I believe that we need to focus public policy much more closely on the role of informal carers and how we might improve their quality of life. Peter Beresford of Brunel University pointed out the irony whereby on the one hand we heap praise on carers for their magnificent and important work, but at the same time we allow their terms and conditions of work to be comparable to, and in many cases worse than, those of supermarket shelf stackers. It is a contradictory attitude. Paid carers are poorly remunerated and poorly trained, and the result is inevitable—high turnover and poor levels of recruitment. Informal carers are, if we are candid, exploited by society as a resource, despite the many things that the Government, to their credit, have done to improve their lot. Good-quality caring requires ability, empathy, warmth and the ability to listen, together with all the things to which the noble Lord, Lord Kirkwood, referred. I hope that we will have a chance to come back to these issues after the Green Paper is published. I look forward to reading it as a basis for future consensus but, equally, I look forward to what the Minister is about to say in response to the excellent speeches that we have heard today.