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Personal Care at Home Bill

My Lords, I come at this Bill as a doctor who has for some 30 years worked in the community as a specialist with older people. I feel passionately about the serious inequities between the provision of health and social care and the seriously unjust system we have at the moment, so you would probably think that I would like this Bill. I am also quite supportive of the policy objective to allow more people to remain in their own home for as long as possible and to support them with adequate personal care there—although I take to heart the point of the noble Lord, Lord Best, about the appropriateness of the home circumstances. I collaborated in a good deal of research with the government-funded Personal Social Services Research Unit—the PSSRU—over many years. More than 20 years ago we demonstrated that the policy objectives of this Bill were feasible even for the most heavily dependent, if—I stress "if"— the appropriate personal case management was applied flexibly to each case and if there were real choices available. This is a good moment to pay tribute to the fantastic evaluative research that PSSRU does. However, it has always been careful to point out that fidelity to a successful model is important in getting the right outcome. This Bill is based on no such evaluative project. As the noble Baroness, Lady Gardner of Parkes, and the noble Lord, Lord Lispey, said, it is a piece of electioneering, presented at party conference as something that would rally support. Most older people’s organisations naturally support this Bill; after all, who in their right mind would turn down more money to enable the most dependent to stay in their own home? Yet this is a horrible Bill. It is socially divisive, bureaucratically retrograde, provides financial incentives to choose one sort of care when another might be preferable, moves money from the most financially disadvantaged to the wealthier sections of society and will be a nightmare to implement. Instead of using this opportunity to develop an innovative state/public and personal partnership approach to the business of personal care, the Government have stepped in during the process of their evaluation of the Green Paper and rejected the development of a realistic and practical formula in the interests of headline popularity. As I say, they have not even finished the consultation on the Green Paper which carefully outlined a whole range of options around which we could build a political consensus. In the small print of the modelling exercise paper on the costs of this Bill, PSSRU has itself hedged it round with some caveats. The modelling exercise depends on choosing exactly the right levels of assessment of activities of daily living, which I will come on to. I expect that any of your Lordships will have looked at the proposed scheme of assessment which will determine who gets the jackpot and who does not. It looks just like the Poor Law scheme of 1834 to determine the deserving and undeserving poor. In this case we will have a magic lift-off point. If you have four prescribed activities of daily living down then you are eligible; if you have only three activities of daily living down, sorry, but you will not be. As the noble Baroness, Lady Campbell, pointed out, this sort of deficit assessment is a truly divisive and horrible tool. Apparently there will be a nationally agreed assessment tool, although who knows who will administer it? I suspect it will be the same workforce which does the current fact assessments. Can anyone remember what happened in the last attempt to devise a nationally agreed joint single assessment tool between the NHS and local authorities? It was a nightmare, taking three years to agree and then implement. Does no one remember the eligibility criteria for NHS continuing care? I used to see all the appeals against the final judgments of the tribunals on the contested cases in the north-east London area. Most of the cases were so arbitrarily unfair, particularly against people with dementia, that it made one weep. This Bill will have exactly the same effect. Let us turn to these activities of daily living. The PSSRU modelling is all based around these assessments. First you have to go through the fair access to care assessment, as now, and then you are subject to the reablement services if possible. I do not know what they are, but I have a pretty good idea. This will be a tool for delay and procrastination, of course, but it has a rationale. Then the ADLs will be assessed. This is crucial. I will mention them all, as they are listed; it is not so much what they contain as what they leave out that is important. The ADLs are eating and drinking, toileting, washing/bathing, dressing, oral care, skin and hair care, plus another, which is the prompting and supervision of a person who is unable to make the decision for themselves about the ADLs on the list. The list excludes cleaning, housework, shopping, laundry, transport, sitting services and so on. I am detailing these because, although it is true that the number of ADLs that people are unable to do correlates well at population level with demand for care services, they are not good at individual level. A body of research, largely from the United States, has shown how inappropriate these eligibility criteria can be for many people with dementia. For example, a patient with profound Lewy body-type dementia can suffer from serious behavioural disturbance, aggressive and deluded outbursts and wandering and can need 24-hour supervision from relatives who are effectively imprisoned in their home and yet they might not be disabled to the point of having more than one or two activities of daily living points on this scale. What happens in a case like this? It has to be interpreted by very sophisticated, well trained assessors, who are willing to use their common sense and to fudge in order to get people into the criteria. Just as hundreds of appeals are upheld every year against mean-minded assessments of night and day rate attendance allowance, this assessment will also generate hundreds of appeals, because the system will be a bureaucratic nightmare and a profound letdown for many who may assume that they will be eligible. The financial incentive to stay put and not go into residential care will, I believe, be a serious and insuperable difficulty. Families will understand very quickly how to maximise their future inheritance. While it is usually right for people to stay at home, it is sometimes right, as we heard from many contributors today, for people to enter residential care, especially when dementia is advanced. There should be as little distinction as possible in financial burden for relatives between care at home and residential care. Without that, decisions are skewed away from choice made on clinical and social grounds to those made on financial grounds. This Bill fails on these criteria. Finally, I turn to matters of social equity. My objections are not simply on the large financial costs. Heavens, I have been quite a psychopath in my time about winkling out of social services and healthcare more than my patients’ fair share of the budget, so I have no guilt if I winkle out of the Government more than a fair share for this very needy cause. However, I believe that the Bill undermines the mechanisms by which we can reach a consensus on meeting a grave and growing social issue. We must find some fair middle way of funding care that is neither old-fashioned means-testing nor frankly unaffordable universal coverage. We are in a big enough mess with the NHS, which inevitably will have to be addressed at some point. Providing public funds, irrespective of assets and income, for all those living at home will transfer wealth to better-off members of society and their heirs at the expense of those most in need. Already we are aware that many people who receive attendance allowance simply do not need it. Such a proposal as the one in the Bill is extraordinary when the Government are groping towards a welfare system that promotes social equity. We need a partnership between public and private sectors. That was made clear by Wanless and by extensive research by Julian Le Grand and others and it was ably outlined today by the noble Lords, Lord Lipsey, Lord Warner and Lord Joffe. Elderly people increasingly want the dignity of choosing for themselves the type of care that they receive by buying it rather than by having assessed care packages. That is the brilliance of the Government’s approach to personal care funding, whereby people can buy their own. Already a third of elderly people pay for their own care and it is estimated that this will rise to more than a half over the next 20 years. However, not a single penny of this extra state funding would go to improving standards of care for elderly people. The Bill will transfer vast sums of money out of the public purse to those who are currently deemed to be able to afford their own care. Since very little of the preserved assets will be spent by disabled elderly people themselves, the state will secure for elderly people’s heirs a better inheritance for the future. Is that the objective? I think not. It is very hard to hope that this Bill will fall, because undoubtedly some older people with profound difficulties will be helped in the short term. However, I think that the funding will rapidly come to an end, as the Bill is not practical. I fear that this sticking-plaster solution will act as a deterrent to the creation of a more comprehensive solution to our profound problem. A Bill with this title is needed, but this is not it. If the noble Lord, Lord Warner, presses his amendment this evening, I shall support him.