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Personal Care at Home Bill

My Lords, I am not sure whether this is a modest or an immodest Bill, but it certainly has much to be modest about. Free personal care at home for those in greatest need sounds like a marvellous idea. As others have said, who could possibly be against that? Yet the moment that you begin to look at what is proposed, it immediately becomes clear that it is not quite what it seems. The more you look at it, the more it becomes clear that it has some quite untoward consequences, which have not been thought through. Although the idea of free personal care at home is initially attractive, I fear that, as enshrined in this Bill, it is overwhelmed by the arguments that have been deployed by the noble Baroness, Lady Murphy, and the noble Lords, Lord Warner, Lord Lipsey, Lord Joffe, and others. It is hard to say anything fresh at this stage of the debate, but perhaps my remarks will come as a handy summary for the Minister before she winds up. For a start, it is not really free personal care at home for all those who might need it. The Bill introduces a right to free care at home for only a proportion of those whose needs are assessed as critical, because they require help with four or more activities of daily living. Thus, only a small proportion of those who need social care will benefit from the provisions in the Bill. The Bill also provides an entitlement to 30 hours of intensive reablement support over six weeks. What is the relationship of that entitlement to the general right to free care at home introduced by the Bill? For those whose needs are severe enough to put them in line for the free help offered under the Bill, that is hardly intensive. They would certainly need more support, and for longer. The kind of people we are talking of here probably need round-the-clock help; what is offered would barely scratch the surface. What is the position of those who receive reablement support but do not qualify for free personal care after the six weeks are over? Those are just some of the questions about which there needs to be a lot more clarity. The additional cost of the measure is set to be substantial. On the Government’s reckoning it is £670 million a year, with £420 million to come from NHS budgets and £250 million from local authority efficiency savings. However, as we have heard, ADASS has estimated that double that will be required from local authorities. What will be the effect on NHS and local authority budgets, which may already be helping people to stay in their homes for longer? What will be the effect of funding free personal care at home, for those with the highest need, on services provided to those with moderate or even substantial needs? One possibility is that they could incur the double whammy of having their attendance allowance—even their disability living allowance, if aged under 65—taken away to fund social care generally under the reforms presaged in the Green Paper, and having the level of social care support they receive degraded at the same time. In practice, the money will have to be found, in whole or in part, through service cuts or, possibly, charges. That could further fuel the pressure for an ever more restrictive process of fair access to care services. What about the practicalities of implementation? The impact assessment accompanying the Bill estimates that at least 70,000 people who currently do not receive formal social care services will be eligible for free personal care from October. The Royal College of Nursing argues that if the changes are to be successful, substantial and immediate investment in community nursing will be necessary—on top of the Government’s estimates that I have already referred to. I suppose that it would say that, but there are worries all the same that, with only nine months until the measures comes into force, there may simply not be sufficient numbers of properly trained social care and nursing staff to deliver the commitment to free personal care in the Bill. The college’s worries on that score would seem to have some force. The complexity of the assessment process is also a major concern. Once the existing fair access to care services rationing process is combined with the new personalisation arrangements and the personal care at home criteria have been added, the assessment process will consist of six interlocking stages of Byzantine complexity. That is all too likely to lead to confusion among practitioners, and service users will be baffled and alienated by the experience of Kafkaesque bureaucracy. Extremely careful guidance and excellent staff training will be necessary if chaos is to be avoided. The draft guidance issued so far is not reassuring, displaying as it does far too little clarity and precision regarding the assessment process, its multiple stages and the relationship between them. There also stand to be some very untoward consequences, as we have heard from other speakers in the debate. The impact assessment makes it clear that the wealthiest old people will be the main beneficiaries. Because care in a residential home can be charged for according to the ability to pay, the requirement to provide care at home free will also give local authorities a perverse incentive to pressurise better-off people into going into care homes, where they will contribute to the cost. That could have the effect of forcing people into care homes even when that is not the best thing for them. Finally, the process is seriously flawed. The Government were in the middle of a consultation on the Green Paper that discussed, inter alia, a national care service, partnership between the state and individuals in paying for the costs of care, and a system of insurance to enable individuals to insure against their care costs. The announcement of free personal care at home for those in greatest need in the middle of that consultation cuts right across it. Indeed, it clashes directly with the Green Paper, since all the options canvassed in it ruled out free care at the expense of the taxpayer. The Government say that this is just a stepping stone or building block on the way to a national care service, but the measures in the Bill are not a subset of the vision set out in the Green Paper. That is really the answer to speakers such as the noble Baroness, Lady Turner of Camden, and others who have welcomed the Bill as a down-payment on implementing a comprehensive and more wide-ranging strategy for social care. The Government have stated that the policy of free care at home will need to be reviewed after 18 months. We need to be reassured, therefore, that this potentially temporary measure will not adversely impact on the plans for longer-term reform that all parties recognise is needed, and which may help many more social care users, and that those who will benefit from the free care at home provided in the Bill will not lose out following the 18-month review. That may prove a very difficult line to tread. Only a small proportion of those who need social care will benefit from this Bill. The wealthy will benefit most; funding it will be difficult; and raiding the pots that the Government have fingered will have unpredictable consequences for those who fall outside the immediate scope of the Bill. What is proposed is full of perverse incentives. The Government have hardly begun to get to grips with the problems of implementation and the labyrinthine assessment process will be a nightmare. If that does not constitute a case for the Government to do some serious rethinking, I do not know what does.