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Personal Care at Home Bill

My Lords, as we have heard in this most interesting debate, this is a very difficult issue. The Government’s proposals obviously have within them a paradox, which many noble Lords have examined. I think that we all recognise the importance of care at home. However, we should also recognise that it is but one aspect of the precarious journey sometimes known as the "continuum of care" that many elderly or disabled people have to make. Of course, we should note that only 18 per cent of people die at home. Tackling the funding of one part of that continuum and, in effect, privileging one element of the journey will create a multiplicity of problems which I believe will have serious consequences in the years to come. In speaking on this matter, I should declare an interest as the chair of the Co-operation and Competition Panel of the NHS and chair of the international operations of McKesson, a distributor of health and social care information systems. I spent 15 years of my life organising care for the elderly in some detail. In that time, it became very clear to me that there were three key issues: first, quality and appropriateness; secondly, choice; and, thirdly, funding. I think we all accept that quality is not negotiable, but it will become a very pressing issue as the current financial pressures start to bite. For that reason, I welcome the proposal to expand the role of the Care Quality Commission in regulating all aspects of elderly care, wherever it is carried out. However, we need to make sure that the frameworks, assessments and regulation are all properly in place before we proceed. With regard to choice, in 30 years we have come a very long way in offering a range of services for the elderly. One of those has been the growth of home care—letting people stay where they want to—and all the research points to that being the main preference. None the less, as we have heard from many noble Lords, sometimes that is not practical. However, it seems to me that the most pressing issue remains funding. As my noble friends Lord Joffe and Lord Lipsey said in their seminal note of dissent in the 1999 report of the Royal Commission on Long-Term Care of the Elderly, to which many speakers have referred, the key issue seems to be the balance between what it is reasonable for the state to provide and what it is reasonable for individuals with resources to pay for themselves. That question has been asked, yet it has remained unanswered—at least for these 10 or 11 years. It was therefore very encouraging to see the excellent government Green Paper, Shaping the Future of Care Together, which sought to examine this issue. Like many, I am concerned that the Government are taking forward this Bill without the benefit of consultation and, in my view, hastily addressing some but not all of the issues of the current system. I know we feel that we should be able to find the money to meet these aspirations but it is worth reflecting for a moment about the amount of money that we have in this system. In this current year, care of the elderly one way or another will total £21 billion. Of that, individuals already find £8 billion and the state £13 billion. Given the demographic projections, and in particular the rise in the over-85 population, it is clear that by 2030 there will be 2.8 million people in that cohort, placing enormous demands on both home care and care delivered in residential settings. There have been many speculations about what it might put on the standard rate of income tax if the Government were to bear the whole of that burden. Therefore, at a moment when we are facing such financial challenges in the public sector, it is surprising that we should come forward with these plans. Even if, as many have argued—and I have some sympathy for the argument—we could afford to spend that amount of money, would we be able to contain costs going forward at that level? We have heard many arguments, including on the situation in Scotland and so on, but we have to ask a serious question. What is a sustainable level of funding that we can find to take this proposal forward? The suggestion that we can divert people from residential care is one of the great myths and simply defies the demographics that we face. Therefore, the question of how the cost is shared becomes critical. Those who have to pay for themselves will have to make a choice about meeting care expenses from savings, property or insurance. Various things have appeared in the Green Paper and in the proposals from the Opposition: free care, mutualisation schemes, insurance schemes and so on. However, most of these proposals suffer from perverse incentives. I shall not revisit that as we have already heard a lot about it today, but of course with many of them the whole question of funding remains unanswered—how are we going to pay for this? Having worked closely with the elderly for many years, I can say that the greatest fear among those who had money was that they would run out of it. Generally people with assets accumulated in their lifetime accept that they need to spend some of those assets on old age. However, we have encouraged people to be prudent, and at the end of their lives people do not want their lifespan to outlast their assets; frankly, it is demeaning. I shall not dwell on the many alternative schemes that have been proposed and on how to mutualise them, but I was very taken with the proposal in the 1999 royal commission report by my noble friends Lord Joffe and Lord Lipsey that there should be some form of state reinsurance so that people can plan to find the money to cover either home care or residential care. As many noble Lords have said, in considering how to spend the money, we need to step back and look at the whole picture. Addressing a part of it is not enough. I was very taken with the points made by my noble friend Lady Pitkeathley on supporting carers. The fact is that throughout the western world 70 per cent of all long-term care is provided by informal carers. I do not like the word "informal"; I think it is pejorative. We are talking about people delivering care, and we should look at how to help them more. Those of us who have delivered care personally know the great moments of panic that carers experience when faced with the unpredictable. The challenge now is to find an equitable funding balance between the individual and the state, and I think that here lies the paradox. On the one hand, I was very taken by the point made by the noble Lord, Lord Sutherland, about the crumb. On the other hand, like many other noble Lords, I was very struck by the problem of having to build an integrated system to avoid the "hand-offs" and perverse incentives which arise from a non-integrated scheme. Funding for long-term care is the elephant in the room. We are normally told that the best way to eat the elephant is piece by piece, but in this case I think that we have to get a picture of how to deal with the whole elephant. When the Minister replies to the debate, I look forward to hearing how, in forming a view on this, we can strike a balance between taking what is on offer, which is clearly important, and understanding how that will fit into a national care service.