Debate on the Address

My Lords, I propose to concentrate my remarks on the most vulnerable people in our society—those who are frail, usually very elderly, and whose numbers are fast rising in our ageing society. I shall touch on three issues: social care, dignity in care, and end-of-life care. First, in the coming Comprehensive Spending Review, the Government must recognise the likely scale of future needs and determine how they will be met. Spending on social care has risen by 14 per cent under this Government, while overall health spending has risen by 90 per cent. Therefore, reconfiguring social care services must be a priority for the next spending review. We should also take on board the fact that much of what constitutes good practice in social care is not really very expensive. The Government must be congratulated on several initiatives, such as A Sure Start to Later Life, better support for carers and the rights accorded to them. But we also need much more flexible provision to allow people to remain in their own homes if they so choose, and to recognise the role of low-level care, which is important to the quality of life of many older people. By the middle of this century, the number of people aged over 65 will rise by some 80 per cent to nearly 17 million. However, there will be an even bigger growth of the number of people over 85, which will nearly quadruple to 4 million. Informal carers are therefore likely to play an even greater role than at present. There are already 5.8 million carers, most of whom care for people over the age of 65. Many are themselves already older people. The Government have recognised that informal carers have rights, but they also require more support as they increasingly have needs themselves. The incidence of dementia is estimated to double over the next30 years, and this is the group with the most complex needs, where the most significant expenditure will be required. Some consensus must be found for the funding of social care, particularly long-term care. Partnership funding such as that recommended in the Wanless and Rowntree reports, with a reasonable split of 80/20 public and private funding, must be considered. Mechanisms such as more flexible equity release schemes, enabling money to be used for care and repayments made from a person’s estate after their death, must also be considered. I welcome the government Dignity in Care initiative, which embraces all aspects of care in its proposals. It is holistic, and includes malnutrition, which, as has already been mentioned, is a huge problem in hospitals and care homes, but also in the community, where International Longevity has done quite a lot of work. The approach involves listening and responding to what so many people in care have themselves said, so I welcome it. I commend the campaigns led by Help the Aged and Age Concern to ensure dignity in hospitals, as well as the new approach, Behind Closed Doors, which the British Geriatric Society and many other organisations are launching, to ensure that older people and other vulnerable adults can be certain of privacy when they need to use the lavatory in a hospital or care home. Terrible incidents have been reported, such as elderly residents being fed their breakfast while using the toilet. It is hard to imagine a more degrading example. Such campaigns cannot achieve their aims without a more professional workforce, which is the key to any improvements. Staff are the linchpin of service delivery. Yet those who do the bulk of this difficult and stressful work—particularly care assistants looking after frail, elderly people—are often not qualified, extremely low paid and largely unrecognised. Many, understandably, leave to work on the checkout tills at Tesco because, as is often said, they get a bit of social life and better pay there. That is appalling. Some work is being done by a group led by a charity, Friends of the Elderly, to see whether a qualification at NVQ level 2 can be introduced to improve that. Much needs to be done as a priority. Another priority for the Government must be to remove the Human Rights Act loophole which fails to protect the majority of care recipients because independent providers are not considered to be public bodies. In 2004, over 91 per cent of care home places, and two-thirds of domiciliary care, was provided by private and voluntary agencies. The Government have intervened in a judicial review, where some local authority care homes were transferred into private ownership. The judge did not overturn the earlier ruling that independent providers fall outside the scope of the Human Rights Act, but confirmed that the local authority remained responsible for protecting the human rights of residents, even after their homes had been transferred. The picture is ever more confused and totally unacceptable. The Minister in your Lordships’ House acknowledged during Report stage of the Equality Bill, over a year ago, that action was required. The Government must close this loophole, if only to be consistent with their own Dignity in Care campaign. My rights as a human being are derived from my basic humanity; they do not change depending on where I happen to be in this country at a given time. We would never tolerate this sort of discrepancy in children’s rights, and rightly so. Legislation on animal welfare now seems to provide more protection than that offered to many frail, elderly people. That is quite unacceptable. I feel strongly about end-of-life care, but am also raising some points that my noble friend Lady Murphy would have brought up were she able to be present for this debate. There are specific difficulties for many older people at the end of life, sometimes in communicating their needs, because they suffer from multiple conditions and failing powers. Great sensitivity is required in how they are treated. How we address their needs is perhaps the ultimate test of dignified care. Where a person is dying, when and how they die, who is with them when they die, and what, if any, intervention they may need are all critical points which must be treated fairly and well. What is the Government’s policy on end-of-life care for people with dementia, for example? We have a Gold Standard Framework, led by Professor Ian Philp, but we must know how it can be implemented without specialist care teams—including geriatricians, old-age psychiatrists and palliative care doctors—going into care homes to ensure care is adequate. I regret that the Bill of the noble Lord, Lord Joffe, did not proceed to Second Reading, as it included a provision that a patient suffering from a terminal illness should be entitled, as of right, to receive sufficient medication to keep them free from pain and distress as far as possible. I am pleased that my noble friend Lady Finlay is introducing a Bill which will hopefully improve this situation. It is urgently needed, as according to a recent study 46 per cent of doctors expressed reservations about prescribing opiates since the Shipman case. There have also been many reports of doctors being reluctant to prescribe adequate pain relief for patients cared for at home since that case. Only a couple of weeks ago, on ““Woman’s Hour””, a daughter movingly described how her mother—dying in agony, totally neglected and suffering from Alzheimer’s disease—died in a mental health unit where nobody was trained to manage her pain. Some states in the USA have recently legislated to make it clear that it is lawful to provide pain relief, even if it hastens death to some extent. We need stronger guidance from the GMC and the BMA to give doctors confidence in prescribing appropriate doses of palliative drugs for dying patients, regardless of their diagnosis. Perhaps the Government could include palliative care expertise in the quality target scores for funding GPs. Despite the immense importance of this issue, the National Council for Palliative Care recently reported that about half of all palliative care services are facing a reduction in NHS funding. Again, this undermines the Government’s own aims in Dignity in Care and must be reversed. In conclusion, I urge the Government to take on board the following three points. First, in the Comprehensive Spending Review, they must include adequate finding for social care, including training for front-line providers. Secondly, the Government must close the loophole in the Human Rights Act regarding public bodies as a matter of urgency. Thirdly, they must ensure that end-of-life pain relief is available wherever and whenever it is needed, and consider whether some additional legislation is needed to ensure it is available and effective. Above all, people’s dignity must be protected throughout, and at the end of, life if we are to consider ourselves worthy of being called part of a civilised society.