Personal Care at Home Bill

My Lords, I have added my name to Amendments 7 and 10, and I support the words of the noble Lord, Lord Lipsey. In these amendments, we want to explore the boundaries that are proposed, the knock-on effects on other funding systems, and particularly the rationale for providing care funds only for those living at home. This was criticised widely at Second Reading, and I want to point out that three very different predictions were made then about the impact this would have on the use and costs of this Bill. In my speech at Second Reading I predicted that financial incentives to stay put would deter people from going into residential care at the point at which it was clinically and socially desirable. There have been numerous times when I, as a clinician, have seen spouses or daughters absolutely exhausted and on the brink of a breakdown caring for an elderly person with dementia. By the way, it is usually not the activities of daily living which are the most stressful problem; wandering, emotional and behavioural difficulties and failures of recognition are far more likely to be the straws that break the camel’s back. At some point, it almost feels as if you want to insist for the sake of the carer’s health that a residential home place is found. If there are real financial incentives to maintaining a person at home, these decisions will be even more difficult. Keeping people at home is an explicit aim of the Bill—a laudable one in many cases—but whenever one introduces financial incentives of this kind, it is remarkable how the flow of patients in and out of institutions changes. I remind noble Lords of the major expansion of nursing homes and care homes which came about in the 1980s, the direct result of the funding of care places through individual, generous grants via social welfare budgets, which then created thousands of new residential places. One-third of business expansion scheme grants—the investment miracle of the Thatcher years—were invested in the care home sector. Care homes were, of course, basically property investments; but property companies were at first excluded from the BES initiative and so the care home sector was an attractive alternative as long as revenue was guaranteed by the Government. I used to watch the Laing and Buisson figures of the growth in residential care places with utter amazement. For a time I acted as an investment adviser to ‘3i’ because the business investment companies were so worried about how much BES money was channelled through these schemes into care homes. They were very worried about the quality of what they were investing in—rightly so, as it turned out. It was a classic case of the Government having a genuinely philanthropic policy hijacked for the benefit of the small business community to the growing frustration and disbelief of the Treasury. It did not last long, of course. In both the USA, where expansion was similarly funded by Medicaid, and in the UK our Treasuries soon woke up to the escalating unaffordability, but here, in 2010, we have witnessed a 15-year decline of the care home sector, although with some suggestion that sheer demographic pressures are now reversing that trend again. Even small shifts in incentives can have major impacts. There has been no modelling of the impact of this Bill on other revenue streams in spite of the theoretical impact of the ADL deficits on the demand for care and the need for modelling. I was predicting in one direction and the noble Lord, Lord Turnbull, at Second Reading, cited the care needs of his mother-in-law, pointing out that after a classic hip fracture and hospital stay, at the very moment her care needs went up from perhaps 30 hours a week to 168 hours a week, her eligibility for financial support went down. That cannot make sense. Crucially, this fails the test set out by the Minister in her exposition of the Bill when she said that those with the highest needs must receive the greatest help. It was that injustice more than the issue of costs to which the noble Lord, Lord Turnbull, objected. A financial obstacle is being erected to prevent decisions being taken which are in the best interests of the elderly person. The noble Lord, Lord Turnbull, and I were predicting in one direction but the noble Earl, Lord Howe, made the crucial point that there is an intermediary body which is going to be the vehicle for this new funding—the local authority. If the total cost of delivering the Bill should exceed the budget, local authorities will have to find whatever extra money is required. In other words, they are being landed with an open-ended commitment, not fully funded as expressed in the famous "new burdens doctrine". The noble Earl pointed out how predictable would be the response of local authorities. He suggested that there would be a stampede of applications for free personal care and, when the money available is used up, local authorities will do their utmost to avoid having to take more people on to the books, and we will find pressure being placed on the elderly to move into residential care instead of staying at home. It will prove harder for people to pass the test of eligibility. Alternatively, and perhaps additionally, in order to fulfil their obligations to those in critical need, councils will be forced to remove social care funding from those who are in lower categories of need. To the extent that this happens, it may drive some people out of their homes and into residential care, thereby serving to dilute the main benefits of the Bill, which is supposed to enable more people to avoid or delay entering residential care. I further predict that, just as used to happen, very dependent old people will end up in acute hospital beds and acute psychiatric units. I hate the phrase "bed blocking"—which means a very frail, needy, older person whose health and social care needs are being denied to them—but that is what we will see. So we have four unpredictable scenarios which have not been explored and I would like the Minister to explain what work is going on to clarify which of these scenarios is likely. Amendment 10 follows up the point made in Committee in the Commons by Andrew Lansley, who wanted to be sure that extra care accommodation would be regarded as a person’s home and not residential care for the purposes of this Bill. People who live in extra care housing have their own self-contained homes, their own front doors, and a legal right to occupy the property. Extra care housing is also known as very sheltered housing, assisted living, or simply "housing with care". It comes in many built forms—blocks of flats, bungalow estates and retirement villages. But it can, and does, sometimes provide an alternative to a care home, and that is the nub of the problem. In addition to the communal facilities often found in ordinary sheltered housing, domestic support and personal care are also available, provided by on-site staff. Properties can be rented, owned, or part owned and part rented. The Government say that people who live in sheltered accommodation or extra care housing are not to be excluded on the grounds that: ""The accommodation and care provided in such accommodation are not provided together but under separate arrangements made by the individual"." The problem is that the increasing numbers of these types of schemes—which I was involved in developing myself when there was lots of Housing Corporation money around—are now providing 24-hour care seven days a week in exactly the same way that care homes do. That marvellous organisation, Methodist Homes for the Aged, or MHA, has, for example, at Moor Allerton resource centre in Leeds a 20-bed extra care scheme especially for people with dementia. It serves as a direct alternative to residential care. MHA established their housing association arm as a subsidiary of their well known care homes charity in order to benefit from the split in funding and also, admirably, from a wish to continue to provide even the most disabled older people with their own homes, however much they needed personal care and support. I applaud them for it. But while the philosophy of care may be different, extra care housing in reality provides identical personal care and nursing services. There are at present only 25,000 or so extra care housing places, whereas there are 500,000 care home places. So maybe the Minister is not too worried about the outright favouring of the minority who find one of these schemes available in the area as an alternative to a care home. Nevertheless, does the Minister agree that, as soon as legislation of this kind is introduced, large numbers of care-service providers that currently make provision by way of a single contract with people—one that provides accommodation and care together—will suddenly find it desirable to provide different separate contracts for accommodation and care services? In just this manner, I and my colleagues in Lewisham managed to close long-stay beds for people with dementia in Bexley and Cane Hill hospitals and provide tenanted accommodation in conjunction with South London Family Housing Association—now part of the Horizon Housing Group—as similar to a specialist care home as to be indistinguishable, but all our residents had personal tenancies. In other words, they were indistinguishable from a residential care home. Is it not peculiar that if people are in extra care housing and they have two contracts—one for care and one for accommodation—they are eligible for free personal care that pays their care needs, but if identical care is provided under one contract it will be charged for. I cannot see how this flaw in the legislation can be reconciled. We could end up with a distortion in the care market with large numbers of care providers recreating their services so as to distinguish between accommodation and care. The Government, whether intentionally or not, are creating a potential loophole for people who are currently in long-term residential care who would not be regarded as being in extra care housing. They will inevitably restructure their arrangements at the point at which they enter care in order to make themselves eligible for free personal care. The Bill does nothing to prevent this from happening. That seems to be an obvious flaw in the legislation—unless this is the intent, but I doubt it. Personally, I have always been an advocate of separating housing and support costs but this is not the policy intention and I fear that we are going to end up with a great confusion.