Personal Care at Home Bill

I added my name to Amendments 26 and 28. It is important for us to explore this discretionary activity around reablement and how it will be implemented. This is also our opportunity to look at the Government’s thinking on reablement. I hope that the noble Lord, Lord Lipsey, will not mind me teasing him for a moment, but I find it interesting that he called it "re-enablement". That is because he cannot find "reablement" in the dictionary either. It does not appear in any dictionary yet; the term has been developed within social services to talk about rehabilitation. I cannot think of a single way in which it is different, but I will come to the cultural aspects of why it is called something different, because that is important. This is exactly what intermediate care was set up to do. Again, therefore, I am afraid that there is extraordinary confusion. It is a bit like the difference between a social care bath and an NHS bath. It is not just the bubble bath that goes in from social services; the question is who delivers it and what the philosophy is. That is also the issue with enablement—I am sorry, I mean "reablement", which is the word that will go into the dictionary eventually. I know that the wording of Amendment 26 is probably the reverse of what is desirable, so I will save the Minister the effort of responding to the wording. I am as keen as anybody that there should be the opportunity for people to have a professional assessment to see whether there is room for improvement and to provide interventions in the physical and social environment that will allow people to function as well as they possibly can. I am worried, however, about how this discretionary intervention will be exercised in practice, particularly in relation to the concerns that were expressed by the noble Earl, Lord Howe, and the noble Baroness, Lady Barker, on the previous set of amendments. The opportunities for confusion, for swapping around and for the exercise of discretion as to who pays for what and who does what are really quite frightening. As the noble Baroness, Lady Greengross, said, the problem arises in particular in relation to those with dementia, perhaps when they come out of hospital and are assessed for the first time, when there will be opportunities for toing and froing between authorities about who is going to do what. The reablement approach is interesting, because it was developed with the sense of a restorative and capacity-building approach to improving the lives of disabled older people. It is as much a philosophical and cultural approach as a specific technique—not doing things for people, but assisting and doing alongside. However, one has to admit that there are at the moment no long-term studies that have demonstrated its efficacy over the longer term for people with a level of disability who will be the recipients of the free personal care. We are talking about a seriously disabled group of people. All successful studies have used very high levels of intervention. The Government’s short-term studies are encouraging for people of all ages and show that one can achieve a small but significant reduction in the use of personal care services. However, it is important to note that the studies in the care services delivery efficiency programme focused not only on those practical aspects of daily living that are the subject of this Bill but on much broader criteria of success. The interventions were often for longer than six weeks and for far more hours than is being proposed here. In fact, the cost of those successful schemes was more than what has been allocated for the reablement process. I suppose that a purist would point out that it is rather bizarre to implement reablement intervention as a prerequisite for receiving assistance, when the long-term studies currently in progress have not reported yet. We know that schemes are nearly always successful in their pilot phases, but long-term sustainability and cost-effectiveness may be difficult to predict. Given how often I have personally pushed for things to be rolled out when there is some indication of support, I have some sympathy with the Government in wanting to do this. However, we should realise that reablement has so far been shown to be effective on, for example, mentally alert people who, after a short stay in hospital with a fractured femur, are coming out and need to get their confidence back. In that scenario, it can be quite successful. However, the Government’s short-term studies, which are fine as far as they go, show that reablement is less effective for those with severe disabilities over a longer period. It can be effective, but there is a group of people for whom an intensive, much longer period of care will be required. I have great doubts about the amount that will be required to get the improvements needed within the proposed level of reablement input. That is the purpose of this probing amendment. As for Amendment 28, one should bear in mind that, for example, following a stroke or a head injury, maximum performance will not be achieved for perhaps more than two years, which would be a long time after the reablement process had finished. Therefore, I wonder whether the word "maximise" is quite right. I suggest that "significantly improve" would be a more appropriate phrase, particularly for people with mental health problems.