I believe that the care of the elderly is one of the major issues facing Britain in the latter part of the twentieth century. Therefore, I think it appropriate that tonight we should be considering the problems associated with caring for the elderly infirm. The debate is designed to focus attention on a significant, yet almost silent, shift in responsibilty for caring for the elderly infirm that is taking place in Manchester and other major cities. I contend, virtually unnoticed.
Traditionally, it has been relatives, voluntary agencies, hospitals, mental institutions and the municipal elderly persons' homes that have honoured the community's obligation to care. Increasingly in Britain's cities it is the municipal elderly persons' home that now provides the long-stay caring environment for the elderly infirm. It is that simple fact which, to my mind, has produced two important consequences.
First, it has brought about a shift in public expenditure from the taxpayer to the ratepayer. More importantly, it has placed the care of these frail elderly people increasingly on the shoulders of care assistants in elderly people's homes.
On a point of order, Mr. Deputy Speaker. The point that I wish to raise is well known to some of my hon. Friends. When we decided to oppose the Government at the end of the previous debate, we were quite clear about it. Mr. Speaker decided that there was some confusion, but there was no confusion on these Benches. We opposed the Government. Mr. Speaker put the Question a second time, and we opposed the Government again.
We have been discussing the matter with the Clerks, and they have affirmed the point that we are making, namely, that there should have been a Division. It looks to me as though, right at the end, there has been another cover-up.
I have some sympathy with my hon. Friends, but I hope that they will accept that I am seeking to draw attention to a moving social problem.
The care of frail elderly people reposes increasingly on the shoulders of care assistants in elderly people's homes. Without the sterling endeavours of the care assistants, whom I describe as working angels, the lives of many elderly people would have been at risk.
A profile of care assistants would show that, in the main, they are dedicated, overworked, underpaid, trained on the job, part-time working mothers with little or no professional medical training.
One might well ask what impact shouldering responsibility for long-stay geriatrics has had on the working lives of the staff of elderly people's homes. The position was summed up graphically for me by one of the splendid ladies on the staff of an old people's home in my constituency when she said:
In some cases, what I can only describe as a macabre game of passing the parcel between the family, the hospital and the municipal elderly persons' homes takes place, the only problem now is that when the passing stops it's almost always us, the elderly persons' home, which is left with the responsibility of caring for those too elderly and unable to care for themselves.
In recent months in addition to the usual maladies which afflict the elderly, we have had cases of dehydration, chronic bedsores, three residents who were mentally confused and of course the recurring problem of incontinence.
It is not difficult to identify at least three factors that have led to elderly persons' homes having to carry that increased responsibility. Hospital in-patient provision in geriatric wards has increased only slowly in recent years, and, irrespective of any Government cuts, it is planned to decline on a per capita basis.
Hospitals are increasingly reluctant to take other than short-stay geriatric patients. Only last week the chairman of the North-West regional health authority confirmed that there is a "total deficiency" in hospital geriatric provision in the North-West. I am conscious of the fact that my hon. Friend the Member for Manchester, Gorton (Mr. Marks), who is also to take part in the debate, can speak with first-hand personal experience of that particularly distressing problem.
For their part, psychiatric hospitals now discharge back into the community those elderly patients who they believe can be rehabilitated. Equally, the emergence of sheltered housing now caters for perhaps more of the ambulant elderly, while voluntary agencies are encountering substantial financial burdens. It is a combination of these developments that has effectively increased responsibilities of care assistants and markedly changed life for residents and staff in elderly persons' homes.
While I have sought to highlight and emphasise the increased responsibility for care assistants in elderly persons' homes, one must bear in mind the impact which the particular cases to which I have referred—the mentally confused, the dehydrated—can have on the normal elderly infirm in elderly persons' homes. It has an appreciable impact.
I believe that the shifting responsibility to which I have referred necessitates Government action in three directions. First, the priority accorded to the provision of long-stay geriatric accommodation in hospitals must be re-examined. Secondly, the training afforded to care assistants in elderly persons' homes should be reviewed. Thirdly, circular 14/57, issued in 1957 by the Ministry of Health, which defined the types of cases which should be dealt with in elderly persons' homes and hospitals, should be looked at again.
That this is an urgent problem is self-evident. The number of elderly people is increasing. In 1986 there will be 20 per cent, more people over 75 years of age than there were in 1976. By 1996 the over-75 years of age will be double that of 1951, and the over-eighty-fives will have increased by 40 per cent.
Frankly, this is one issue that we owe it to the nation and our people not to ignore.
I am grateful to my right hon. Friend the Member for Manchester. Openshaw (Mr. Morris) for the opportunity to speak in this debate.
My right hon. Friend is talking about the city of Manchester, which has one of the outstanding local authorities in this country in regard to its care for old people and for the disabled. If the situation in Manchester is as my right hon. Friend has described, what must it be like in the rest of the country?
This year's cuts are already having an effect. I believe that next year's cuts will make life intolerable for a great many old people and their relatives. The argument that the local authority has choice is nonsense. Local authorities will have the choice to do worse or much worse. That is all that the Government are giving them. In The Times today an article said:
… it appears so far that the elderly are bearing the brunt because most local authorities are cutting both their residential and domiciliary provision… Plans to build old people's homes are being abandoned, new homes are not being opened, and the services that keep elderly people in their own homes are being cut back. New charges are being imposed for home help and meals-on-wheels services, and transport charges are being made for travel to day centres.
There is a domino effect here. The hospitals cannot cope, and the Government will not let them try to cope. Elderly people's homes are having to bear the brunt of the overflow, and the wardens of sheltered accommodation are being asked to do jobs which it is not their duty to do. Old people living on their own, and only occasionally getting to day centres, will suffer most of all. Old people being looked after by relatives—many of the relatives being old-age pensioners themselves—will very much feel the draught.
The Government have got their priorities wrong. They are not coping with the growth of the problem or with the problem that exists. I believe that the Under-Secretary knows that. However, he must convince his Secretary of State, who seems to think that it can all be passed over to voluntary organisations, and he must convince the Cabinet, too. If ever a U-turn was needed, it is on this matter.
I should like to thank the right hon. Member for Manchester, Openshaw (Mr. Morris) for providing an opportunity to respond to questions which are clearly of great importance for his constituents. To begin with I should like to set the local issues in the national context.
The right hon. Gentleman may find it helpful if I briefly review our general policies for care of the elderly in this country. Any such review must begin with a salutary reminder of the scale of the problems with which demographic changes will present us. The right hon. Gentleman gave us some figures.
In 1951 there were just over 4½ million people aged 65 and over in England and now there are over 6½ million—that is, one in seven of the entire population of the country. The number will continue to increase and will reach over 7 million around 1990. However, these overall figures mask an even more fundamental change. More people are living well into old age, and the average age of the older generation is increasing. Before the end of this century, the number of people aged over 75 is expected to increase by nearly one-third and the number of people over 85 by nearly two-thirds.
The implication of these population changes will be clear to this House. It is well known, sadly, that the older one gets, the more likely one is to need help from the health and personal social services. More than three-quarters of those aged 85 or over covered by a recent survey had some illness or disability requiring care.
Therefore, we are well aware of the demands that lie ahead of us. However, I must say this to the hon. Member for Manchester, Gorton (Mr. Marks). Meeting the needs of elderly people must be considered against the background of the battle against inflation, and the Government's determination to halt the decline in Britain's economic performance The rate of inflation must be brought down if living standards are to be maintained and elderly people, especially those on fixed incomes, stand to gain considerably. Until the economy is on a sounder footing we cannot go on spending ever-increasing amounts in real terms on all benefits and services.
It would be wrong to pretend that there will not be some adverse consequences for the services used by the elderly when health and local authorities make their decisions about what they can afford. But we have made it clear that authorities should, as far as possible, seek to protect services for the most vulnerable, including the very old and frail. Moreover, we in central Government have taken steps to protect those spending programmes which mean most to old people—personal income, access to health services and improvements in housing conditions.
Again, I have to say this to the hon. Member for Gorton. Some local authorities have been able to meet the spending targets which we have set them and manage to safeguard social service programmes. There is a real choice for these local authorities.
The Government's general aim in the provision of health and personal social services for the elderly is to enable them to maintain independent lives in their own homes wherever possible. That is what most elderly people want. Next year we will be publishing a White Paper—the first ever to be devoted specifically to elderly people—which will cover a wide variety of issues.
To enable enderly people to enjoy independent lives in their own homes, health and local authorities need jointly to plan an effective network of services. Many elderly people can be helped to remain at home by good primary health care services and social services. Sheltered housing provided by local authorities allows many others to keep a home of their own, which they would find difficult without the oversight of a warden. Adequate hospital services for the elderly with acute illnesses, with severe mental infirmity, or needing longer-term nursing care, are also crucial. For old people who can no longer cope in a home of their own, but who do not need continuing nursing care, there are residential homes provided both by local authorities and by the voluntary and private sectors. Joint finance has an important role in helping to underpin joint planning and in achieving better use of resources across the board. Well over a third of the money available for joint finance is being spent on the elderly.
In preserving the increased level of NHS resources for 1980–81 set by the previous Government, we have also preserved the increased level of joint financing. This means that, at present prices, nearly £50 million will be available to health authorities to help support the personal social services. This will clearly be a significant help in alleviating some of the worst effects of any direct cuts in social services budgets.
I shall now try to describe how the challenge of providing the appropriate sort of care for the elderly has been met in Manchester. I think that both the right hon. Gentleman and the hon. Gentleman will agree that a considerable amount has been achieved.
In Manchester, it is hoped that the development of supportive services in the community will mean that an increasingly large part of hospital facilities for the elderly will be providing short-term care. The strategic plan of the area health authority envisages a slight drop in the number of geriatric beds overall—although the number in the central district shows a considerable rise. At the same time it is hoped that an increase in the number of assessment beds and an improvement in rehabilitation services will relieve the pressure on the remaining beds. The area strategic plan also recognises that at present hospital provision for the elderly, severely mentally infirm is inadequate, and it is hoped to raise the number of beds from 133 at present to 234 in 1988–89.
The principle of providing small units to provide a day care service locally has been accepted, although financial considerations will obviously affect the speed at which this can be achieved. It is hoped to double the number of geriatric day places available in Manchester in the next 10 years, which should bring the total to 280. This includes 60 new places in a new unit at the Manchester royal infirmary, and a new 50-place unit at the Wythenshawe hospital. Physiotherapy and occupational therapy services are being developed in day hospitals and the area health authority is looking into ways of improving transport for day-patients, so that the most effective use can be made of the facilities.
The right hon. Gentleman mentioned particularly the question of arrangements for discharging elderly people from hospitals into the community, and these clearly become more important if we see it as the primary purpose of the hospitals to provide short-term care. It is true that the Department has issued no recent guidance on this—our current circular on the subject dates from 1963, though I think the general principles it embodies are still valid. But here I must enter a doubt about how far the Department can usefully go in defining arrangements which really have to be worked out by sensible co-operation locally. The need for community services to be geared to coping with patients discharged from hospital is, I know, something to which the health authority in Manchester is very much alive, and the authority employs a number of district nurse liaison officers whose specific job it is to ensure this.
Community and domiciliary health services for old people in Manchester have been, as one would expect, very much a growth area. The amount of attention given by health visitors and domiciliary nurses to the elderly, relative to other age groups is rising rapidly. The night nursing and night sitting service is also expanding, though not so quickly. Of particular importance to the elderly is the chiropody service, and the authority is at present looking at the most effective way of providing this service.
As I indicated earlier, there is often no clear dividing line between those who require health service provision and those who are cared for by social services; and both services have a great deal to contribute to the care of the elderly.
I apologise for interrupting the Minister. I know he is under pressure of time. I posed certain questions concerning the training of care assistants in elderly persons' homes and the need to look again at circular 14/57 which determines the cases which can be channelled to elderly persons' homes and hospitals. Will the Minister give me his view on those matters?
I hope I am pacing myself carefully so that I will have time to reach the relevant sections in my speech which answer those questions.
The establishment of the joint care planning team and the involvement of local authority representatives on district planning teams have helped make everyone involved aware of the contribution made by all services to the care of the elderly. I am told also—although I am afraid I cannot quote figures on this point—that the authorities in Manchester have been enthusiastic in their use of joint finance and have never failed to make full use of the funds allocated to the area health authority for this purpose. I find that a tangible indication of a good level of general co-operation.
In the last few years there has been quite a big expansion of social services generally for old people in Manchester. At present the local authority provides residential accommodation for about 1,770 elderly people in 45 homes, most of which are purpose built. It is quite true, as the right hon. Gentleman indicated, that there is a much greater degree of infirmity among the residents of these homes than would have been the case, say, 10 years ago. I have noticed this myself going round my own constituency. In his remarks the right hon. Gentleman put a good deal of emphasis on the training of staff to cope with these needs and he described graphically the problems facing them. I totally agree with him about the importance of this.
It is certainly our view that all staff engaged in residential care of the elderly are likely to need some form of training to equip them for the wide range of talks involved. Suitable training not only significantly enhances existing skills; it can also enable staff to extend the services provided by visiting professionals. Our policy is that wherever practicable local authorities should release staff to those training courses provided by polytechnics and colleges of further education which are recognised by the Central Council for Education and Training in Social Work.
It is, of course, the local authorities themselves that are responsible for ensuring that staff are adequately trained for their duties, and this is in fact a field in which the local authority in Manchester has been extremely active. The authority has a deliberate policy of giving priority to training for residential and domiciliary staff, as distinct from field social workers. At present 70 of its care assistants are engaged in training on the basis of one day's release a week. Apart from this, all care assistants undertake home nursing courses in the various local colleges. I hope that gives the right hon. Gentleman some reassurance on that point.
I think it is also worth mentioning that the Manchester area health authority has undertaken a study of the nursing needs of residents, with a view to providing an improved nursing service. It seems clear from the study that with great dedication staff of old people's homes have long been carrying out tasks more appropriate to nurses. It is hoped that the provision of an improved nursing service to people in old people's homes will release other care staff, so they have more time to spend with residents and involve themselves with social rehabilitation.
The recommendations made as a result of the study include joint training sessions for employees of the health authority and the social services department which would provide a forum for the exchange of ideas. There will also be training sessions on topics such as drugs and their side effects, and methods of coping with incontinence. At the same time it was recommended that nursing assessments should be carried out at regular intervals, in the hope that potential problems will be identified and dealt with at an early stage. It is also envisaged that where possible domiciliary nursing care will be provided for the sick and the bedfast, as if they were in their own homes, and it is hoped that these recommendations will help residents maintain their independence and health as far as possible.
The right hon. Gentleman made a point about a fairly ancient Ministry of Health circular—circular 14/57 issued in 1957. There is, in fact, more recent departmental guidance on the care of the elderly in residential homes—notably HM(65)77 issued in 1965, and HC(77)25 which was issued in 1977 and accompanied a booklet on health care in residential homes.
The right hon. Gentleman is absolutely right. The earlier circular needs to be read in conjunction with these later documents, copies of which I am sending to the right hon. Gentleman. But I should like to make the point again that the Department is not the fountain of all wisdom. What matters more is an enlightened local approach, and certainly from the evidence I have collected for this evening's debate Manchester does not seem to be wanting in that respect.
At the other end of the scale, Manchester has made considerable efforts to ensure that those who could manage in their own homes, or in sheltered accommodation, are given this opportunity to do so, and are not in residential care. For instance in 1976–77 there were 240 units of sheltered accommodation. The total now is more than 900, almost a fourfold increase. Each sheltered nursing scheme has a resident warden and nonresident assistant warden, who provide a focus and stimulation for social activities as well as help in any emergencies which might arise. In addition, neighbourhood wardens and neighbourhood visitors provide a regular visiting service to people living in their own homes.
The number of day centres with places for the elderly has increased rapidly in recent years, and it is intended that it should continue to do so. Funding has come from both joint finance money, and inner city partnership money. There are now 15 day centres caring for the elderly, of which 12 are solely for the elderly, and three are mixed. In addition, there are 27 day centres and 43 luncheon clubs.
Of course, the social services department is not concerned merely with providing day facilities where these elderly people who live on their own can go and meet. It also provides practical help in the home. No reductions have been made in these services. Indeed, at present 70 additional homes helps are being recruited, and the Department is continuing to provide concessionary travel for all elderly people, and help with holidays for those who are disabled through age.
I have given a picture of some fairly solid achievements in the care of the elderly in Manchester in the past few years. We are, as I said earlier, determined to restore the strength of the country's economy, and our strategy includes bringing public expenditure under control. Nevertheless, we have, as the House knows, provided for spending on the NHS to remain at the previously planned level, and the planned volume of spending next year is about 3 per cent, higher than the latest estimate for the current year. The North-West as a whole has benefited from the policy of shifting resources towards deprived regions, and although Manchester is a relatively wealthy area in the North-Western context it has benefited in its turn. The increase in its revenue allocation has consistently been above the national average until this year when it fell only very slightly below it. We shall continue to shift resources towards the deprived regions so far as the overall level of expenditure on the Health Service allows us.
I do not want to end, however, by suggesting that the statutory services are the be-all and the end-all of the community's efforts. No discussion of services for the elderly would be complete without reference to the voluntary sector. Its value lies not only in the provision of additional resources, to meet the demands of a growing elderly population, but also in improving the range and choice of care. Here we should not forget that the younger elderly—those aged between 65 and 70—are themselves a potential resource in having time to devote to voluntary activities, particularly help to the more frail elderly in the older age groups.
Finally, we should never forget how the families of old people have the central role in looking after them. I emphasised at the outset our primary aim of enabling old people to maintain independent lives in their own homes wherever possible. The more the whole network of statutory services—hospital, residential, community and domiciliary—is geared to assisting and supporting what is done by the family, the better use we shall be making of the community's resources as a whole.