I am very grateful to my hon. Friend the Under-Secretary of State for coming to the House at this late hour to answer the debate. I hope that the people of Wales will take note of how assiduously he carries out his duties even in the very small hours of the morning.
I should make it quite plain that I am concerned only with one specific point and not with the much wider question of the impact on pensioners and others of the changes in the social security system resulting not just from the Social Security Act 1986 but from many other factors, such as the increases in water charges and electricity tariffs, the requirement that all except the very poorest should pay 20 per cent. of their rates and the loss in many cases of rate rebates and lower interest rates for their savings, which is a very heavy factor for other people, but not so much for pensioners. Those factors, which affect the standard of living of many of the poorer pensioners, though not the very poorest, led me to abstain in the vote yesterday afternoon.
My abstention was intended as a criticism not of the DHSS or of my hon. Friend and his handling of these matters at the Welsh Office, but of the way in which they have been forced by the Treasury to make choices which they should not be forced to make in the country's present affluent circumstances. What is more relevant to the particular point that I am making tonight is that they are being driven into an approach which penalises even modest thrift, as part of the process of targeting benefit to the most needy.
I know that that problem crops up over all areas of social security. It is inseparable from any attempt to target help on those who need it most, though I think Ministers, and especially the Prime Minister, would do well to face it a bit more frankly and to admit that targeting benefits inevitably means damaging the people and discouraging the instincts that ought to matter most to a Conservative Government. I have to admit that the problem is one that has baffled Governments throughout the ages when they have set out to relieve poverty or distress.
The specific point that concerns me is the support for elderly people who are discharged from NHS hospitals into private nursing homes. As long as they are in hospital they are accommodated and treated free of charge, apart from an abatement of their pension after eight weeks, which no one will complain about. That is regardless of their means or the means of their spouse. But if that elderly person is discharged from a National Health Service hospital into a nursing home other than one run by the local authority, very different considerations apply. The fairly hefty fees must be paid, and in practice—certainly in my own county of Clwyd and, I suspect, in most other health authority areas—they are paid by the elderly person himself or herself, or by the spouse, if either have savings above the £3,000 level that disqualifies them from income support.
Let me put the case of one of my constituents who prefers not to be named. I shall call her Mrs. X. She is in her seventies and suffers from Parkinson's disease. Her husband is suffering from senile dementia and is being very well looked after in a private nursing home. Her savings exceed the £3,000 limit, so the only help she gets is the attendance allowance, plus her husband's state retirement pension. All this goes towards meeting the nursing home fees. To pay the balance of £110 per week she has to draw on her savings. Last year she spent over £5,500 in this way. At this rate she will soon have no savings left, and only then will she be able to get the fees paid.
One solution is for elderly people to remain in NHS hospitals until they die and for their spouses to refuse point blank to pay any fees for them in nursing homes if they are moved out of hospital. That is what another of my constituents has been driven to do. He is 78 and has looked after his sick wife as best he could for many years, but he is now too infirm himself to go on doing so. His wife was admitted to hospital with fluid on the lung, and while there she first had a heart attack and then broke her femur. Now she is fit enough to be moved from hospital to a nursing home, but the husband wants to know who is to pay the fees. If he uses his remaining savings to do so, she may live a few years but he will be reduced to dependency on the state for the rest of his life.
I might mention another way in which the regulations are hurting people who move out of hospital into nursing homes. The hon. Member for Gower (Mr. Wardell) has been much concerned by this, and I am indebted to him for this example. I have other similar though less clear-cut cases in my own constituency. It concerns an 88-year-old lady who owns her own home and has been in a nursing home since 1985. On 1 April she was informed that she was no longer eligible for income support, presumably because the house she owns, though it yields no income, is a capital asset, valued above £3,000. She is trying to sell the house but she cannot do so. In the meantime, there is no money to pay the nursing home fees of £180 per week. The obvious answer in this case should be a bank loan, but it seems that bank managers are not sympathetic towards cases such as this, and under the new regulations the DHSS seems to have no discretion to help. So what is the poor woman to do?
It may be that my hon. Friend the Minister will quote to me from Health Circular 81(1) and tell me that where a consultant or a general practitioner recommends the transfer of a patient from an NHS hospital to a nursing home the health authority has the power to enter into contractual arrangements with the nursing home to care for that patient, at no cost to the patient or his or her spouse. But the health authority does not have to exercise that power, and certainly at Clwyd it has chosen not to do so. With the other pressures on it, and given the age profile of its area, I can see very clearly why it has so decided.
The solution suggested to me by my constituent Mr. Alun Roberts, to whom I am indebted for much of my information, is that funds should be allocated to health authorities for specific purposes such as this. I am not so sure about that. I can easily envisage other problems which would require specific funds to be dedicated to them, and there could be no end to such piecemeal financing.
None the less, the Government should surely be seeking some way not just of mitigating the very damaging effects that their targeting polices are having on people's instincts for thrift, but£more specific to my purpose tonight£of making it easier instead of harder for elderly people to move out of hospitals and into nursing homes. Even if we consider the matter purely in terms of value for money, it must make sense to encourage people to move out of hospital, where they are very costly to look after, to nursing homes, where they can be looked after at substantially lower cost.
It seems absurd to do anything to discourage that. By withholding financial support from public funds and making what may in the end prove to be a vain attempt to force spouses to spend their small savings to pay the fees, we may well end up by placing a greater burden on public funds. Moreover, we shall have added substantially to the heavy burdens already being borne by the relatives of elderly sick patients.
I congratulate my hon. Friend the Member for Clwyd, North-West (Sir A. Meyer) on his success in obtaining this Adjournment debate. His compassion and concern for the more vulnerable members of society—and particularly for his constituents—is always apparent. I am particularly grateful to him for raising this important subject, because it is one that concerns us all and one to which the Government have given considerable and detailed attention.
My hon. Friend has given the House examples of the needs of individuals which raise important general principles. If my response seems concerned primarily with principles and with general rules, that is in no sense because that is how the Government perceive the issues. However, soundly based principles are the essential bedrock of a system of support that best meets the needs of individuals as individuals.
Let me start with one of the most important of those principles—one to which my hon. Friend has rightly referred. It is that there is no question of our departing from the fundamental principle that access to medical care should not depend on the ability of an individual to pay. Let me be specific about this. Our position is clear and on the record in all our public statements, and in our advice to the health authorities: no patient who comes to the NHS should be placed in a private nursing home against his or her wishes if that person, or a relative, would be responsible for the home's charges.
I know that my hon. Friend chooses his words carefully, and I did not hear in what he said any suggestion imputing any undue influence, direct or indirect, on the individuals, the details of whose circumstances he draws to the House's attention, or any suggestion that they or their relatives had been persuaded against their better judgment to agree to placement in a private home. If, however, my hon. Friend has any such evidence I should very much like to have it so that I can take the matter up with the relevant authority and receive a full explanation.
That would be a serious matter. I stress this not least because not only are the consent of the individual and the views of affected relatives to be respected, but decisions about the discharge of people from hospital are for the medical consultant in charge of the patient's care to make—and they must be made on clinical grounds. Financial considerations, therefore, should not enter into the consultant's decision. Thus, when a consultant decides that a patient requires continuing medical or nursing care as an in-patient, it falls squarely and unequivocally on the NHS to supply it, at no cost to the patient or his or her relatives.
The care needed may be provided either directly by the NHS in an NHS bed, or by transfer to a private nursing home under contractual arrangements under which the NHS—not the patient—meets the full costs and retains the ultimate responsibility for the patient's care.
I should like to stress that the status of patients in such contractual facilities is thoroughly safeguarded and protected. Let me quote from the circular referred to by my hon. Friend:
A patient admitted to or using a contractual facility remains an NHS patient and may only be charged for services as permitted by the NHS Acts. The arrangements for the use of independent facilities should provide for treatment and maintenance with the usual amenities without charge to the patient in exactly the same way as a patient in an NHS establishment. Authorities should be careful to ensure that patients are not pressed into paying for extra amenities (outside the terms of the contract) which they do not want. There should be no disparity between the clinical care and services provided to NHS patients and the hospital or home's private patients.
When someone in hospital no longer needs the level of medical or nursing care provided, it is open to the hospital to arrange a more suitable placement. When patients are moved from an NHS hospital to a nursing home, the health authority should make it clear whether or not it will pay for the patient's care before he is transferred; and, as I have already said, no patient can be transferred without his consent if he or a relative has to be responsible for the home's charges.
I hope that I have established clearly the approach that the Government have taken, and continue to take, on the protection of the rights of the individual. Clearly, the fulfilment of the objective of meeting the needs of individuals for medical and nursing care is a major and continuing challenge for our health authorities. They must meet it by making maximum use of their own community health staffs and by working in collaboration with social service authorities and others with a part to play in enabling people to live in their own homes whenever possible, where that matches their wishes.
That increasing throughput, and the keeping of hospital episodes to a minimum, must be seen as part of our overall strategy for the elderly in Wales. That has been aimed—through effective collaboration with all the agencies involved—at trying to maximise people's potential to remain living independently and to keep to a minimum any spells of inpatient care that may be needed.
Last year we launched our elderly initiative. under which we are making available some £7 million to fund pilot, innovative and, it is to be hoped, replicable projects in the provision of care for elderly people.
I turn now to the second important set of issues that my hon. Friend raised when he appeared to suggest, by referring to particular cases among his constituents, that it is in principle unfair that a person who decides he wishes to be cared for in a private nursing home on a permanent basis should be required to contribute towards the costs of that care. I should be surprised if that is what my hon. Friend intended to imply, and it may be that I have not fully understood him.
The Government's view is clear. Where people genuinely cannot afford the care they need, but where they elect to have that care in a private nursing home, income support will be payable to them up to the relevant limit. Incidentally, we have recently increased the limits significantly. For instance, in nursing homes for the elderly, the limit has been raised a further £10 to £185. That means the limit for those homes will have increased by £50 in three years.
Government spending on support for people in private and voluntary homes has risen from £10 million in 1979 to some £0·5 billion now, but the Government believe it is right that the individual should look to his or her resources before drawing on public funds. I hope that my hon. Friend can see the sense in that. Any other arrangement would not only be grossly unfair to the taxpayer, but would make it impossible to concentrate assistance on those who need it most. It must be remembered that we are talking about people who should themselves have decided that they wished to be cared for in a private nursing home.
Once the principle is accepted that it is right to have regard to an individual's own resources before deciding what public resources might be paid, difficult, sensitive and complex questions arise as to the circumstances in which individuals should receive support—and to what extent. So we have developed a number of important safeguards that are relevant to the issues and examples my hon. Friend has raised.
First, where one of a couple is permanently resident in a nursing or residential home, their entitlement to income support is assessed—as was their entitlement to supplementary benefit—separately. So if the spouse in residential care has no savings, but the partner who is not in residential care has, that will not affect the entitlement to benefit of the spouse in residential care.
Moreover, where there are joint assets, for the purpose of assessing entitlement to benefit they must be divided equally between the two individuals. Perhaps most important of all, where the partner of someone who has entered residential care permanently, or another elderly or incapacitated relative is still living in the family home, the value of the house is disregarded in the assessment of entitlement to benefit of the person in residential care.
I should say also that the cases referred to by my hon. Friend arose before this week's social security changes came into effect, and no doubt he will welcome the fact that the capital exemption limit has been doubled to £6,000. That means that a substantial number of people have become eligible for benefit who were not previously eligible.
In those ways, and with those safeguards, the Government have sought to strike the right balance between helping those in real need who genuinely cannot be expected to help themselves, or help themselves fully, and our duty as stewards of public resources paid for by the taxpayer.
Let me repeat my invitation to my hon. Friend to pass on any details of cases that he has mentioned, including the case of the lady who has a problem in selling her house, where individuals do not appear to have been treated in accordance with the arrangements that we have laid down. However, I must ask him to draw those matters to the attention of my right hon. Friends at the Department of Health and Social Security. More directly, he might like to suggest to his constituents, or to the local DHSS officials, where appropriate, that a fresh assessment of the entitlement of individuals should be carried out.
I began by saying that the issues which we have been able to debate at this late hour are fundamental and important. They concern, as I have said, some of our most vulnerable citizens. As I am sure my hon. Friend is aware, the number of very elderly people in Wales—those aged over 75 in particular—is set to continue to rise dramatically in the years ahead, from an estimated 189,000 in 1986 to more than 220,000 by the year 2001—a mere 13 years away. Their needs for care will be one of the principal issues facing us as a society.
That is just one of the reasons why we are reviewing with the greatest care the future arrangements for the public financing of community care in the light of Sir Roy Griffiths' recent report. To pick up what my hon. Friend has referred to, Sir Roy has not said what level of financial support should be provided by the Government towards community care. What he has done is to produce proposals aimed at securing the better organisation and delivery of care for individuals, whatever the level of public funding.
We are considering that report and we will come forward with our own proposals as soon as possible. I shall certainly bear in mind all that my hon. Friend has said as we do this and as we review how we should meet this great human challenge.