Dementia Services (Norfolk)

– in the House of Commons at 7:10 pm on 27 October 2004.

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Motion made, and Question proposed, That this House do now adjourn.—[Gillian Merron.]

Photo of Christopher Chope Christopher Chope Shadow Spokesperson (Environment, Food and Rural Affairs)

On a point of order, Madam Deputy Speaker. This raises an issue of command and sanction. Mr. Speaker has repeatedly commanded that the Government should comply with his rulings. He now has the opportunity of exercising a sanction by requiring that the Home Secretary comes to the Dispatch Box tomorrow.

Photo of Sylvia Heal Sylvia Heal Deputy Speaker

I remind the hon. Gentleman of what I said earlier. Both the Home Secretary and the Speaker will have heard what has been said. The hon. Gentleman is now taking time out of the debate for a Back Bencher.

Photo of Norman Lamb Norman Lamb Shadow Spokesperson (Treasury), Liberal Democrat Spokesperson (Treasury)

I am grateful for the opportunity provided by this debate to raise the concerns of friends and relatives of patients at Rebecca house, a specialist unit for people with dementia that was built just 10 years ago in North Walsham in my constituency. The unit faces closure as part of a review of older people's mental health services by Norfolk Mental Health Care NHS trust. The introduction of a report prepared by the trust stated:

"Older People's mental health services will change. Services, resources and staff will join existing localities to provide an age-integrated service within Primary Care Trust boundaries."

It also said:

"Supported by national policies, the local Social Services strategy and carers and users workshops, mental health services for Older People will be updated to provide more community focused person centred care."

If hon. Members can interpret the jargon, that might sound like a good thing, but there is a casualty, as we will lose specialist residential units, including Rebecca house and a unit in the constituency of Mr. Bacon.

Photo of Ian Gibson Ian Gibson Labour, Norwich North

Have the economics been satisfactorily analysed; and, if so, do they point to closure? It would help to know, because many other services in Norfolk and other parts of the country are in the same situation.

Photo of Norman Lamb Norman Lamb Shadow Spokesperson (Treasury), Liberal Democrat Spokesperson (Treasury)

This is all about finding the resources to improve care for people with dementia in the community, but we must consider what is lost in the process.

Rebecca house was built just 10 years ago as a specialist unit for people with dementia, but now it may be closed. It is highly regarded, and the common consensus is that it would be tragic if it were lost. The backdrop to the review is the Government's direction to strategic health authorities on the criteria for free NHS continuing care. At present, 101 beds for the elderly mentally ill are provided by the mental health trust, which has concluded that only a minority of the patients in Rebecca house and similar units qualify for continuing NHS care. Its assessment is that the whole county needs only 28 beds for acute cases meeting the eligibility criteria. The plan is to build a new specialist intensive care unit for those patients in Norwich.

The Minister will be well aware of the report by the health service ombudsman last February about cases in which the NHS had been too restrictive in the eligibility criteria that it applied to the receipt of continuing care. As a result, strategic health authorities were asked to review their criteria, but since then there has been a great deal of criticism about their lack of progress. I should be grateful if the Minister could provide an update and explain how long it will take to complete those reviews.

Wherever the line is drawn between individuals who qualify and those who do not—many people believe that the criteria are too restrictive, and exclude too many patients from free personal care—it is inevitably arbitrary. Many people find it hard to understand why someone who needs intensive 24-hour care but does not meet the extremely restrictive criteria for NHS continuing care should be subject to means-testing, which, the Minister will know, sometimes leads to people having to sell their home to pay for personal care. People who have budgeted carefully throughout their working life are penalised for behaving responsibly.

As the Minister knows, Liberal Democrats on the Scottish Executive insisted on the introduction of free personal and nursing care as a condition of their continuing support. Does the hon. Gentleman plan to review the unfair penalty that applies in England and Wales, which is imposed on families already under enormous pressure as a result of the tragic illness affecting a loved one? What is his reaction to the fact that because of the way in which the criteria are being interpreted, patients who have qualified for NHS continuing care might subsequently be disqualified because they have become frailer and more sedate? There has been no improvement in their health, their condition has continued to decline, yet they are excluded from free personal care. Surely that must be wrong. I know that the Alzheimer's Society shares that view.

I return to the situation that we face in Norfolk. As I said, in presenting proposals the trust is essentially following Government policy. It was clear from a meeting that I attended at Rebecca house that staff have to care for a wide range of patients with very different needs, some of whom, because of their dementia, display fairly challenging behaviour, whereas others are more frail and sedate. That clearly presents difficulties, so I can see the case for a specialist intensive care unit. However, that raises the question of what happens to those who do not qualify for that unit, but whose care needs are such that they cannot easily be looked after at home. In all this we must remember the interests of those who are frequently required to care for a loved one at home. Often those people themselves are elderly and frail and find it difficult to cope on their own.

Of most immediate concern are all the existing patients of Rebecca house and the other units who do not qualify for continuing NHS care. Where will they go? If Rebecca house closes, they face the prospect of a move to a residential care home or nursing home in the private sector. Given the quality of care that they have received at Rebecca house, we can assume that there is a considerable risk that they will end up in less appropriate surroundings, and in addition it must be borne in mind that the Alzheimer's Society says that it is best to avoid moving people with dementia. In the society's words, that should be "avoided at all cost". A move can disorient the patient and accelerate the decline in their condition.

The trust has made it clear that those who were admitted to the service before 31 March last year will continue to have their care funded by the NHS, irrespective of whether they meet the criteria for NHS continuing care, but it is also the quality of the care that concerns loved ones, not just the cost. For those admitted after 31 March last year there is no commitment to continue to cover the cost. There is also concern about the capacity of the private sector to provide the extra specialist beds that would be needed. There is already a national shortage, according to the Alzheimer's Society. At a meeting for carers held at Rebecca house, one lady described how each week it was necessary to search a local website availability list to find the odd bed that might become available that week.

It also remains unclear what will happen to those who have used Rebecca house for respite care. Four beds are set aside for that purpose. Will the respite care of those people be paid for the rest of their lives? That is incredibly important to those affected. Privately funded respite care is very expensive. When I raised the point with trust representatives, they said that no decision had been reached.

Everyone recognises how important respite care is. If more people are to be cared for at home, resources must be committed to provide an effective support infrastructure. In a rural area such as North Norfolk, people can be isolated in small village communities without public transport. If the carer has inadequate support, they can rapidly sink. The nature of dementia is such that the demands on the carer are intense and constant. Carers need a break. My fear is that the closure of the units will result in less respite care, not more. Does the Minister share my view about the importance of improving access to respite care for those cared for at home?

Rebecca house provides what is described by the trust as informal day care. The loss of that facility will hit many more people. Again, the facility is part of the infrastructure of support for people caring for loved ones at home. We have a situation in which there is a strong case for not moving existing patients, based on their needs; a lack of capacity in the private residential nursing care sector; the imperative of increasing the availability of respite care and not reducing it; and existing day care facilities that are under threat.

For me, that all points to a very strong case for trying to keep Rebecca house open. How that can be achieved given the rather unfortunate and clumsy demarcation between the mental health trust, the primary care trust and the county council social services department, I am not sure, but every effort needs to be made collectively to secure the future of this much-loved and much-valued unit.

I have an open mind about who could run Rebecca house in future, but in an area that has an ageing population and already has one of the highest age profiles in the country, it is foolhardy and reckless to contemplate the closure of Rebecca house. The same goes for other units around the county. I note the commitment of the trust to use the resources freed up by the closure of these units—I understand that the amount will be about £1.5 million—for the improvement of mental health services in central Norfolk, but at the moment there are genuine and continuing concerns about the overall package of proposals.

My plea to the Minister is to ask him to do whatever he can, working with the local trusts, to help Rebecca house and those other units, to help ensure not only that today's patients who are in the home and need it for the rest of their lives are protected, but that there are high-quality facilities for the future.

Photo of Richard Bacon Richard Bacon Conservative, South Norfolk 7:37, 27 October 2004

I congratulate Norman Lamb on securing this debate, and I pass on to him the thanks of Mr. Iain Dale for having done so; I know that Mr. Dale secured a meeting at Rebecca house on a cross-party basis to express the widespread concerns of residents and relatives about the position being taken by the trust.

I want to highlight for the Minister a fact to which the hon. Gentleman alluded—this is not an isolated case, and the same situation is widespread across Norfolk. Indeed, there are five such units, including Cygnet house in Long Stratton in my constituency, which I understand the Minister visited today. I also understand that some friendly local fox hunters were present to greet him, although I had nothing to do with that. I hope that he found the visit congenial, notwithstanding some of the people by whom he was greeted.

Cygnet house is one of the five units for the elderly across Norfolk. It has units catering for long-term residential care for the elderly mentally ill, and it also offers respite care. The number of units can vary from day to day. On 25 October, it had 11 residents, compared with 14 in Rebecca house. Adding Ellacombe, Yew Tree and Laburnam, which are located in Norwich, produces a total of 49 places on that date—a number that will fall to some 28, as the hon. Gentleman said, under the proposals.

That raises a number of concerns. First, some facilities, especially at Cygnet house, are very local to people in South Norfolk, for whom it is not always easy to get into Norwich, especially when they are elderly people. The Minister will have seen today how large my constituency is; it covers some 350 sq miles. At the moment, Cygnet house provides easy access for relatives, and there is no doubt that Norwich is more difficult to visit.

In addition to the question of access, there is the quality of care that is provided. The father of a councillor in my constituency, Councillor Martin Wilby, has been at Cygnet house for two and a half years, and has received excellent care, both physically and mentally. Mr. Wilby senior has been in homes of various kinds for some 10 years, but his time at Cygnet house has been the best, according to Councillor Wilby. Mr. Wilby senior spent some time at Hellesdon hospital in Norwich, but there was a high staff turnover and the care could be patchy. Cygnet house, which has a low staff turnover and a higher and more consistent quality of care, is in my view and that of many local people better for residents.

The hon. Member for North Norfolk also alluded to cost, which is the other issue that I want to raise. I have a copy of the report to the board of the Norfolk and Waveney Mental Health Partnership NHS trust, which refers to potential options for Cygnet house, including the refurbishment of the facility and its use as a care unit for the whole of central Norfolk. However, the report states that if that option were pursued, clinical and out-of-hours cover, as well as the high revenue costs, would raise concerns. On the face of it, it seems that the change is a cost-cutting exercise, with not enough thought being given to the needs of elderly people with mental health problems who need specialist care, and it does not seem right to make relatives pick up the tab, again.

I strongly endorse the point made by the hon. Member for North Norfolk that Norfolk's demographic profile is old and that in many cases it is getting older—people move to many parts of my constituency in order to retire—so dementia services will grow, not decline, in importance. There are serious concerns about whether the trust's proposal is the right way forward. I have asked Pat Holman, the chief executive of the partnership, to reconsider the closure of Cygnet house, and I look forward to the Minister's reply.

Photo of Stephen Ladyman Stephen Ladyman Parliamentary Under-Secretary, Department of Health 7:41, 27 October 2004

I appreciate the interest that Norman Lamb takes in his local health service and congratulate him on securing the debate. I thank my hon. Friend Dr. Gibson and Mr. Bacon for their interest.

I also thank the hon. Member for South Norfolk for his concern for my welfare. The fox hunters in his constituency were friendly and took their democratic opportunity to express their views in a reasonable manner.

Photo of Stephen Ladyman Stephen Ladyman Parliamentary Under-Secretary, Department of Health

As my hon. Friend says, they are simply wrong, but we will leave that matter to another day.

I would also like to take this opportunity to pay tribute to all the staff in the local health economy, who are committed to the improvement of local services and who are doing a fine job. I agree that older people with dementia deserve better services, which is why the Government have set in place a number of initiatives to try to ensure that that happens. More money than ever before is being invested in older people's services, and if I have one message for hon. Members on both sides of the House tonight it is that if we want better services for older people, and especially older people with dementia, we must modernise those services and be prepared to engage constructively and with open minds.

As part of the ongoing process of "Shifting the Balance of Power" to a local level, it is for local NHS organisations to assess the needs of the local population and meet them from general allocation funds. They are in the best position to do that because of their specialist knowledge of their local communities. By devolving funding to the front line, we have given the NHS in every local area the freedom and the resources to develop a strategy for the future that will deliver financial balance and sustainable services.

The latest round of allocations has been made for three years. That certainty of funding will enable health communities to plan their finances and will provide a surer foundation for PCTs to commission services in a way that will deliver improvements in performance. Older people will benefit from those record allocations to primary care trusts, as a considerable portion of those allocations will go to services for older people, including the care and treatment of those with dementia.

That brings me to a point raised by the hon. Member for North Norfolk and challenged by the hon. Member for South Norfolk: if the reconfiguration frees up any resources, the intention is to reinvest those resources in further and better support for older people—the reconfiguration is in no way a cost-cutting exercise. The hon. Member for South Norfolk may be interested to learn that North Norfolk PCT has been allocated £97.6 million for 2004–05, which is an increase in cash terms of about 9.5 per cent.

Just because we have given power and resources to the front line, it does not mean that the front line can duck difficult decisions. All hon. Members have a duty to help their local NHS face those challenges, which is what I ask the hon. Members for North Norfolk and for South Norfolk to be prepared to do.

Before I deal with local issues, the hon. Member for North Norfolk raised some national issues about progress with continuing care. I have made two written statements that detail progress on that. The last one reported on progress up to the end of July. I have no plans to make a further statement on that, but when I have sufficient data I shall do so.

The hon. Gentleman referred to criteria. The legal judgment to which he referred did not suggest that the criteria were too strict. It stated that there is an upper limit beyond which it is ultra vires for councils to provide support. It did not distinguish between social care and health care. The ombudsman, when investigating cases, subsequently said that errors were being made and that there was too much variation in the criteria. Consequently, we asked all strategic health authorities to produce new criteria based on central guidance and to ensure that they were legally compliant. They have all done that. The review is retrospective and covers people who may have been unfairly treated in the past. In addition, we are introducing new procedures to ensure that people are properly assessed in future. I believe that the new procedures are working well.

Reassessment is necessary because people's conditions change from time to time. When their condition changes, the care package that they need changes. We must reassess to ensure that people are getting the care that they need.

Photo of Norman Lamb Norman Lamb Shadow Spokesperson (Treasury), Liberal Democrat Spokesperson (Treasury)

I fully appreciate that care package needs will change, but does the Under-Secretary concede that that results in a change in the financial package? It means that people move from free NHS care to means-tested care.

Photo of Stephen Ladyman Stephen Ladyman Parliamentary Under-Secretary, Department of Health

That is possible. National health service continuing care applies not only to people with dementia, but to people with all conditions. Some conditions are curable and it is therefore necessary to remove the continuing care package when someone is cured. That is not the case for people with dementia. However, their care package will need to be changed and, in the very unlikely event that they are cured, it is theoretically possible that they would revert to means-tested support. That would happen only if their predominant needs were no longer health needs and they no longer fulfilled the eligibility criteria. The primary reason for reassessment is to ensure that the care package always matches people's needs.

The hon. Gentleman mentioned personal care and the fact that it is not free in England. I do not know who controls the social services of his local council, but it is entirely in their power to make home care free if they wish to do that because the matter is devolved to local councils. Not one Liberal Democrat council in the country has chosen to do that and I doubt whether any councils will do it because it is not financially viable. It would cost £1.5 billion a year, not the £1 billion that Liberal Democrat Front-Bench Members claim. The Rowntree Foundation has suggested that the cost will increase to approximately £10 billion by 2050. That would be entirely unaffordable.

I have listened to the hon. Gentleman's comments. The changes that he discussed locally in Norfolk, and especially in Rebecca house, are part of a set of proposals that Norfolk and Waveney mental health partnership trust developed in partnership with the PCT, social services and other stakeholders in a wider programme of service improvement and modernisation. There has been a robust and inclusive local process to develop the proposals, including a full needs assessment and options appraisal.

Those proposals are a work in progress and it is for all hon. Members to engage in it and try to influence it. I can assure hon. Members that no final decisions have been made by the local NHS and its partners pending a formal public consultation process, which will commence later this year.

The hon. Gentleman is a member of a party that says that it believes in power to the people, local decision making and devolution. Yet one could interpret his comments this evening as following none of those principles. He seems to have made up his mind before he has listened to the consultation and the views of his constituents—[Interruption.] Well, the formal consultation has not yet begun, and he did not sound to me as though he was keeping an open mind. He sounded as though he had made up his mind. If the services in his constituency are not properly modernised, he will be doing his constituents no favours because they will not be getting the level of service that they deserve.

The hon. Gentleman has talked about local services. There are several thousand older people with dementia in central Norfolk at any one time. Thankfully, only a few require specialist mental health in-patient treatment, yet there are five separate units providing elderly mentally illness—EMI—in-patient continuing care services in central Norfolk. These are Laburnum, Yew Tree, Ellacombe, Rebecca house and Cygnet house. They provide a total of 101 beds. However, only 65 of the 101 beds are occupied, and only 22 of those 65 patients meet the criteria for NHS-funded and provided continuing care and, more importantly, require a specialist mental health in-patient service. The total cost of the services that I have just described is £3.8 million per year. That is an awful lot of money to be spending on empty beds and services that do not best suit some of the people in those places.

Clearly, the demand for these services has changed since they were established. New therapies are now available, and there is a greater recognition that it is important to identify and intervene in the onset of dementia early. That is why the proposal to reshape the services currently provided from these units is being put forward. It will ensure that the resources available to mental health services meet the needs of more people with dementia and their carers, and better fit the needs of the hon. Gentleman's constituents. If we close our eyes to the need to reshape these services, we are ducking our responsibilities. If the hon. Gentleman's first instinct is to say that there should be no change, or even—heaven forefend—to climb on the bandwagon of sentiment that is often associated with establishments, rather than with the people in them, he will not be doing his constituents any favours.

Photo of Norman Lamb Norman Lamb Shadow Spokesperson (Treasury), Liberal Democrat Spokesperson (Treasury)

I am certainly not suggesting that there should be no change. Indeed, I acknowledged in my speech that there is clearly a case for the proposed specialist intensive care unit. I took on board the views of staff who said that it was very difficult to care for people with all these different types of needs in the same unit. I accept that, but this debate is about engaging in the process that the Minister wants us to engage in.

Photo of Stephen Ladyman Stephen Ladyman Parliamentary Under-Secretary, Department of Health

I am glad to hear that, but I would be even more glad to hear the hon. Gentleman say that he still had an open mind about the outcome and that he was prepared to accept that it might be in the best interests of his constituents if Rebecca house did not continue to offer the services that it offers at the moment. He will also have to consider the idea that, if there are to be fewer of these units, the 28-bed unit to which he referred will almost certainly have to be very close to acute services, because of the intense health care that many of the people in these facilities require. The primary consideration in determining the location of that unit will have to be the safety and the health care of those patients, and it might not be appropriate for that type of unit to be in his constituency. It might be much better for his constituents—although it would no doubt be more inconvenient for carers—for it to be in Norwich. That is one of the issues that the local population will have to grapple with and talk about in the consultation. The hon. Gentleman will clearly have views about whether the right decision has been made, but we all need to keep an open mind about this.

The national guidance to improve services to which the hon. Gentleman referred includes the national service framework for older people and the national service framework for mental health services. That is the national guidance that his local primary care trust is trying to deliver—

The motion having been made after Seven o'clock, and the debate having continued for half an hour, Madam Deputy Speaker adjourned the House without Question put, pursuant to the Standing Order.

Adjourned at six minutes to Eight o'clock.