My Lords, the Care Bill represents an important recognition by Government of the need to tackle one of the major problems facing society: how we cope with the growing number of elderly dependent people. The fact is that we are all living longer, and although we are also remaining healthy and active for longer—here I must disagree slightly with my noble friend Lady Hollis; we are extending healthy life for longer, at least for women—we are leaving behind a long tail of unfortunate elderly people who are increasingly disabled with multiple chronic illnesses, many living in poverty, lonely and neglected. It is this growing group that is too frequently admitted to hospital as an emergency when they are tipped over by an acute exacerbation. They stay in hospital for far too long when they would be much safer and certainly better off at home. This is the picture that is painted so clearly in a recent Age Concern publication.
The Bill goes some way to providing help for pensioners themselves in the cap it will put on how much they have to pay for their long-term care. We can argue about how high or low the cap should be, but it is important to recognise that an extra financial burden will be placed on local authorities. Once an individual’s cap is reached it will be up to the local authority to pick up the bill for their care. Yet the local authorities are already under severe constraints and are complaining bitterly about being unable to fund even basic levels of care. The projected shortfalls in the face of increasing demand over the next few years are positively frightening, and I shall return to funding issues in a moment.
The Bill also takes up the challenge of the Francis report and proposes a number of measures to try to reduce the scandal of abuse and neglect. However, in focusing on systems for the detection of bad practice and more punishment of those who offend, the Bill seems to be missing the need to prevent bad practice in the first place. I believe that it would be much more effective in preventing bad behaviour to have someone on the ground at ward level who has responsibility and sufficient clout to ensure that high standards of care are maintained. As I have said in previous debates, that person has to be the sister or charge nurse in charge—really in charge—in a career grade post, not rushing off up the nursing career ladder in a year or so. Here I would echo very much what the noble Lord, Lord MacKenzie of Culkein, said. She or he should be rewarded and given a salary similar to that of a consultant, in recognition of the level of responsibility that she or he carries. These preventive measures are likely to be more effective than simply looking for abuse once it has happened.
One really big problem is how to prevent elderly patients being admitted in the first place, where we have been failing miserably. The Bill talks of the responsibility of local authorities to promote well-being and to prevent the need for care and support but it cannot say how they might do this or where they might find the money. There are many constructive things we could do now, without waiting for government action. It is worth examining what makes so many patients end up in accident and emergency departments. Many turn up with “dizzy do’s” and falls, and yet we could prevent most of those. Poor lighting at home and the absence of handrails or chair-lifts could all be discovered by regular home visits and corrected in a timely way, which may prevent many a fall. We can reduce the incidence of fractures, particularly hip fractures, which have such a big impact on the need for admission, by reducing the prevalence of osteoporosis through screening for it, treatment with calcium and vitamin D, and regular exercise, all at trivial cost compared with hospital admission. Then there are the “blackouts” that are so common. Screening the vulnerable elderly for predisposing causes—cardiac rhythm disorders such as atrial fibrillation, transient ischaemic attacks, epilepsy—and checking for hypertension and diabetes could prevent even more admissions. Far too often, it seems that patients with a diagnosis of dementia turn up in casualty. It is surprising but true that this may be the first time that a diagnosis of dementia is made, despite it being hardly likely that their dementia has suddenly appeared overnight.
All these rather obvious, and you might think straightforward, measures should be taken in primary care with the help of social services. Unfortunately, the regular screening of the vulnerable members of a practice is far from routine. I hope that the noble Earl, who is not here at the moment, will say in summing up whether it is possible to press those in primary care to include such screening. Focusing social and mental health services around GPs will bear dividends, but we need to take more action at that level than we have managed so far. It is particularly needed in poor inner cities, where it is least likely to be available. I was, incidentally, encouraged to hear that the Secretary of State was asking for ideas along those lines. There they are.
That still leaves us with what to do about patients lingering too long in hospital when they should be at home. Here again we have lots of ideas about what to do but seem quite unable to put them into practice in more than a few places, patchily, around the country. Why do all hospitals not appoint an officer whose sole responsibility is to plan for a patient’s discharge from the moment they enter the hospital? Better co-ordination between hospital and social services now occurs in a number of well rehearsed places but we have failed in trying to scale this up. The idea of pooled budgets between the NHS and local authorities is a good one, since it promotes better integration of functions, even though pooling two rather inadequate sources of funds will not provide much of the extra money that is needed.
All these measures can help, but the overriding problem will remain one of trying to provide more care in the community with too little money. Some believe that we should close NHS hospitals and beds to provide the money. Although there may be good service and quality reasons to focus expertise in fewer places—I am all in favour of that—it is a vain and somewhat naive hope that simply closing beds will save much money. To be clear, I am talking here of the 30% of beds occupied by elderly patients who should be at home. Close those, and Bob’s your uncle. However, hospital costs are not simply dependent on bed numbers. They lie much more in the high level of acute care, which is so labour-intensive. It is the high-cost medical and nursing care that severely ill patients need for their investigation and treatment that consumes so much resource. Those services are now so stretched but are hardly used at all for long-stay patients sitting in beds waiting to go home. Closing those beds will save very little, since the hospitals will still be stretched by their acute, high-intensity work. Certainly, discharging patients home quickly is a worthwhile endeavour for the patients but I do not believe that we should be looking for much in the way of savings there.
So where is the money to come from? In his excellent report, the noble Lord, Lord Filkin, pointed quite rightly to the need for the whole Government to respond. We need a combined effort across the whole of government, including housing, transport and work and pensions, and the Treasury and the Cabinet need to consider their overall priorities. Ultimately it is the priority that government as a whole gives to care of the elderly compared with the many other pressures it is under that will count.