My Lords, there is no doubt that this is indeed a momentous Bill. It will affect the lives of many who are already old, and the many millions whom medical progress and judicious lifestyles will bring to a multiplicity of years. It attempts to deal with what is not simply an immediate domestic crisis, although of course it is that. It is about a change in human society on a Darwinian scale: for the first time in history the human race will be living substantially longer than ever before. In Japan, there are already 50,000 people who are more than 100 years of age.
We have to realise the scale of the change that is under way. When Beveridge wrote his 1940s report he confronted five challenges: the evils of squalor, ignorance, want, idleness and disease. Today there are just as great evils stalking the old in this country: they are fear, ignorance, need, loneliness and neglect. In dealing with the problems that this creates, society has a mountain to climb. This Bill, which is much needed, deals merely—and deals well—with the immediate foothills. In doing so, it endorses two important priorities, which I welcome. Part 1 defines the central concern of the legislation as being the well-being of the individual. Later, the Bill shifts the emphasis of legislation towards,
“preventing … the development of needs” in the first place. This is an honourable objective but there are many obstacles that the Bill does not resolve. In examining and improving this Bill, we must bear in mind the scale of the problems as they already exist and the expectations that such problems will vastly increase in future.
Considered as a “foothills” measure, the Bill may be judged a very good one. It now includes many of the recommendations made by the Joint Committee on the draft Bill, and I pay tribute to the committee’s efforts. But there are many issues that we still have to address more thoroughly so, on behalf of older people, I will address the five evils I enumerated.
The first is fear: old people are haunted by what will happen as they age. They fear having to give up their home to move into strange places among strange people. The Bill goes some way in the implementation of the Dilnot report recommendations to assure them on this account. However, Dilnot had suggested a cap of between £25,000 and £60,000; the Government have set the cap at £72,000. This will clearly be of greater benefit to the wealthiest. It is not yet clear what types of insurance packages might be offered to the less well-off to cover their costs. It is obvious that with average earnings currently at £26,500, many people will not be buying such insurance at all. At the same time, the funding cap could create a new form of regional inequality due to the wide variation in average house prices in different areas of the country. In addition, with the increase to £123,000 as the upper threshold for receiving means-tested support, the King’s Fund estimates that the result will be an additional 100,000 older people in need of public funding. The fear will persist.
The second is ignorance: many old people long ago took to heart the phrase “from the cradle to the grave” and are still in shock when you explain to them that the NHS comes free but that social care—however it is defined—must be paid for. Confusion about the difference between medical and social exists in the system and the Bill makes a gallant attempt for care provision to integrate the two. However, the difference remains: one is a free service and the other must be paid for, either by the state responding to precise criteria or by the individual. Given that no one would have conceived things this way when the NHS was created, the dilemmas persist about how to inform those who implement the system as well as its beneficiaries about exactly how it works.
An example of how such issues come to a head can be seen when an individual is discharged from NHS care—a hospital—into social care. Caroline Charles, the director of external affairs at Age UK, tells us that 6% of hospital beds are occupied by people readmitted to hospital within a week of discharge because their care arrangements have not been worked out satisfactorily. The Bill tasks local authorities with integrating care and health provision—a hugely costly and convoluted undertaking.
I will round up my final three concerns into one. Need, loneliness and neglect all afflict far too many of our old people. The Bill’s answer to these issues is to define need. The noble Lord, Lord Rix, referred to this concern as it affects the disabled. Levels of need were introduced and defined in 2003 as critical, substantial, moderate and low. Different local authorities applied different criteria, but the Nuffield Trust cites a recent survey that found that 82% of councils now provide care only to those with substantial or critical needs, an increase from 62% in 2005-06. The trend towards setting higher needs thresholds is driven remorselessly by funding pressures on local authority budgets. The Bill moves the responsibility for eligibility to a central, nationally consistent measure—an important and welcome step forward. However, whether it will succeed in setting the criteria back to moderate, as so many of us wish, depends very much on a substantial increase in spending.
So we come remorselessly to the issue of money. With appropriate judgment, the Bill loads local authorities with many of the tasks of meeting the needs of older people, but without strong commitment to central government spending, many of those changes will be unworkable. According to Age UK, since the Government came to power, £710 million in real terms has been cut from social care spending, mostly as a result of cutting local authority budgets at the very time when needs are rising. ADASS reports that more than a third of local authorities anticipate having to reduce services and a fifth expect to have to increase charges. All of this is moving in the wrong direction and towards further disasters and tragedies. The implementation of the legislation calls for a commitment in the coming spending review to a major increase in spending on social care.
Finally, as we contemplate the mountain peak of need from the foothills of reform, let me reaffirm my suggestion: I believe that it is time for England to have its own commissioner for the old. That would be a unique role that would give such a commissioner access to planning across different government departments. The life of the old is influenced by housing, transport, justice, and now, with the encouragement of David Willetts, education; each department should have a strategy for the old linked across departments. Of course, a commissioner for older people would be a new cost. In Wales and Northern Ireland, where such appointments already exist, each commissioner has a budget and an office, but it is already proving money well spent in keeping people informed on the available options, and keeping all departments immediately aware of needs and impending crises. In the long term, that will represent major and consistent savings. Such an appointment would help both the needy and their providers to find their way around this confused and confusing system. The 10 million people now over 65, the 3 million over 85, deserve no less.