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With this it will be convenient to take new clause 11—Exclusion of long term care from community care services in Wales—
`.(1) The National Assembly for Wales may by order provide for the exclusion of long term care from the provision of community care services in Wales.
(2) ``Long term care'' means any care in a residential or care home setting that is not board and lodging.'.
The amendment seeks to avoid the House debating whether to allow another body to decide how to proceed with personal care and whether or not it should be provided. The amendment and the new clause make it clear that these are devolved matters for the Welsh Assembly. It is a matter of ensuring that the Welsh Assembly is able to take decisions on the provision of personal care in the context of its own priorities and resources and the situation in Wales. In other words, it would enable the Welsh Assembly to reach its own view, on the basis of the evidence, on whether to follow the royal commission's recommendations for free personal care. That is the purpose of the amendment and the new clause—to allow the Welsh Assembly the same freedoms as the Scottish Parliament.
In the debate in the House last night, the Minister referred to the current position of my colleagues in Wales, for the simple reason that the Liberal Democrats are committed to devolution. We accept the possibility of different solutions in different places. We do not have a problem with that. In the case of England, we believe that the Government should adopt the policy that has been adopted in Scotland, because it is right. If our colleagues in Wales, having assessed the situation there and having considered the representations that are made to them, reach a different conclusion, that is the consequence of devolution. There should be no problem with that. The amendment and the new clause were tabled in order to secure for the Assembly the same power as the Scottish Parliament and allow them to consider the matter for themselves.
I am grateful to the hon. Member for Sutton and Cheam (Mr. Burstow) for tabling the amendment. He and the Minister had the pleasure of slugging out the debate on personal care last night in the House. Unfortunately, I was not present, so I apologise to both of them if it turns out that some of the issues that I want to raise were discussed last night. I know that some of them were, but I am sure that neither hon. Gentleman will be dismayed by having to discuss them again.
The amendments give us the opportunity to discuss the devolution-related issues, to which the hon. Member for Sutton and Cheam has already drawn our attention. There are continuing controversies surrounding the matter. Essentially, in this part of the Bill, there will be three separate debates. The first would be about balancing the desire to address the concerns of older people and their families about the iniquities of—and the perverse incentives in—the current system of means-tested support for long-term care with the fiscal concerns. The second issue relates to devolution and the third concerns the Government's definition of nursing care and how the provision will work in practice.
On the second matter, the devolution-related issue, the hon. Gentleman has set the amendment in in the context of Wales, but he referred to the situation in Scotland. Theoretically, the amendments would place Wales in the same position as Scotland. I am sure that the Liberal Democrats would like that to happen, as they are currently exploiting to the full the Government's discomfort over the Scottish fiasco—and who can blame them? Labour's problem in Scotland really concerns its approach to devolution. The controversy over personal care throws the issues into stark relief. We have said for some time—and I have said it more times than I care to remember in Standing Committees—that Labour's perception of what devolution means and how it works was always based on the assumption that the same party would be in control of both sides of the equation. The Liberal Democrats have exploited the leverage that they currently have in relation to the Scottish Parliament in order to embarrass the Government and place them in something of a dilemma.
I was referring to the Liberal Democrats in England who are exploiting what is going on in Scotland for their own purposes—and I am not necessarily criticising that. I am simply observing what is going on. It is obvious to us all that there has been pressure from Westminster on the Scottish Labour party to fall into line with what the Government are proposing. Ministers face a real dilemma. If Labour Ministers in London dictate the Scottish agenda, then devolution will be shown to be a sham. However, if the Scottish people are to receive materially different levels of benefit from the state, that presents a different problem for the Government. It raises a different question. The question that it raises in my mind is for how long the people of England and Wales will accept such a solution, because the arrangements for financing the block grant to Scotland have always been based on the assumption that there is a need to make fiscal transfers between regions of the United Kingdom—and now between different countries—in order to address different levels of economic deprivation. In other words, it is a a balancing exercise. People will view that in one light. However, when they see fiscal transfers being made and taxes being set in one country in order to transfer public funding to another country, not to make up for economic deprivation or to balance the situation, but to ensure that people in one country can enjoy a higher standard of public services than people in another country—I suspect that there will be some backlash and some questioning as to whether that is an appropriate way to proceed.
Let me remind members of the Committee of the context in which the debate about devolution and personal and nursing care expenditure is conducted. Health service spending per capita is 20 per cent. higher in Scotland than in England. I have repeated that figure ad nauseam, because it alarms me. It explains why it is affordable in Edinburgh to take some of the actions that the Scottish Executive are considering, and that the Liberal Democrats are pressing them to take. If we had 20 per cent. higher health spending per capita in England, there would be all sorts of options.
Several hours ago, the hon. Member for Runnymede and Weybridge (Mr. Hammond) raised some points about the operation of the Barnett formula. He has tried to bring the subject into a debate that is narrowly drawn around devolution to Wales. Will he set his remarks in the context of the position that his colleagues in the Scottish Parliament have taken, and say whether he has come to the same conclusion as them and favours the implementation of the royal commission's proposals?
Order. It would be useful for me to make it clear that it is possible to debate what has happened in Scotland in the context of the clause. However, if it is debated on this group of amendments, I cannot reasonably allow it to be debated on the next group as well. I am being fairly tolerant in allowing a debate on it now.
I am grateful for that guidance, Mr. Maxton. I carefully considered the structure of the Bill and the amendments to it, and felt that, since the England-Scotland issue could hardly be avoided in our debate, this group of amendments was probably the best one on which to discuss it. Indeed, the hon. Member for Sutton and Cheam mentioned Scotland when he introduced his remarks.
I appreciate the fact that the hon. Gentleman's intervention was mooted some time before he made it, but I think that I have answered his question. I said that the NHS spending per capita in Scotland was 20 per cent. higher than in England. Scottish Ministers, and his and my Scottish colleagues, have a much larger fund to dispose of. If there were no resource restrictions, everyone would like to see the maximum extension of care provision. No one suggests that there is some reason in principle why a narrower definition of what will be provided free of charge is better than a broader one. The issue relates to the opportunity costs of doing so, and the priorities to be set by the Government or parties that have any prospect of being in government.
I am interested in the hon. Gentleman's comments. He seems to have got into the same JCB digger as the hon. Member for Meriden (Mrs. Spelman) when she dug a hole for her party in last night's debate on the issue. On his analysis of the opportunity costs involved, does his party have no commitment to finding additional resources for England, and so rules out the extension to free personal carers, as defined by the royal commission?
The hon. Gentleman obviously hopes that I will wriggle around the issue, but I will not. I was hoping to talk about it in the next debate, but I shall bluntly tell him our view now. With the limited resources available in England, and considering the priorities for health resource spending, we agree with the Government that there are better ways of spending that limited sum on the elderly who would benefit from the change that he proposes.
I will tell the hon. Gentleman later where we disagree with the Government. I do not seek to have my cake and eat it. The line dividing the Committee will change as our debate continues. The difference between the positions that the official Opposition and the Government have to take, and the position that the hon. Member for Sutton and Cheam has the luxury of adopting is the likelihood of the policies advocated being put into effect. It is easy for the hon. Gentleman to tick off a wish list of things that he would like to do, such as to link pensions to earnings or make all personal care free, but he does not have to say how he will raise the resources to do so. He has not told us where he will make cuts in order to deliver his party's wish list.
It is not part of my responsibility to do the Minister's dirty work for him, yet I am standing here doing what I was accused of this morning—making the case that the Minister will inevitably have to make against the amendments. I hope that I have answered the hon. Gentleman's basic question, but we need to take the matter further in the next debate.
I am grateful to the hon. Gentleman for that clarification. Would he clarify another matter, which is to do with resources and devolved governance? Does he suggest that the Barnett formula should be abandoned so that the Scots would not be in a position to have a more favourable package?
It is self-evident that if it becomes obvious to elderly people in England that they have access to a lower level of publicly funded services than elderly people in Scotland, questions will be asked and there will be a groundswell of opinion against that inequity. I have said before that most people accept the principle that, within our United Kingdom, money needs to be moved around to help even out some of the inequities and differences in economic prosperity between the various regions. However, if money is being taken away from taxpayers in one area in order to fund a gold-plated service in another area, questions will be asked.
That goes to the heart of our fundamental concerns about the devolution settlement. If the Government are successful in their objective of keeping the lid on it so that we have devolution in name but not in practice, with similar policies being arrived at by different Parliaments that are essentially seamless, there may not be a problem. However, as soon as we arrive at distinct policies that deliver different services to the different peoples of the United Kingdom, we shall start to see the tensions that we have always predicted would result from the devolution settlement.
I am grateful to the hon. Gentleman for giving way; it might mean that we shall not have to revisit the subject in later amendments. The hon. Gentleman seems to be arguing that people will look across the border to Scotland, envious of what will be thought a better service, but he also subscribes to the Government's view that the policy in Scotland will not result in a better service. He seems to be arguing two entirely different points.
No. The hon. Gentleman must remember the context in which the debate is being conducted in Scotland by his hon. Friends, by my hon. Friends and by Labour Members. Scotland has 20 per cent. per capita more to spend on health, so options are open there that are not available to us in England. It is in that context that the hon. Gentleman needs to view those matters.
The announcements made by the Scottish Executive have, in my view, been rather unclear—perhaps deliberately so. I would hate to be ungenerous, but it has not slipped my notice that a general election is in the offing, and it may not be entirely inconvenient to the Government if the Scottish Executive's proposals for Scotland remained woolly for the next couple of months. However, I hope that the Minister will agree with me about the dangers of public reaction in England if there is a clear difference between the two countries in the standard and level of service provided. Can the Minister tell us something about how he sees this issue playing out over the next couple of months, in the context of what he is now proposing in this Bill for England, what the hon. Member for Sutton and Cheam is proposing for Wales, and what his own colleagues in Scotland are proposing for Scotland?
I am sure that we will want to deal with some of the wider issues, although not in relation Scotland, when we discuss the next group of amendments.
May I return the Committee's attention to amendment No. 279 and new clause 11 tabled by the hon. Member for Isle of Wight (Dr. Brand)? Amendment No. 279 would restrict the impact of the clause to England, whereas new clause 11 would give the National Assembly for Wales the power to make an order removing all local authority responsibility for long-term care, except those aspects that relate to board and lodging and residential care. The hon. Gentleman may be concerned about who pays for nursing care and personal care, but sadly his amendment does not say who should provide or resource that aspect of care.
The national health service does not currently have any responsibility to provide such care except when a patient's needs are predominantly for health care, and personal care is incidental to that. The amendment does nothing to impose any duty on the national health service, or on any other agency, to plug what would otherwise be a very substantial hole in community care services in Wales. I accept the point that the hon. Gentleman was making, and I assume that it is more of a probing amendment than a substantial one. None the less, it is worth pointing out that his proposals would leave thousands of people in Wales with no one responsible for funding their personal and nursing care costs. I am sure that that is the last thing he has in mind, but that is what would result from his amendment.
As the hon. Gentleman is aware, the National Assembly for Wales already has the power to make precisely those decisions. That is why Jane Hutt in the Welsh Assembly earlier this week set out their response to the issues that the royal commission identified. It may not be the hon. Gentleman's purpose in tabling these amendments, but that is the effect that they would have. It would be disastrous for the people of Wales, and I am sure that he will not want to put this to a vote for that reason. The structural changes that could follow if the Government were to accept the tenor of these amendments would be very significant. The local authority social services role would be seriously diminished and, importantly, the integrated community care framework of assessment, care management and monitoring would be dismantled. As a result, the social care service framework would be entirely disjointed.
The hon. Member for Runnymede and Weybridge discussed important, wider issues to do with the funding of long-term care. Most of the comments had more relevance to the decision of the Scottish Executive. He and I have discussed these issues before. I suspect that it is quite a widespread view among his right hon. and hon. Friends that devolution is just about all right as long as everyone comes to the same decisions. As soon as there is any divergence of opinion, they say that devolution is not working. That is a completely bogus argument.
No. The hon. Gentleman and his colleagues should go away and think about their commitment to the principle of devolution. It strikes me that it is entirely superficial. At the first sign that the Scottish Executive want to make their own decision, he and his right hon. and hon. Friends run around screaming to the rooftops about how terrible devolution is. If I heard his comments rightly, he was holding out the prospect that a future Conservative Government—heaven forbid that we have to face that prospect—would punish the Scottish Executive by withdrawing health and social care services from the block grant, to ensure that they were penalised for funding long-term care. If that is not what the hon. Gentleman is proposing, I would welcome some clarification of his position.
I certainly did not say that at all, and I confidently predict that Hansard will show that tomorrow. I take exception to the Minister characterising our position as supportive of a sham version of devolution, when that is exactly the charge laid at the Government's door. To make the matter explicit, does the Minister deny that Labour members of the Scottish Executive have come under pressure from members of the Government to withdraw their proposals, water them down, or postpone them, in order to avoid embarrassment for the Government on their proposals in England?
With respect to the hon. Member for West Chelmsford (Mr. Burns), I shall answer the question in my own way. He might want to answer the question for me, but that is not how the structure of the Committee works on such occasions.
What the hon. Member for Runnymede and Weybridge said is transparent. He chose his words carefully—he is good at that--but there is no doubt that anyone who heard his remarks would have come to the conclusion that he was saying that the Scottish Executive could have free personal care, but the Conservatives would reassess the Barnett formula to ensure that there was a subtraction from the resources allocated. That is what he meant to say, but he did not have the courage to put it in as many words. He dropped a few hints and lit a few fuses by suggesting that that is what a future Conservative Government would do, and his remarks would certainly have been listened to in Scotland with great interest.
There are disagreements on the issue, not only between the parties, but within them. I understand that the Scottish Tories support the principle of free personal care. The English Tories do not. The Welsh Liberal Democrats have not fully embraced the implications of the Sutherland report. The Scottish Liberal Democrats have, and we now know that the English Liberal Democrats have as well. There are differences between the response of the Scottish Executive and that of the Government at Westminster, but that is the natural consequence of the devolution settlement. The hon. Gentleman has not raised any substantial issue of principle that should trouble or detain the Committee for a second.
I may not have raised an issue of principle, but I have asked the Minister a specific question, which is relevant to the case that he is trying to make. Have Labour members of the Scottish Executive come under any pressure from members of the Government in Westminster to water down, withdraw or delay their proposals, in order to avoid embarrassment to the Government?
No. Let me make it quite clear that it is entirely the responsibility of the Scottish Executive to come to their own decisions on these and any other matters that are devolved.
We will probably have an opportunity to discuss the wider issues relating to who pays for what in long-term care when we debate the second group of amendments. I certainly want to return to that issue, because there are important and serious arguments of principle and practice that we need to have. Those debates will continue.
The amendments would take the wrong direction for Wales. They would open up a black hole right in the middle of community care services in Wales, and they should not be part of the Bill.
It has been useful to air some of the issues related to the interplay of the royal commission's report and devolution. The Minister has advanced the usual argument about the technical deficiencies of an amendment, which is perhaps part of the armoury of a Minister in Committee. On that basis, I am persuaded that the amendment should not be pressed.
However, I am not convinced that the Welsh Assembly has the necessary powers to consider fully the issue of free personal care. We wish to return to that matter. My colleagues in Scotland will be interested to learn that Conservative Members covet the difference in health spending between Scotland and England, and have an implicit desire to equalise that expenditure—presumably downwards, in the case of Scotland. That will be remarked on in Scotland with some interest.
May I ask the hon. Gentleman, because I know that Liberal Democrats usually operate straight out of the gutter, to make it clear to his colleagues in Scotland that it was he who used the words ``presumably downwards'', not my hon. Friend.
I shall send my hon. Friends in Scotland a copy of the transcript. They will draw their own conclusions, and I am sure that many others in Scotland will do the same. The words of the hon. Member for Runnymede and Weybridge are more than adequate testimony to the policy that the Conservative party has now espoused. I see that the hon. Gentleman is keen to continue digging that hole.
I am not digging a hole—that seems to be the latest Liberal Democrat catchphrase. I ask the hon. Gentleman to do me the courtesy of urging his hon. Friends to read my words, not what the Minister thinks I wanted to say but did not have the courage to utter. I must tell the Minister that if I want to say something to him, I shall say it to him. The hon. Gentleman has been on Standing Committees with me often enough to know that that is so.
With this it will be convenient to take the following amendments: No. 287, in page 42, line 42, at beginning insert
`care for a prescribed condition or'.
No. 262, in page 42, line 42, leave out `nursing'.
No. 298, in page 42, line 42, leave out from `care' to end of line 6 on page 43, and insert
`or health care within the meaning of subsection (2)'.
No. 263, in page 42, line 42, leave out `by a registered nurse'.
No. 304, in page 42, line 42, at end insert
`unless such provision or arrangement is made under partnership arrangements under sections 27, 30 or 31 of the Health Act 1999'.
No. 288, in page 42, line 42, at end insert—
`(1A) In this section ``care for a prescribed condition'' means any services including—
(a) the provision of care; or
(b) the planning, supervision or delegation of the provision of care which is required by a person suffering from a prescribed condition, whether or not the same involves nursing care by a registered nurse.
(1B) For this purpose a ``prescribed condition'' is any condition which the Secretary of State may from time to time prescribe by regulations.'.
No. 299, in page 42, line 42, at end insert—
`(1A) In subsection (1) of section 3 of the 1977 Act (which consolidates provisions relating to the Health Service in England and Wales)—
(a) for paragraph (c) there is substituted—
``(c) medical, dental, nursing and ambulance services including nursing care and health care services within the meaning of section 48(2) of the Health and Social Care Act 2001, which are provided in and to residents in local authority, private or voluntary residential or nursing homes.''
(b) for paragraph (e) there is substituted—
``(e) such facilities for the prevention of illness, the care of persons suffering from illness and the after care of persons who have suffered from illness as he considers are appropriate as part of the health service including nursing care and health care services within the meaning of section 48(2) of the Health and Social Care Act 2001, which are provided in and to residents in local authority, private or voluntary residential or nursing homes.''.
(c) for paragraph (f) there is substituted—
``(f) such other services as are required for the diagnosis and treatment of illness including nursing care and health care services within the meaning of section 48(2) of the Health and Social Care Act 2001, which are provided in and to residents in local authority, private or voluntary residential or nursing homes.''.
No. 300, in page 42, line 42, at end insert—
`(2) In this section—
(a) ``nursing care'' means any services—
(i) provided by a registered nurse, or
(ii) involving the planning and supervision or delegation of the provision of care by a registered nurse, or
(iii) provided under the supervision or delegation of a registered nurse whether that nurse is present or not present when the service is carried out, or
(iv) provided by a non-registered staff or care workers following training or assessment by a registered nurse, or
(v) involving the provision of any equipment or personal aid that has been assessed as needed by a person and which would be provided by or under contract with a National Health Service body if that person did not reside either temporarily or permanently in either a residential or nursing home;
(b) ``health care services'' means the diagnosis, assessment, monitoring and any care, treatment or therapy which the person is assessed by a practitioner either employed by or working under contract to a National Health Service body as requiring, and which would be provided by or under contract with a National Health Service body if that person did not reside either temporarily or permanently in either a residential or nursing home;
(3) Any assessment for the provision of nursing care shall be carried out by a registered nurse.'.
No. 264, in page 42, line 43, leave out subsection (2) and insert—
`(2) The Secretary of State shall by regulations prescribe the meaning of ``care'' in this section.'.
No. 307, in page 42, line 43, leave out `by a registered nurse'.
No. 308, in page 43, line 1, at beginning insert
`usually or routinely of a type'.
No. 309, in page 43, line 4, leave out from beginning to end of line 6.
No. 225, in page 43, line 6, at end add—
`(3) The Secretary of State shall make regulations providing that all those involved in community care shall be required to undergo a training course explaining the role and responsibilities of those providing nursing care.
(4) Before making such regulations the Secretary of State shall consult relevant medical, social and pensioner organisations.'.
No. 301, in page 43, line 6, at end add—
`(3) In section 22 of the National Assistance Act 1948 (which provides for the assistance of persons in need by local authorities) subsection (2) is omitted and the following subsection is inserted—
``(2) Subject to the following provisions of this section, the payment which a person is liable to make for any such accommodation shall be in accordance with a standard rate fixed for that accommodation by the authority managing the premises in which it is provided and that standard rate shall exclude any costs for personal care services, within the meaning of section 48(5) of the Health and Social Care Act 2001.''.
No. 302, in page 43, line 6, at end add—
`( ) In subsection (2) of section 17 of the Health and Social Services and Social Security Adjudications Act 1983 (which makes provision relating to the financing of certain social services in England and Wales), after ``services'' there is inserted ``excluding any personal care service within the meaning of section 48(5) of the Health and Social Care Act 2001''.'.
No. 303, in page 43, line 6, at end add—
`( ) ``Personal care services'' means any service or services which a person has been assessed as being in need of under section 47 of the National Health Service and Community Care Act 1990 and which is care provided in respect of the following matters—
(a) personal toilet (including washing, bathing, skin care, personal presentation, dressing and undressing and skin care);
(b) eating and drinking (but not the obtaining or preparation of food and drink);
(c) the management of urinary and bowel functions (including the maintenance of continence and the management of incontinence);
(d) the management of problems associated with immobility;
(e) the management of prescribed treatment (including the administration and monitoring of any medication);
(f) behaviour management and ensuring personal safety (including the reduction of stress or risk for persons with cognitive impairment); or
(g) associated teaching, enabling and psychological support from a skilled professional, and assistance with cognitive functions to enable a person to undertake personal care tasks himself or with help.'.
The large number of amendments in this group, which were tabled by various Members, suggests that various issues need to be debated. We shall be dealing with two essential questions, which are linked but separate—the principle of extending free care to include personal care as well as nursing care and the fiscal implications of such a move; and the rather narrow practical issue raised by amendment No. 306.
With your indulgence, Mr. Maxton, I would like first to address some of the wider issues raised by other amendments in the group and then to return to the narrower subject of amendment No. 306 and related amendments. With those latter amendments, we essentially accept the principle from which the Government start but seek to probe the practicality of the distinction that the Government have made. I do not labour under the delusion that the broader debate will be harmonious; but I hope that when we come to discuss the practical working arrangements, we shall have a constructive debate about some of the real concerns that have been expressed in Parliament and outside.
The history of the subject is well known. The Government responded to the debate on the funding of long-term care of the elderly by setting up a royal commission. The commission reported the year before last, following which we waited for a considerable time for the Government to announce how they intended to proceed. I hope that the Minister will allow me to say that, prior to the general election, the then Opposition's stance was a rather grandiose commitment to deal with the problem. The suggestions, solutions, attempts to introduce some measure of alleviation and partial solutions to the problem that my right hon. and hon. Friends proposed were dismissed out of hand. I would be the first to admit, as I have acknowledged before, that those proposals were modest and pragmatic. They have often been criticised, but have not yet been bettered, to my knowledge.
On assuming office, the Government brought with them the implicit promise of a comprehensive and early solution to the problem of funding long-term care for the elderly. They deliberately raised public expectations, and have waited as long as possible before starting to let them down gently. This clause of the Bill is the result of Labour's rhetoric, when in opposition before 1997 and then in government, about the need to solve the problem. It may sneak in under the wire before a general election, depending on the mood in the other place, but it is unlikely to satisfy anyone after all the hype that has surrounded the debate.
The initial expectation among those who concern themselves with the long-term care of the elderly was that the means test would be abolished, and that there would be free nursing and personal care. After the royal commission reported and the Government made it clear that their preference was for the conclusions of the minority report, there was an expectation that nursing care would be free. Many people were disappointed about that. Now we have an extremely narrow definition of nursing care, and that sense of disappointment has been enhanced. There is a serious danger that public expectation will be dashed, even on the limited offer that was made after the Government backed the minority report. There will probably be a serious shortfall on the NHS contribution to the average £100 a week difference between residential care and nursing care.
The Minister would inform the debate if he confirmed the figures that the Government are working with. Last night, he said that the Government's proposals would be worth up to £5,000 a year to someone in nursing care. Clearly, that assumes that, for such a person, the whole of the difference between residential and nursing care would be eligible for funding under the Government's current proposals. So that we can better grasp the significance of the Government's proposals, will the Minister confirm the Department's budget estimates of the cost of providing NHS-funded nursing care in residential and other settings under the proposals? The most important thing for older people and their families in planning to meet their future care needs is certainty. As it stands, the Bill fails that test.
I should like to re-confirm a position that was dragged out of me during the last debate, although I had hoped to make it coherently in this debate. We do not believe that taking personal care out of the means test is the optimum way to maximise support for older people from a limited resource budget. Unmet care needs are significant. The Opposition's view—I think that it is also the Government's—is that it must be right to focus available resources on expanding the total care delivered, even if that means acknowledging that at present the inadequacies and inequities of the means-tested system cannot be addressed by that route.
We would all like the abolition of means testing. It delivers perverse incentives, and so sends perverse signals to people when they plan for their older age, especially in relation to the funding of long-term care. Those signals go directly against the grain of the Government's stated intention to enhance personal saving and secure greater responsibility for personal care planning among the population. The Government are increasing the use of means testing under the new name of targeting.
A question arises over priorities. It is not a question of whether we use the money to support elderly people or for some other purpose. It is a question of how we can best use a given and finite sum of money to support elderly people. In other words, it is about how best to deliver care to elderly people. We concur with the Government's analysis that, given resource constraints, the money that is available would not be best used if it funded the personal care needs of those who already had assets and who, under the current system, were being required to use them.
I do not want to be partisan on that point, because I am accepting the principle of what the Government are doing. It would, however, have been easy to say that we were going to stand up and be counted for the people who have to use their assets or sell their houses—a group of people who are not poor. It would have been very easy for us to say that. We have taken the view, however, that that would not be right and that we have to look at the care needs of the whole community of elderly people.
In that respect, I was rather injured to read the Minister's suggestion of last night that it was clear to him that it would be Conservative policy to focus any cuts on those least able to bear them. He was clearly referring to social services spending. I hope that he will acknowledge that by supporting the Government's position on the funding of long-term care, we are clearly acknowledging that it would not be right to target the available money on the best off, but that it must be used to broaden the base of care available for those who are less well off.
Divisions within the Committee will change. At the moment, I find myself arguing with the Government, and, implicitly, against the Liberal Democrats. The Liberal Democrats' position usefully allows the debate to take place, but we have to be responsible. We have to consider the fiscal implications of what we propose, as an Opposition, just as the Government have to consider the fiscal implications of what they propose. No-one costs the Liberal Democrats' proposals. No-one gets out a calculator. Indeed, when I was thinking about that this morning I was reminded of the brief period when I worked in Italy where calculators have an extra couple of digits to take account of the lire factor. We would have to distribute such calculators if anyone intended seriously trying to cost Liberal Democrat spending commitments.
Free personal care for all would drive a coach and horses through the Government's budget and through any likely future Conservative budget. It is for the Liberal Democrats to say where the cuts would fall in order to raise the additional funding that would be needed to deliver the policy that they promote, but they did not appear to be eager about doing that at the last election when they laid out their manifesto commitments.
The hon. Gentleman has been reading the Minister's script from last night very carefully and is sticking to it very well. I wonder, however, whether the hon. Gentleman, given his desire to see things costed, could give the Committee a lead by itemising the cuts that would be needed to achieve £8 billion worth of savings.
In answer to the hon. Member for Sutton and Cheam, the Opposition Front Bench spokesman said that he accepted the principle on which the Government had predicated their proposal. However, he also said that his party had differences with the Government. However, he also said that his party had differences with the Government. Will he come to those difficulties?
I shall do that right now. It says here ``but take issue with the Government,'' so I will now take issue with the Government.
I have acknowledged that the Government have taken a difficult decision, and that, after careful consideration, we have decided that we agree that that was the right decision to take, given the resource constraints. We differ from the Government in our contention that the Bill does not address the longer-term issue. There is a need to ensure that, in future, older people are better prepared and have better arrangements in place to cope with their long-term care needs. In that context, I shall welcome clause 54, which is an attempt by the Government to address, via another route, the ways in which long-term care could be funded without precipitating the trauma of asset disposal at the worst possible time for the individual involved.
Not necessarily. Insurance products are available for people who wish to protect themselves against long-term care costs, but the evidence suggests that they have not been successful. Take-up has been poor.
There is no point in the hon. Gentleman sitting there, saying ``exactly'' and nodding his head.
I hope that the Government would acknowledge that there is a need to consider the long term and to consider what message we want to send to people who are in their 30s and 40s about how they should prepare themselves for their long-term care. In 20, 30 or 40 years time, the retiring population will include a much higher percentage of property owners, so it is possible that, under the proposed arrangements, the state's share of the burden of long-term care will fall. More and more people will be subject to the means test by virtue of being property owners—which is a good thing that we all support. Whether or not using property is the best way of arranging for people to make an affordable contribution to their care costs, and whether or not the current means test is the best way forward are legitimate questions that we expect the Government to address, along with the proposals in clause 48.
The Opposition are considering issues such as the appropriate roles of the individual and the state, and are debating those issues with people and bodies outside the House. We aim to create a situation that encourages those who are able to do so to make proper provision for themselves, and to do so in a way that does not present them with unpleasant decisions, such as selling a family property, at an awkward moment in their life, when that might not be the best way to meet the requirement to contribute to their own care. We also aim to define the proper role of the state in ensuring that everybody has access to the care that they need and that people do not face long periods of care and open-ended bills just because they have been prudent during their lifetime and saved, when their neighbours have not.
I do not want to outline our innermost discussions at the moment, but I will give the hon. Gentleman some ideas, because they are not rocket science, and they are not secrets. We have not heard anything from the Government about equity release arrangements for property, other than those that they are putting in place under clause 54. Perhaps we shall discuss how those will work when we reach that clause. There is scope to use the saving schemes that the Government and previous Governments have promoted to orientate people to think about the need to contribute to their long-term care needs.
More and more people who reach retirement, even though they do not consider themselves especially wealthy, will find in the context of our means-tested system that they are considered wealthy enough to contribute to their care needs. It is essential that people who will be asked to contribute to their care needs are fully aware of that eventuality and are assisted in every practical way during their working lives to prepare for it, rather than having to deal with it on the hoof in adverse and emotional circumstances, perhaps having had to give up their homes to go into residential care.
The hon. Member for Eccles (Mr. Stewart) is oblivious to the previous Government's proposals for an alternative to current insurance policies. Before my hon. Friend takes another intervention from the hon. Gentleman, does he think that the hon. Gentleman should read the proposals, as they are a viable alternative?
My right hon. Friend the Member for Charnwood (Mr. Dorrell) made those proposals. I have already said that they have often been derided, but in my view have not been bettered. They are a contribution to the debate.
I strongly believe that one size does not fit all. We should seek to create a sense of personal responsibility in individual members of society, in relation to long-term care, so that there is a partnership with Government. The sooner individuals understand that role, the better, rather than their finding out as a nasty shock after retirement that the state will not provide them with the level of support that they had expected. That comes as a rude awakening to many people. I hope that the Government will actively pursue such an approach in parallel with the arrangements.
I have talked around the principle of the Government's proposal, but amendment No. 306 and related amendments tackle a practical issue. I hope that the Opposition can all agree on that issue, as that would realign the division in the Committee. The Government's decision is that nursing care will be provided. Many Members from all parties believe that it would be artificial to assess nursing care and personal care separately. However, if we accept the Government's proposition, we have to define nursing care. The Government propose, as a definition, only services provided by a registered nurse that cannot be provided by others. That is an extremely narrow definition.
The briefing sent to members of the Committee by the Royal College of Nursing states:
``In practice, much of the nursing care received by frail older people in nursing homes is delivered by health care assistants, working under the supervision and delegation of a registered nurse.''
The hon. Gentleman is right.
I have two worries about the Government's proposal at a practical level. First, it will constrain the total supply of NHS-funded care that can be made available. As the Minister knows, nursing manpower is a constraining factor. If he says that only the care that is provided by the registered nurse is eligible, he will be rationing the amount of NHS-funded care that can be on offer in areas where registered nurses who are available for work are more rare than hen's teeth—a matter that I shall explore with him.
Secondly, the proposal will create a sub-optimal division of labour. Nurses, when deciding whether to delegate tasks to a health care assistant, will have regard not only to the competence of the person and the efficiency that that will create in the care setting, but to the implications that any such decision would have on charging. That conflicts with the Government's avowed intention—which we support—to ensure that, within our health care establishment, all professionals work to the maximum of their capabilities. Surely it would be a retrograde step if a perverse and unintended consequence of the Government's proposal was that work that could safely be delegated to health care assistants and, as the hon. Gentleman says, is delegated to heath care assistants in hospitals, in a nursing home setting had to be carried out by a registered nurse.
Amendments Nos. 306, 307, 308 and 309 recognise the Government's decision on nursing care, but would define it in a way that avoids the worst difficulties of demarcation and the most perverse resource misallocations. The test would be whether the care was of a type routinely or usually provided by nurses. Nursing care would be defined according to the type of care, not the person who delivers it. That would optimise the use of the total care work force, reduce costs and overcome the labour cap that is otherwise being applied. That is not so much a cash limit as, in areas in the south-east where nurses are difficult to come by, a human resource cap, which is being applied to the total amount of care that might be provided under such arrangements. It will allow nurses to continue to delegate their responsibilities when it is clinically appropriate to do so, without having to have regard to the financial consequences of such action for the people in their care.
The Government have not been clear about the assessment process in relation to nursing and personal care. Can the Minister confirm that the assessments will be carried out by nurses, not other NHS personnel? What impact do the Government expect the assessments to have on manpower resources? How many nurses will be diverted from patient care activities to undertake those assessments? Will the global amount of available NHS-funded nursing care be limited? In other words, will the assessments be competitive? In practice, social services assessments often are. A limited pot of resources is available and it is a matter of who demonstrates the need for it, as a result of the assessment process. Or will the services be available as of entitlement, without there being a strict cash limit being placed on the amount of resources that can go into NHS-funded nursing care? I look forward to receiving the Minister's response to such a large group of amendments.
The hour is quite late. I do not want to repeat yesterday's excellent debate other than to express my disappointment that the Government and the Conservative Opposition have not taken on board properly the message from the Sutherland report. They also failed to take on board three reports from the Select Committee on Health, which set out the difficulties involved in charging regimes that got in the way of team working and patient or client access to services. I pay tribute to my hon. Friend the Member for Sutton and Cheam, who set out the case clearly, and to my hon. Friend the Member for North Devon (Mr. Harvey), who made it clear how an extended scheme could be funded. [Interruption.] The Minister is not happy and says that it was not clear.
I must say that I was not clear myself about the motivation behind the Government's position. In his opening speech yesterday, the Minister bravely talked about the difficult choices that had to be made, and said that resources had to be allocated. He almost seemed to regret that the Government could not, at this stage, accept the majority recommendations of the Sutherland report. The winding-up speech from the Under-Secretary, the hon. Member for Birmingham, Edgbaston (Ms Stuart) implied that the Government's adoption of the majority recommendations would, in some way, impede better patient care.
I find that difficult to accept. In the modern health service, care is delivered by teams, which may be headed by nurses, doctors, social workers, psychologists or physiotherapist, depending on the task involved. One may also define the tasks as being predominantly medical, nursing or social work. However, it is less clear how one defines that activity by the team member who carries it out.
The hon. Member for Macclesfield (Mr. Winterton) made a good intervention about physiotherapists and chiropodists—a subject that has not otherwise been mentioned and may not be relevant to the Bill. However, it is a clear example of what I mean. Most physiotherapy for people who have had strokes is delivered by care assistants under the supervision of a physiotherapist. Would that care be defined as a nursing-type intervention, or as personal care for which people will have to pay?
The definition adopted by the Government, although administratively simple, contradicts the ethos of team membership that we have all tried to encourage. Successive Governments have encouraged that ethos, as have the caring, medical and nursing professions; all agree that people should be trained for a relevant task irrespective of their specific qualification. To base the entitlement on qualification is extraordinarily negative and may have dangerous consequences for the way in which care is delivered, especially in the home.
As the hon. Member for Wakefield (Mr. Hinchliffe) said last night, preventative work done in the home could make a tremendous contribution to keeping people out of institutions. That is clearly what we all want to happen. However, preventative work is carried out by teams—not necessarily with a registered nurse—and the task may be difficult to define as a nursing or personal care task. When the Select Committee asked the previous Secretary of State to define the difference between a medical bath and a social bath, he could not. Nobody can define it, other than those who carry out those functions.
It is important that that issue is addressed. We shall not try to force the Government into reversing their decision about whether the full recommendation of the Sutherland report, or the minority recommendation, is accepted. That is for Government. However, I am worried that the Government are specifying the boundaries through primary legislation. Should the Scottish experiment work out well, and be seen to be cost-effective and clinically effective, it would be a nonsense for the Government to have to return to primary legislation to extend the role of the NHS team beyond work carried out, for instance, by a registered nurse.
I urge the Government to consider redrafting the Bill to meet current requirements, in order to allow flexibility to extend the non-means-tested provision if they find that they have made a mistake. I think that they are making a mistake, which is why my hon. Friend the Member for Sutton and Cheam and I tabled the amendments. They were difficult to table because of the curious nature of the Bill—it does not impose a duty on the NHS and health authorities to provide a service, it merely forbids a local authority to provide a service. That is a strange way of trying to create a care package. I listened with amusement to the Minister pointing out the deficiencies of our new clause in relation to Wales. That is a consequence of the way in which the Bill has been drafted. I want the Government to suggest an amendment to ensure that, once the Bill is enacted, there is not a fixed position. The Government should not have to return to primary legislation to provide a greater service. Clearly, they should not be able to provide a lesser service, but we should provide them with the flexibility to do more if they wish, if the nation can afford it, and if it is seen to be cost-effective.
The other issue, which is reflected in all the amendments—and especially well expressed in amendment No. 306—is that the Government should revisit the issue of how to define nursing care. I have given examples of how extraordinarily difficult that will be. We should consider the institutional setting in which there are no longer specific nursing homes as opposed to residential homes. A residential home that happened to be owned by a state registered nurse might put in all sorts of claims because the proprietor has performed a caring role as opposed to that of an ordinary care assistant. Clearly, that is nonsense. Who determines the kind of nursing, even when carried out by a registered nurse, that qualifies for NHS funding? Is it only nursing care that is provided by an NHS nurse? Will district nurses be introduced to homes? Alternatively, will NHS nurse managers try to run nursing homes, to determine which bit of the nursing can be claimed for, and which cannot? The fact that there are no boundaries to be drawn makes it look administratively easy, but the Government's proposals will, in practice, create an administrative nightmare, which was well described by my hon. Friend yesterday. The bar coding system for community nurses was tried 10 years ago on the Isle of Wight and it failed absolutely, mainly because the software was so useless. I do not want matters to move in that direction.
Our debate probably cuts in three directions. We are disappointed that the Government have not accepted the strong argument put forward in the Sutherland report. We shall not overturn such a decision this evening, but I urge them to create more flexibility under the Bill so that they can accept the majority recommendation if it comes to be regarded as a sensible move. Will they reconsider how they define nursing care, because the definition is not workable as it stands at the moment?
Clause 48 marks splendid progress, as a result of which residents in nursing homes have regained their entitlement to NHS services, which will be provided according to their need rather than their ability to pay. That will be of significance to thousands of people over the years. It is a great step forward and is something that should have been done a long time ago for elderly and vulnerable people.
I prefer to carry on and make a little progress, after which I shall give way.
I wish to thank the staff of Methodist Homes, who helped to draft amendments Nos. 287 and 288. They very much reflect my worries about personal care, which go back more than 20 years to when I worked with older people and those with disabilities, particularly when they were being admitted to residential care. My principle was founded in those times. Personal care services should be free at the point of use, as the national health service is. There are certain reasons for that. Help with personal care, washing, dressing, feeding and toileting issues is of obvious fundamental help to people. Such assistance enables people to live comfortably, to keep their dignity—sometimes to regain it—and their independence. Personal care services assist people to live and participate in the world, and should be available as of right. Such services should be provided free because they are an important part of holistic care. They can immeasurably improve the quality of people's lives and can offer choice and reassurance. I support holistic services for whole people.
It really is impossible to differentiate between personal care and health care. By definition, personal care requires physical contact with people, sometimes in the most intimate of situations. It falls within internationally recognised definitions of nursing, but includes functions that are carried out by many people who are not nurses. There is a dilemma between free nursing care and means-tested personal care. Given that nursing care is a service that is provided by a nurse, it is bound to lead to significant anomalies. References have already been made to the health or social services bath. The fact is that someone suffering from dementia in a nursing home would get their care free under the proposals whereas someone with dementia—perhaps with almost exactly the same needs—in residential or domiciliary care would not have that advantage.
I congratulate the Government on having the courage and openness to talk the language of priorities and to address with such clarity such a complex and difficult issue. Amendment No. 288 is intended to build on what is being achieved, and suggests, as resources allow—under a Government committed to strong levels of public expenditure based on a strong, sustainable economy—a way to make significant progress towards the goal of making personal care free. We have had a revelation this afternoon: the Opposition have finally balked at the prospect of their black hole in public expenditure and have decided not to go so far down that route. What I propose has nothing to do with the judicious application of another penny on income tax either, it is only to build on the significant achievements that the Government have already brought about.
I would hate the Committee to be misled: our proposal this time is to soak the rich and put some extra money on those people who earn more than £100,000.
I enjoyed hearing that.
The amendment provides the opportunity for Government to list those priority conditions—we can talk dementia, Parkinson's disease or Alzheimer's—for which care would be free, whether it were at home or in intermediate care, residential care or a nursing home, regardless of whether that involved or required a registered nurse. I hope that that list will be developed over time.
The amendment would support ordinary life principles and remove any perverse incentive for someone to move into more formal or intrusive forms of care—taking them out of care in the community simply to achieve financial advantage. It consolidates the excellent work of the Bill in removing barriers between health and social services. It would reflect all the work that has been done in pensions policy to encourage people to make their own savings and provision in the knowledge that that would be affected only by the hotel and accommodation costs of long-term care, rather than having to take on nursing care, with which the Bill deals, or personal needs, with which the amendment deals. It would assist the Bill's clear intention to produce a high-quality system of holistic nursing and personal care, meeting assessed needs in a variety of community settings in flexible and imaginative ways. The amendment is in keeping with the spirit of what the Government are trying to achieve through the Bill and the clause. I hope that it can be supported, as it offers a clear way forward to deal with some fundamental issues.
I shall not say too much about amendment No. 288 for fear of doing harm to the cause that it espouses. It sets out a useful alternative route that might be pursued. I congratulate the hon. Member for Lancaster and Wyre (Mr. Dawson) on tabling it and Methodist Homes on the work that they have done.
I want to comment briefly on issues affecting people with dementia and the care of such people. The hon. Member for Lancaster and Wyre is absolutely right on the need to consider care of dementia sufferers holistically. One cannot simply parcel up aspects of their care. Time and a listening ear is often an essential part of that care. Many specialists in dementia care provision, for a variety of reasons, do not necessarily choose a registered nurse to lead the team or even be part of the team providing specialist support for a dementia sufferer. It would be strange and unfair for providers of care in community or residential settings who have constructed teams that are not led by or do not involve registered nurses—but which are nevertheless highly qualified, skilled and trained—not to have access to even the limited free nursing care arrangements under the clause. I at least welcome the possibility set out in amendment No. 288.
I want to speak to amendments Nos. 299 to 303, and try to explain the intent behind them. They are at the heart of debate. In a way, we had a clause stand part debate on the Floor of the House last night. I want to deal with some of the details. Amendments Nos. 301 and 302 make changes to those sections of current legislation that allow for charges to be made for personal care services, provided under section 21 of the National Assistance Act 1948 in respect of residential services. Those sections are also listed in section 17 of the Health and Social Services and Social Security Adjudications Act 1983. I do not want to keep repeating that, although it is an important piece of legislation. Personal social care services, which would be excluded from charges, are defined in amendment No. 303. They are clearly in line with the definition set out in the royal commission report.
Other services, especially those listed as community care services in the context of the National Health Service and Community Care Act 1990, would or could, under the existing discretions in operation, attract charges. They would be subject to the guidance produced by the Department and to decisions by local authorities. Non-residential services involving a care package that includes services of a domestic nature, such as cleaning, shopping, pensions and so on—the tasks that I identified in the royal commission report—would still be charged for. That is accepted by the Liberal Democrats and the royal commission, and provides a demarcation in terms of the way in which charging would operate.
Residential and nursing home services involving a local authority providing accommodation for a person in need of care and attention that is not otherwise available—housing and living costs are included—can still be charged for under the National Assistance Act 1948. We are not removing from the individual the responsibility for picking up living costs, lodging costs and accommodation costs. We believe that those can properly be left to the individual. When a person is accommodated in a nursing home, the nursing and health elements of the care, under amendments Nos. 299 and 300, would be met by the NHS and therefore free at the point of use, by virtue of the National Health Service Act 1977.
I do not pretend that the amendments were lovingly crafted by my hon. Friend and me; that would be misleading. However, I want to give credit where it is due. The Social Policy and Information Network has spent much time working on such matters and has involved 17 organisations in trying to reach a statutory basis, without the benefit of the full resources of the Department and parliamentary counsel to help draft amendments. It has provided a workable basis for implementing the recommendations of the royal commission.
Amendment No. 299 would establish in primary legislation that the duties of the Secretary to State to provide nursing care were extended to those individuals in residential nursing home settings. The amendment to section 3 of the National Health Service Act 1977 would establish that nursing services provided in nursing homes or residential settings fell within the duties of the Secretary of State. The aim of that proposal is to ensure that nursing care is the responsibility of the NHS and that the social care package purchased by local authorities does not include any elements of nursing care.
I am listening carefully to what the hon. Gentleman is saying. He talked about free personal care. Has his party worked out precisely how it would quantify the amount of personal care that a person might receive in a residential care home or a nursing care home? How will that be identified? Will it be worked out on the basis of a flat-rate payment to such people, or does he expect the amount of hours of personal care that each person receives to be properly recorded and identified?
I am genuinely puzzled by the Minister's question, not least because of the firm foundation on which we are basing our amendments. The royal commission makes it absolutely clear that the whole process of assessing need for personal care is just that; an assessment process. I shall refer later to the importance of having a statutory basis for the assessment process. Undoubtedly, needs-led assessment is essential.
Yesterday, in response to an intervention, the Minister made the point that the Government's nursing care proposals are also needs led and that no cash limit is being set on them. Presumably, the Government are envisaging a form of assessment procedure to enable that to happen. We, too, want an assessment procedure.
It is important for it to be clearly understood that the Liberal Democrats are proposing that, for example, one hour of personal care—or six, 10 or 12 hours of personal care—will have quantified. The hon. Gentleman is rejecting funding his party's proposals through a flat-rate payment that would cover nursing and personal care costs.
The Minister is suggesting that there is a flat-rate basis to our proposals. In response to questions that I have tabled, the Government have come up with the basis for costing the policy. They say that they take away the amount that is currently spent on a residential care home from the amount that is spent on a nursing home and that that produces a figure of £100 a week, which is what it will cost to provide free nursing care. Is the Minister saying that that is all that will happen? I do not think that he is.
The Minister has said that the figures are not cash limited and that we have a estimate. The reality is that we must start somewhere, and we start from the propositions set out in the royal commission's report of an assessment of need and its costings. Because we cannot be clear about the Government's assessment of unmet need and what the true level of need is until such assessments are made, we cannot say for certain that the amount of money that they put in or that we would need to put in is what would be needed.
As the Minister knows, working groups are to report back to the Scottish Executive by August. They will be advising the Parliament about how to take such matters forward. His colleague, the First Minister, has made it clear that the Executive are intending to implement in full the royal commission's recommendations. That is far as the Scottish Ministers have gone and is a reasonable position for holding this debate in terms of implementing such policy. If I were a member of the Labour party and wanted to implement the policy, I would expect officials to furnish me with more detail. The way in which we have framed the amendments provides an adequate basis for testing where the Government stand on the matter and the Bill. That is what the Committee is supposed to scrutinise, unless we have changed the procedures and Committees are now intended to scrutinise the Opposition.
Amendment No. 300 relates to the definition of nursing care. The amendment would include those services delegated by a registered nurse to be undertaken by a suitably qualified non-registered nurse. It picks up on the concerns expressed by the hon. Members for Lancaster and Wyre and for Runnymede and Weybridge about who is providing the care. That is an important concern that has been brought to the attention of all members of the Committee by the Royal College of Nursing and many others.
The hon. Member for Runnymede and Weybridge quoted from the RCN brief, from which I would also like to quote.
``At present, nursing care is provided free on the NHS to people in hospitals and their own homes, but is means-tested in nursing homes. This means that the only group of people who have to pay for their own nursing care are frail, vulnerable older people.''
The fault line in the Committee lies between those who are prepared to accept a continuation of that means-testing arrangement and those who reject it as unfair and inequitable.
The RCN provides a useful set of case studies to show how the measure might stand in practice. One such case study involved a Mr. Martin, aged 75, who is cared for in a nursing home.
``He has had a heart attack and stroke and has furred arteries. He has symptoms of Parkinson's disease. His prostate has been removed, and he uses a catheter. He needs help in moving around. During a typical half-day shift, Mr. M needs the following kinds of care . . . which is always delivered by a registered nurse:
Administering medication—Mr. M's pulse must be taken regularly because of the nature of his medication . . . Changing catheter . . . Re-ordering drugs.''
Then comes a long list of tasks undertaken in most circumstances, which would not be free in the context of the Bill. Those tasks can be carried out by an NVQ level 3 health care assistant, and include:
``Attending to hygiene needs . . . Checking urine pH levels and administering bladder washouts . . . Changing abdominal dressing . . . Checking vulnerable areas . . . for pressure sores . . . Evaluating bowel function and intervening if necessary to prevent constipation . . . Assisting with all eating and drinking, to maintain healthy diet and fluid intake''— and so on.
Those tasks would not be provided free under the clause before the Committee, but they go to the heart of an individual's dignity. They are not tasks that individuals would choose to have done for them, if they had the knowledge, will or strength to undertake them for themselves. That is why the RCN and many others are worried about the definition that the Government are seeking to impose, and why we have tabled amendments Nos. 299 and 300.
The hon. Member for Runnymede and Weybridge made an important point about nurse shortages and the impact that they may have on the Government's intentions to have a nurse-led assessment procedure for their policy of free nursing care. From work done by the RCN, we know that there is an anticipated shortage of some 57,000 registered nurses over the next four to five years. Out of the United Kingdom Central Council's total pool of nurses, some one in four nurses will reach retirement age over the next 10 years. We know that the average retirement age is 55, so those problems of shortages will become intense, if not severe, over the next five to six years.
The Government do not have enough nurses and will not be able, in my judgment—and in others' judgment, judging by the literature—to find sufficient nurses from abroad, not least because the demographic problems of our nurse work force exist elsewhere. We are competing with other health services that offer far more attractive packages to persuade our trained nurses to go abroad.
The problem that I am outlining—and which the Minister does not seem to want to address—is that even if there is extra money, it will be difficult to achieve the recruitment that the Government want over the next few years. It will be hard to fill the extra 2,000 head count number of nursing positions that will be created over the next few years because of the demographic profile of the nursing pool in this country. Even with the best will in the world—so far I think 7,000 extra nurses have been attracted to this country in a single year—unless the level of recruitment from abroad is significantly increased, there will be a shortage. If the NHS is to grab all the extra nurses needed to meet the Government's laudable targets in the NHS plan, where on earth will the extra nurses needed to deliver free nursing in the private and voluntary sectors come from?
Is it not true that if our proposals—or the amendment tabled by the hon. Member for Lancaster and Wyre; or the amendments tabled by the hon. Member for Runnymede and Weybridge—were accepted, the NHS could recruit more nursing assistants, train them within a nursing team and deliver the very service that all parties want?
My hon. Friend makes a fair point. The logical destination of the policy that the Government are espousing will probably be that that blurring will have to take place to allow it to work at all. Of course nurses must be an important part of that—our amendments provide a statutory basis for nurse assessments—but a compelling argument has been made by Members on both sides for the need for multidisciplinary approaches to assessment: the bringing together of health and social care assessments, so that we have not different approaches but a seamless assessment as well as a seamless service. Everything that the Government are doing in this area is unpicking that seam and creating two services again by sustaining the divide.
My final point on amendment No. 300 relates to health care and our concern about charges that are already being collected for NHS services. A survey undertaken earlier this year found that one in three care homes for elderly people were paying extra for GP services. The research covered a number of charitable bodies: the Association of Charity Officers, the Occupational Benevolent Fund Alliance and voluntary organisations involved in caring in the elderly sector, such as Voices. The survey found that extra fees ranged from more than £150 per resident to an average retainer fee of around £41 per annum per resident. Those sums are being paid by residents in nursing and residential homes for services already paid for through NHS capitation fees, which is a cause for concern. I hope that we can get clarity, which is the purpose behind paragraph (2)(b) in amendment No. 300.
The amendments are intended to implement the purpose behind the royal commission. We have taken specifically from the royal commission the definition of intimate care—the touching of the person. If the Government are not prepared to accept that—and so far they have not been, although it is the equitable basis on which the issue should be resolved—I hope that the Committee will be persuaded by the amendments tabled by the hon. Member for Runnymede and Weybridge. The Government have taken the view that if people are wealthy but sick, they will pay for their care. We take the view that if they are wealthy, they should contribute to the care of all, whether they be rich or poor. That is the difference between the Liberal Democrats and the Government: we do not want simply to penalise the sick rich, but think that taxation is the way to redistribute wealth, and that wealth can be used to maintain social justice through the health care system.
This has been a full and comprehensive debate, and I pay tribute to all Members who have spoken. There is disagreement on the matter—that is clear—but no one should question anyone's motives, or the compassion and concern that Members on both sides rightly feel about improving the health and well-being of older people in our society. We have a disagreement about the best way to do that. We have made no secret of our view on such matters, including the choices and priorities that any Government have a responsibility to address as they respond to important issues affecting the future of our society.
We all know that we are living in an ageing society. Before too long, all of us in this Committee—some sooner than others—will have to address those issues in our own lives. We have set out a principled, well-argued case for going down a different road from that suggested by the royal commission. The royal commission did a great deal of important work, and we are grateful to all of its members. However, we have a different way forward. I shall say more on that in a moment.
I want to do two things in responding to this wide-ranging debate. First, I want to address the issues of principle raised by Conservative and Liberal Democrat Members. Secondly, I want to deal with the particular issues raised in the amendments discussed this afternoon.
It strikes me, however, that one thing has been missing from this debate. The debate has followed a traditional line—within two minutes, we were all in our bunkers, firing from our fixed position—and there was no discussion of the wider responsibilities of the NHS in funding continuing long-term health care. About 10 per cent. of residents of nursing homes in England currently have all of their care costs—including personal care and accommodation costs—met by the NHS. According to the guidelines, those people need to be under the supervision of a consultant, specialist nurse or other member of the NHS multidisciplinary care team. The NHS therefore has responsibilities to fund personal and nursing care, as well as long-term care costs, which we discharge currently. I accept, in the light of the Coughlan judgment last year, that there is a need for the national health service to look carefully at continuing health care guidelines, and we are doing that. We shall introduce revised guidelines when that work is completed.
However, there has been a falseness about some of the argument today. Nursing care and personal care have been polarised. The attack from Liberal Democrat Members in particular was that the NHS should have a wider responsibility to meet all the care costs associated with those in long-term residential care, whose needs, in the widest sense, are broadly comparable to those in hospital receiving health care. We completely lost sight of that group of people in today's debate. They were lost sight of in yesterday's debate, too. The issue has been presented starkly and slightly inaccurately to suggest that the NHS has no existing responsibilities for meeting personal care costs, and that the solution proposed by the Liberal Democrats would introduce for the first time an NHS responsibility to meet the personal care costs of people in long-term residential care. That is not so, for reasons that I have outlined: 10 per cent. of those in nursing care currently have all of their costs, including personal care costs, met in full by the state.
It was argued yesterday and again today—the Liberal Democrat view—that the Government should try to provide a solution that will treat the person who is in long-term residential care in as broadly similar a way as possible as a person who is in hospital. In fact, the continuing care guidelines address that issue. I accept that there is an argument about those guidelines in the light of the Coughlan judgment. As I said, we are considering the issues carefully.
The other issue that it is important to address—Conservative and Liberal Democrat Members have made great play about the definition of nursing care under the clause—is the accusation that we have somehow not acted on or taken into account the recommendations of the royal commission in relation to nursing care. The suggestion is that we have chosen a different definition of nursing care than that proposed by the royal commission. I think that the hon. Member for Sutton and Cheam said yesterday that we had done so in the meanest and narrowest way possible. I absolutely refute that allegation. I do so not from the rhetorical position of a Minister who is bound to say that anyway, but on the basis of what the royal commission proposed. In that respect, I pointed out many paragraphs of the royal commission's report to the hon. Gentleman during our debate on the Floor of the House yesterday. I challenge him to find in the royal commission's report a definition of nursing care that includes care provided by a health care assistant. He will have plenty of time over the next hour or so in which to do so, and he can come back and tell us where it is.
Paragraph 6.22 of the royal commission's report states:
``At present, if a person receives nursing care—that is care which involves the knowledge or skills of a qualified nurse, either in a nursing home or a home which is registered to provide both nursing and residential care—he or she has to pay for the nursing care as part of the home's fees''.
It is clear to what that refers—care provided by a registered nurse. When other parts go on to deal with the anomalies of the system, it is clear that they are referring to registered nurse care. The only definition that appears in the royal commission's report was that proposed in the minority report, which again referred to the skills of the qualified nurse.
We have tried to take those issues into account, as well as the anomaly and injustice that the royal commission rightly identified, and which others before it recognised too, that it is wrong for people in a residential care setting to have to pay for the services of a registered or qualified nurse when they would not have to pay for those services in any other care setting. Our definition is wider, not narrower, and goes beyond the definition proposed in the minority report by the two commissioners who signed it, in that it provides a more expansive definition of what nursing care involves.
I put it to the Minister that the expression
``care using the knowledge and skills of a qualified nurse'' could embrace a health care assistant operating under the supervision of and with power delegated by a registered nurse, a circumstance that is, regrettably, probably more common than we would like, but which recognises the reality of the manpower problem that the nursing profession faces.
I can only tell the hon. Gentleman that we have tried to take into account the royal commission's clearly expressed anxieties about the injustice of people in a care setting paying for the services of a qualified nurse. That is the anomaly that was identified. It is that anomaly that the costings and estimates produced by a good friend of mine, Chai Patel, and by others for the royal commission tried to quantify and deal with.
It is unfair for the Liberal Democrats to suggest that the Government's solution is the least that we could have done. I reject that absolutely. We have tried to consider the issue in the light of the royal commission's recommendations, and we have acted on what we understand to be its anxieties and those of others about the problem.
I reject the argument that the hon. Gentleman has advanced. He said last night that he thought that the Bill was a mean response from the Government. It is not. We genuinely want to remove the anomaly in the charging arrangements, and we are doing so. It was clear from what he said last night that he does not have a word to say about the Bill being a good step forward, because he does not believe that it is. He nods his head; he does not believe that the Bill is a sensible way to proceed. I believe that he is fundamentally wrong. If he is so opposed to the Bill, I assume that he will vote against the clause, which will make free nursing care available to residents in England for the first time. I look forward to seeing how he will vote on the matter.
In clause 48, we have not pushed to one side the royal commission's recommendations but have taken them into account. We have also provided a clear definition of what we are providing and the certainty that the hon. Member for Runnymede and Weybridge, and perhaps the Liberal Democrats, have requested in relation to the definitions.
It is important to provide absolutely clear definitions and a clear boundary in relation to who pays for what under the arrangements. The alternative is not one that any of us would want to embrace—confusion, uncertainty and a lack of clarity about who has responsibility for funding which element of a person's long-term care.
With the greatest respect, none of the amendments, including that tabled by my hon. Friend the Member for Lancaster and Wyre, would provide what Opposition Members have requested, which is greater clarity, certainty and precision in the definitions. For that reason, among others, I shall be asking my hon. Friends not to support them.
Does the Minister accept that, because of differences in the labour market for nurses in different parts of the country, he is in danger of creating a postcode lottery in which the amount of care that is eligible under his proposals will vary from place to place and be determined by whether it is possible to recruit and employ registered nurses to undertake tasks that may otherwise have to be done by health care assistants?
No, I do not accept that. The hon. Gentleman is the architect in his party of the postcode lottery of care.
No, I am not. We are now dismantling such matters from the NHS. We were asked questions on the Floor of the House today that were not connected directly with the issue of nursing care, but about access and availability to new drug treatments. Without rehearsing such arguments, I must say to Conservative Members that they had nearly 20 years in which to sort out the random accessibility and availability of important drugs and treatment in the NHS, and they did not do anything about it. We have tried to resolve such issues with the National Institute for Clinical Excellence and others.
Perhaps I can bring the Minister back to the matter before us this afternoon. He is narrowly defining nursing tasks, which would fit in better with the minority report than with the report of the royal commission on long-term care. Should the time come when nursing assistants become members of the RCN, which is being talked about, they would enter a register that gives them a professional qualification. Would they then meet the criteria that the Minister is so keen to stick to? I am concerned about the nursing task, not the exact level of qualification of the person carrying it out.
All Governments must bear in mind such issues and consider the position if matters change. Our definition is not task-based.
With respect to the hon. Gentleman, it is a better solution than that which he and his hon. Friends are proposing, which is a list of tasks, some of which would be funded by the taxpayer and some of which would not.
No, I shall not give way. The hon. Gentleman has had long enough to develop his arguments. I hope that he will allow me to develop my response to what he has been saying, after which I shall give way to him.
I hope that the hon. Gentleman will understand my argument, although I am not sure that he will. However, I shall try once more. His proposals would not remove the boundary issues and the disputes about who pays for what, which he and his hon. Friends are trying to resolve. I am not criticising him, because he was fair in making it clear that, under his proposals, people would be means-tested for their long-term residential care. Certain elements would be removed from the means test, which is what his party believes in.
From what the hon. Gentleman said, however, about how personal care needs would be assessed, it is clear that he envisages a process that would identify certain tasks. He prayed in aid what the royal commission said about such matters, in that it regards a list of tasks as being the definition of personal care. That will raise difficult issues about what is or is not on the list. I am not saying that the issue cannot be resolved. Of course, it can, but it will not be free of difficulty.
Many people will consider the hon. Gentleman's list of tasks and say that it is not complete and should include other factors. He will face the same allegation that he has made against me—that his proposals are miserly and that his party has used a narrow definition. His proposals would raise many complex issues. I do not believe that they have been resolved fully by the royal commission, and nor is that the view of the Scottish Executive who want to re-examine the definition of free personal care. I shall be interested to see how such an argument unfolds among members of the Liberal Democrat party in England and whether they take a different view from their colleagues in Scotland.
Will the hon. Gentleman's party propose a flat-rate contribution towards the cost of long-term care that will cover nursing and personal care or does it want what he described yesterday as a barcode process, whereby individual tasks and the time to be spent on them must be identified, after which we will end up with a fixed price to be met by the NHS?
``(a) the provision of care, or
(b) the planning, supervision or delegation or the provision of care,
other than any services which, having regard to their nature and the circumstances in which they are provided, do not need to be provided by a registered nurse.''
Presumably, to make that system work a list of tasks will have to be published to show what a nurse does not have to provide. Will the Minister accept that such a list will have to be published to enable that to happen?