This is an important issue and probably one of the most important topics that we as a Government and a Parliament will need to consider. On current estimates, the number of 85-year-olds will double by 2026, so it is a serious issue and I congratulate my hon. Friend Tracey Crouch on securing this timely debate.
Dilnot focused on the financial issues and found that the current system is not fit for purpose. I think that there is another issue in relation to quality. The Government clearly want to ensure that we have a system that, ultimately, is fair, affordable and sustainable. They want to invest in a system that will ensure that we have more care and support in the community, so that we can keep people in their own homes rather than force them into residential care as the only option. However, if we want that quality, we need to ensure that there is proper monitoring and proper regulation. Although I am not a great fan of over-regulation, we have to bear in mind in this particular argument that we are dealing with consumers who are often not very vocal or not able to be very vocal. Therefore, it cannot necessarily be assumed that the way in which a market would normally self-regulate will be the way in which this market will regulate itself.
My comments are based on conversations I have had with the Care Quality Commission, a number of local authorities and private providers. I have a long-term interest in the issue. I was a county councillor and chairman of the health overview and scrutiny committee, and in Devon we currently have the largest number of retired individuals in the country. I will turn first to residential care, then to domiciliary care, look at how they are regulated and monitored, and raise some concerns that need to be addressed by the Minister.
Residential care is commissioned by the local authority. Although provision is monitored by the CQC, the commissioners, per se, are not. I have a concern about that, because it is the local authorities that are determining whether to commission in their own homes—where one might argue that they have a conflict of interest—or in the private sector. What I have found particularly disturbing is the price that is paid for each of these contracts. I hear that local authorities—I give this by way of an example—are paying £700 in the public sector, compared with £350 for a private provider. Whatever the savings might be, there is no way that, for half the price, the same quality of care can be provided.
There is no standardisation of contract in the current system. Although choice is clearly important, I think that, for a consumer who has a difficult time getting their voice heard, it is difficult to ensure that they get consistently good quality. If we are to ensure that there is real choice, genuine quality and fair pricing, we need to look seriously at how the commissioning bodies—the local authorities—might be monitored and regulated in future. I believe that the Government have looked at HealthWatch as a possible source. My concern about HealthWatch is that, first, it does not yet exist and, secondly, it seems to have been conceived as a reactive rather than proactive body.
The provider of residential care is, principally, either the local authority or the private home, and here CQC does monitor. Although the intention was to set out a new framework that, rightly, was more outcome-focused than process-focused, the challenge for the care homes is to comply with this new care quality regulation. I have talked to a number of homes and the majority have indicated that they expected a light touch from Government. They expected that they would be able to provide evidence of compliance and that there would not be many onerous visits. I hear that there are many visits, which surprises them and surprises me. They are saying that it is taking up an awful lot of administrative time. Given that, as a Government, we are committed to cutting red tape, something is clearly not working somewhere. The position needs to be reviewed. Clearly, it is important, because we need to guarantee quality, but let us find a way of doing it better. The other concern that homes have expressed to me is that, with the new outcome framework, there is no guidance as to how to meet the new requirements. In the old days, the CQC used to provide guidance, but now it does not see it as within its remit.
Domiciliary care is, perhaps, one of the most tragic and most important areas of concern. Commissioning of domiciliary care is done by local authorities. Here, again, there is no monitoring and, I understand, no regulator; I would love to hear the Minister tell me that I am wrong. I cannot therefore see how we can ensure that our local authorities are really making sensible, informed choices about how they award contracts for domiciliary care. Indeed, I have heard stories of local authorities trying to take out costs and to sub-contract their role to lead providers, who then take on the role of sub-contracting further to find individuals and more providers of domiciliary care. In all that process, the quality control and the quality test seem to be lacking. I have talked to providers in the private sector who have seen some of what goes on, and the stories are horrifying.
Let me give one example. A provider indicated to me that she had gone into the home of an elderly person who was having to be put on to the toilet. The lady was literally sitting in her chair eating her sandwich lunch and the providers came in and lifted her up in a way that is apparently not appropriate or correct from a nursing perspective. They put her on the toilet, went out, smoked a cigarette and came back in. The sandwich was still in that poor old lady’s mouth. They then took her and stuck her back in her chair. That does nothing for the dignity of the older person.
The provider of domiciliary care is sometimes the local authority but, increasingly, it is the private sector. Unlike the residential end of care, there is no Care Quality Commission monitoring domiciliary care and I understand that there are also no spot checks. Although there is an obligation on local authorities to have a watching brief, what I am hearing anecdotally shows that very little of that is actually happening.
The concept of e-monitoring was introduced to try to assist with that. The idea behind e-monitoring is that, when someone goes in to provide care in a home, they pick up the phone in the individual’s residence and log in. When they have finished dealing with the client, they log in again through the telephone. However, the reality is that once someone has logged in, frankly, they can do almost anything. As in the case I mentioned, that could be putting a lady on the toilet and then disappearing outside and having a cigarette. Therefore, e-monitoring is not an effective way forward. The other thing happening is that, because there is no monitoring of quality, cost rules and consequently quality are going down.
I shall make this a very short contribution. In conclusion, the Minister should carefully consider having a regulator to deal with the monitoring process for commissioners both of residential and domiciliary care. In addition, certainly with regard to domiciliary care, some urgent and immediate action needs to be taken to examine current practice.