Mr Major’s Commons Response to the Elderly Persons Debate – 12 March 1986

Below is the text of Mr Major’s Commons response to the Elderly Persons Debate, held on 12th March 1986.

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Mr. Christopher Chope (Southampton, Itchen) I am grateful for the opportunity to have a debate about the financial arrangements for people in registered rest homes for the elderly. I know that I am not alone among hon. Members in being concerned about the matter. My hon. Friend the Member for New Forest (Mr. McNair-Wilson) wishes me to associate his name with some of the concerns which I want to express.

I appreciate the keen interest which my hon. Friend the Minister has taken in the subject since taking over responsibility for it. May I thank him in particular for the way in which he has listened to the representations of my constituents? In January he visited Southampton and, after meeting several residents at the Brookvale care home, he had a discussion with other rest home owners, a consultant geriatrician, general practitioners and nurses about the problems of residential care for the elderly. Later the same day he opened a new rest home which I am pleased to tell him is prospering, although it is charging fees greater than those who are on supplementary benefit can afford. More recently, my hon. Friend had a follow-up meeting lasting about an hour with two registered rest home owners in Southampton. If he paid the same attention to every constituency, I do not think he would have time to do anything else. I am most grateful for his concern.

The Conservative Government have an excellent record in extending care in the community, and the expanding national network of residential and nursing homes in the private sector is testament to this. The passing of legislation to improve the standards of care in these homes has ensured that those who look forward to spending the later years of their life in residential care can do so with confidence. The national picture is fully reflected in Southampton and Hampshire. In Southampton, the success of the programme of extending care in the community is such that, despite increasing numbers of elderly, and particularly frail elderly, there are now fewer on the waiting list for long-stay hospital care. My hon. Friend will know, however, that one does not seek a debate on the Adjournment merely to praise the Government but to draw attention to particular problems.

The first problem to which I draw attention is the position of those who were in receipt of supplementary benefit in respect of their rest homes charges at 28 April 1985. When my right hon. Friend the Secretary of State first proposed a new structure of national limits for the residential care and nursing home sector on 29 November 1984, he said, These new limits will be designed to reflect the varying cost of providing different types of care. There is no question, however, of elderly, handicapped or disabled people being moved out of their existing accommodation, and their position will be protected.” – [Official Report, 29 November 1984; Vol. 68, c. 1098-99.] In circular LASSL 86(1), issued on 14 January 1986, there is confirmation that the level of charges being met in a person’s supplementary benefit before 29 April 1985 will be maintained indefinitely where the person is over pensionable age. I welcome that, but it does not meet the problem of rising costs and charges. Most residential rest homes have had to increase their charges since April 1985 or, if they have not already done so, will soon have to. Who is to pay the increased charges?

The DHSS will not if the charges are already above £120. By definition, the residents do not have the means to pay the extra and even if they did this would be offset against their supplementary entitlement. I know of several proprietors of rest homes in Southampton who will have to take a crunch decision soon – next month is the crunch time – about whether to waive increased charges for the residents in the category I have described or ask those residents to leave. Surely if my right hon. Friend is to be consistent with his pledge to “protect the position” of such residents, he should be willing to allow increased supplementary benefit in line with the retail prices index. He should not rely upon the charity of the home owners, and should remember that because the residents do not enjoy security of tenure both they and their relatives are extremely worried about what may happen.

The second problem to which I draw attention is the position of those who were resident in rest homes at 28 April 1985 but who were paying privately and whose means subsequently fall to such a level as to cause them to qualify for supplementary benefit. Many of those who enter residential care use the capital released from the sale of their homes to meet the costs, but even £30,000 from the sale of a house pays for only three or four years in a rest home at £150 per week. These people expected that, once their capital was depleted, they would be in the same position as anyone else who qualified for supplementary benefit. Surely the pledge given by my right hon. Friend to which I have referred should extend unequivocally to these residents as well.

In this context I welcome the contents of paragraph 5 of the circular of 14 January, which states:

For those claiming supplementary benefit after 29 April 1985 the new system of national limits applied straight away. But Ministers have decided to introduce a new provision to help some long standing residents in residential care homes who did not claim supplementary benefit until after 29 April 1985…Where application of the new limits could produce exceptional hardship the Secretary of State has the discretionary power to extend to an individual the benefit of transitional protection so that he could receive the same rate of benefit as he would have received had he claimed before 29 April”. I hope that much greater publicity will be given to this very welcome concession by the Government, because I know that the problem has been a cause of concern to many. I have met many residents and their relatives who are still concerned, however, about what will happen when the money runs out. I doubt that the discretionary power will allay all their worries and concerns. I find it hard to contemplate a situation in which my right hon. Friend would choose not to exercise his discretion to extend transitional protection. If I am right in that, why cannot he go the whole way and guarantee that, in the situation that I have described, the transitional protection will be extended?

The third problem on which I seek my hon. Friend’s comments is the rigidity of the limit of £120 a week on supplementary benefit payments for residents in residential rest homes for the elderly. In most homes in Southampton this limit is well below the fees charged to those who pay privately. I imagine that £120 a week is probably too much for a pensioner who is up and about and fully in command of his faculties and who does not qualify for attendance allowance. Such a person should not, perhaps, even be in a residential rest home – at any rate, not at the expense of the taxpayer.

However, at the other end of the scale there may be a nonagenarian who qualifies for the full attendance allowance, who is very frail and who is incontinent. For such a person, living in a centrally heated, single room with full board, 24-hour care and free laundry, £17 a day is a bargain. It is clearly far below the reasonable cost. One needs only to consider the cost of care in a long-stay hospital. It is £48 a day. Therefore, £17 a day is very much on the low side where a very considerable degree of care is required.

I do not underestimate the problems involved in having separate levels of supplementary benefit entitlement, depending on the extent of the infirmity and the degree of care being provided. But the present system, particularly now that the attendance allowance payments are taken into account and set off against supplementary benefit, discriminates against the very people that we should be most eager to help. My hon. Friend saw some such people on the occasion of his visit to the Brookvale care home in Southampton.

The fourth problem is the one of topping-up payments. If a person is below pensionable age and a home’s charges exceed the supplementary benefit limit a local authority is able to top up the balance above supplementary benefit. The same principle does not apply, however, to a person who is a pensioner. I am sure that many local authorities would much prefer to top up a payment rather than have to provide home help services and meals on wheels. A district health authority might also be willing to make a topping up payment because it thereby saves on district nursing services. In Southampton, in the light of a recent decision to remove payments for incontinent aids, it would mean a saving of between £40 and £50 per resident per month if a person moved into a residential rest home.

There is also a problem about topping-up payments by relatives. I hope that in his reply this evening my hon. Friend will spell out clearly what those rules are. I have spoken to the officials in the supplementary benefit office in Southampton. They are in a state of confusion. The result is that some of the decisions that have been handed down seem to be wrong. I understand that under the regulations it is possible for relatives to top up payments, but I do not believe that that is the general understanding. I look forward to hearing what my hon. Friend has to say about that problem.

The fifth problem concerns the inflexible arrangements which apply to the categorisation of residents. A nursing home resident can receive between £170 and £230 per week from supplementary benefit, yet I have had constituency cases of individuals who would clearly qualify for nursing home provision but who would prefer to stay in a residential rest home where they have already spent many years, where the environment is familiar and the standard of care is as high as they would wish or need. My hon. Friend wrote to me about one such case on 28 February. The 89-year-old lady has charges of £180 per week. When I wrote to my hon. Friend he suggested that, in view of her disabilities and the high degree of care she needs, it may be that she should now be accommodated in a nursing rather than a residential care home. The limit for a non specialist nursing home is £170 per week. This higher limit could not be paid for” – this particular lady’s – present accommodation unless the home were jointly registered also as a nursing home. But joint registration of this home is not a practicable possibility. There are planning problems and the additional facilities which the owner would have to provide would only be worthwhile if all her residents were in need of the level of care provided in a nursing home. The owner does not wish to register as a nursing home and the resident does not wish to move to a nursing home.

If a pensioner resident suffers from disablement but had become disabled before reaching pensionable age, the maximum supplementary benefit payable is £180 rather than £120, provided of course that the home is duly registered for the elderly and physically disabled. Yet if a pensioner resident becomes frail and disabled in old age, the limit is fixed at £120.

Circular LASSL 86(1) explains: This distinction is intended to avoid ambiguity between those suffering from substantial and permanent disablement and those simply becoming frail in old age. That is Civil Service newspeak of the worst sort. If an 85-year-old bedridden amputee is frail and incontinent, he is disabled. Why should the cost of looking after him be deemed to be £60 a week less, if he was disabled at the age of 65 rather than 64? That is one of the worst anomalies.

There is a similar inflexibility in the assessment of those with mental disorders. Senile dementia is not apparently classified as a mental disorder, although its symptoms are often similar. The amount of care needed to look after someone with it is a great deal more than that for an ordinary old person. Yet supplementary benefit allowances are no different.

I know that my hon. Friend does not have responsibility for incontinent aids, but does he agree that it is desirable for health authorities to provide incontinent aids at no cost to residents in local authority, private and voluntary residential rest homes? I can understand why such facilities should not be provided to nursing homes because by their definition they are meant to provide full care and treatment, including all nursing services. But at a time when resident rest home owners are being pressurised from all sides, it is most unfortunate that in the Southampton health district the provision of such incontinent aids to residents in residential rest homes has been withdrawn by the health authority.

In a masterly understatement in a letter to me, my hon. Friend said: We do not regard the present arrangements as immune to change if the need can be shown. I hope that he will show that he has thought further about the possible ways in which the system can be improved and changed, and that he will not delay in putting right some of the present shortcomings which threaten to discredit an area of Government policy for which there should be only properly great praise.

The Parliamentary Under-Secretary of State for Health and Social Security (Mr. John Major) I have listened with care and interest to the wide-ranging speech of my hon. Friend the Member for Southampton, Itchen (Mr. Chope). In the time available I shall respond to as many of his points as possible. I welcome the opportunity to debate this important issue, and understand and sympathise with many of the concerns that he has expressed. It is characteristic of his assiduity on behalf of his constituents that he has pursued this matter extremely vigorously over recent months. I have no objection to that, although I have frequently been on the sharp end of his activities, because few topics are more pressing to those concerned with social welfare than the provision of care for our growing numbers of elderly, especially very elderly, people. There will be an increasing number of them in society year upon year for as far ahead as we can see.

First, I wish to look at the background to the present circumstances since it is important that it is properly understood. There have been radical changes in the past few years, which have transformed the whole character and scale of the provision of help for the elderly. Historically, many people who could no longer cope on their own have gone into local authority homes, or local authorities have sponsored them in private or voluntary homes. Many others have been cared for in the long-stay geriatric wards of our National Health Service hospitals.

The new and welcome feature of the 1980s has been the substantial opening up of the private and voluntary sectors to many more people, who have been able to exercise choices previously open only to those with substantial private resources. That has occurred because of the substantial availability of high rates of supplementary benefit, which has become a major source of funding, enabling many people to be cared for in the private sector. The figures show beyond dispute the rapidity of this change. In 1978 supplementary benefit helped 7,000 people to pay their fees in residential care and nursing homes. By 1984 the estimated figure was not 7,000 but 42,000, a sixfold increase in as many years. Expenditure too has risen sharply. The figures have been often quoted but they bear repeating. In 1978 expenditure in this area was £6 million. By 1983 it had soared to just over £100 million and the estimated figure for 1984 was £190 million. It will undoubtedly be higher in 1985.

In most ways, that growth has been beneficial. But the system was open to exploitation and abuse; and it had other features which have caused widespread concern. In the longer term, we would very much like to find a way of restoring a greater measure of responsiveness to individual need. My hon. Friend dealt particularly with that point.

More immediately, I must reiterate what I have said. We simply could not have allowed the growth that was continuing prior to April 1985 to continue uncontrolled, in the interests both of the taxpayer and of the elderly residents themselves. My hon. Friend will know that the numbers of elderly in the population are increasing, and they must be cared for. We entirely accept that and are anxious to seek the best ways of caring for them in their interests and those of the taxpayer. Therefore, it is right that we should make a comprehensive attempt to address this issue, not simply fudge it by paying ever-increasing amounts of benefits, as some people have urged on us. We need to take a comprehensive look at residential care and that is what we are seeking to do in a number of surveys that we have undertaken.

As a first step, in April last year we introduced a new structure for the payment of supplementary benefit to people in homes. Our aim was to regain control of expenditure and to relate benefit levels to the type of care and the cost of care provided. The system of limits that we introduced was intended to allow reasonable charges to be met on the basis of the registration categories set out in the 1984 Act. The limits were set by reference to the best information that was available to us and for residential care homes they initially ranged from £110 to £170. I should mention that the limit for Southampton before April 1985 was £110, the same amount as the limit we set for the elderly under the new structure that we introduced in April.

My hon. Friend asked about the position of people who were already in residential care homes when the changes were made. We have provided, as he acknowledged, extensive protection arrangements for people in homes who were in receipt of benefit when the changes were made and who would otherwise have been adversely affected. Those over pension age will continue to get their existing benefit for life or until payment under the new rules becomes more favourable for them. The new limits will normally apply to those who were in homes but not claiming benefit before April 1985. However, as my hon. Friend acknowledged, in cases of exceptional hardship the Secretary of State has discretionary power to treat certain long-standing residents in a similar way to transitionally protected claimants.

My hon. Friend asked particularly about the vexed question of topping up payments, which he believes is being misunderstood, and I believe that he is correct. He asked me to spell out the position. I assume that he was referring to payments made by relatives or charities to meet the difference between the supplementary benefit payable and the homes’ charges. Such payments are not – I repeat not – taken into account when benefit is assessed. The guidance in the S manual advises local offices to disregard payments from charities, friends or relatives specifically intended to meet the balance of the charge to the extent that they are used for that purpose”. That is entirely clear, and I hope that none of our local offices will misunderstand it.

But we recognised that this was the first step. When the measures were introduced, we promised a full programme of monitoring and research. We did so partly because we had an early sense of some of the difficulties to which my hon. Friend drew our attention this evening. One result of the initial feedback was an increase in the limits in November 1985. The residential care home limits were increased by £10, giving a range from £120 to £180. The limits for nursing homes, which are higher because of the more intensive care provided, were also increased by just more than £30 a week. Those substantial increases show our willingness to listen and to take action when we believe it to be necessary.

As my hon. Friend may know, we are in the process of reviewing all the residential care and nursing home limits. I listened with special care to what he said about the difficulties and problems faced by residential care home owners and residents in his constituency. We shall consider carefully the comments that he and other hon. Members have made during the review.

As an integral part of the review, we have commissioned a firm of independent management consultants, Ernst and Whinney, to undertake a wide-ranging inquiry into the costs incurred by homes of all sorts. The review will also draw on our monitoring of the arrangements since they were introduced last year, information from our local offices and representations from interested organisations and individuals. Any changes shown to be necessary following that review will be introduced in July this year at the time of the general benefit uprating. Although there is a tendency to think of £120 as the limit for the elderly, assuming that a home is registered to care for them., a range of higher limits is available to residents in residential care homes that stretches between £120 a week and £180 a week.

As to the longer-term future, most people would agree that there are inherent difficulties in the present system of public funding in this area. The present duality, with local authorities and supplementary benefit as major purchasers and providers of care, has caused problems administratively and, in some cases, for the people whom the system is supposed to help. Our aim is to draw together the two disparate strands so that when someone needs care, it can be provided simply and at a reasonable cost to public funds.

The first step towards that was made with the joint central and local government working party, which was set up in late 1984 by my right hon. Friends the Secretaries of State for Social Services, for Scotland and for Wales. The working party examined the scope for improving collaboration between the Department and local authorities over financial support for residents of private and voluntary residential care homes.

In its report, issued last year, the working party made two major recommendations. The first deals with an issue which I know worries my hon. Friend – the assessment of supplementary benefit claimants’ need for care. I recall clearly the remarks of Mrs. Armstrong and the consultant geriatrician when we met in Southampton about a month ago. The working party recommended that we should explore the feasibility of extending local authorities’ existing multi-disciplinary assessments to anyone in residential care claiming benefit and of local authorities advising DHSS offices on appropriate payments. We have agreed with the local authority associations that we should carry out pilot studies to test the proposals. They will take the form of a dry run and will not affect anyone’s benefit. The pilot studies will be conducted by the social policy research unit at York university. The aim will be to explore how the arrangements would work in practice and to identify any new problems and, I trust, their solutions.

The second recommendation was that we should seek long-term solutions to the problems created by the existing parallel systems of support. We have also accepted this recommendation. We and the local authority associations have agreed to set up a further joint working party to consider ways of harmonising financial support for people in residential care homes. The first meeting of this working party will be held at the end of this month and it is expected to complete its work within a year.

As I hope my hon. Friend will agree, we therefore have a substantial programme m hand for reviewing the financial arrangements for people in residential care homes and the problems that he mentioned. In the short term, we are reviewing the current supplementary benefit limits, and in the longer term we have the pilot studies on the assessment of supplementary benefit claimants’ care needs and the joint central/local government working party.

A related issue is the dual registration of homes. A home registered with the local authority as a residential care home may also be registered as a nursing home with the district health authority. We call this dual registration. Indeed, the home has to be so registered if it is providing nursing care of the kind proper to a nursing home. Residential care homes themselves are classified for registration purposes according to the main categories of dependent people, such as physically disabled or mentally disordered people, or elderly people, without attendant, exceptional disability. As I mentioned earlier, different rates of supplementary benefit apply to people in those categories, providing that they are registered in homes that are properly registered to care for them.

I hope that from all this my hon. Friend will see that we are very carefully considering the financial arrangements for residents in registered rest homes for the elderly. I emphasise that a home can be registered for more than one category, and this is being made clear to local authorities, as the registration authorities, in a circular that is about to be issued, a copy of which I shall put in the Library. A home may therefore be classified to take physically disabled as well as elderly people. I hope that what I have been able to say in the few minutes at my disposal this evening will be of some assurance to my hon. Friend, to the many people who are running residential care homes and, above all, to the many residents of such homes, who may have had some uncertainty about the present arrangements.

Question put and agreed to.